Clinical trial NCT01451515
Conditions: Lymphoblastic Lymphoma
Keywords: Lymphoblastic lymphoma
Sponsor: St. Jude Children's Research Hospital
Start date: 2012-05-25; Completion date: 2022-05-31
Enrollment: 23 participants; Allocation: NA; Intervention model: SINGLE_GROUP

Brief summary:
This is a phase II clinical trial using risk-adapted therapy. The treatment is acute lymphoblastic leukemia (ALL)-based therapy, using multi-agent regimens comprising of induction, consolidation, and continuation (maintenance) phases delivered over 24-30 months. Participants will be classified into 3 treatment stratums, based on bone marrow/peripheral blood lymphoma cells involvement at diagnosis and day 8 for T-lymphoblastic lymphoma and bone marrow/peripheral blood lymphoma cells involvement at diagnosis for B-lymphoblastic lymphoma.

The Primary Objective of this study is:

To improve the outcome of children with lymphoblastic lymphoma (LL) who have minimal disseminated disease (MDD) equal to or more than 1% at diagnosis by using MDD- and minimal residual disease (MRD)- based risk-adapted therapy.

The Secondary Objectives of this study are:

* To estimate the event-free survival and overall survival of children with lymphoblastic lymphoma who are treated with MDD- or MRD-based risk- directed therapy.
* To evaluate the prognostic value of levels of MDD at diagnosis and MRD on day 8 of remission induction.

Detailed description:
TREATMENT PLAN

Treatment will consist of 3 main phases: remission induction, consolidation \[only for patients with any central nervous system (CNS) disease and/or testicular involvement\], and continuation.

* Induction (6-7 weeks).
* Consolidation for participants with CNS involvement or those with testicular disease only (10 weeks).
* Reintensification - Participants with residual disease any time after induction therapy may receive 1-2 cycles of re-intensification therapy and may proceed to allogeneic stem cell transplant if suitable donor is available.
* Continuation Therapy (98-120 weeks).
* Intrathecal Chemotherapy (days 1 and 15; if needed also on days 8 and 22)

TREATMENT SCHEME

T lymphoblastic lymphoma: bone marrow/peripheral blood (BM/PB) involvement (MDD/MRD): Diagnosis: less than 1%; Day 8: +/- (Stratum 1)

* Induction

  * Single dose of Cyclophosphamide
  * Steroid: prednisone
* Continuation: 98 weeks

T lymphoblastic lymphoma: BM/PB involvement (MDD/MRD): Diagnosis: equal to or greater than 1%; Day 8: - (Stratum 2)

* Induction

  * Fractionated Cyclophosphamide
  * Steroid: prednisone
* Continuation : 98 weeks

T lymphoblastic lymphoma: BM/PB involvement (MDD/MRD): Diagnosis: equal to or greater than 1%; Day 8: + (Stratum 3)

* Induction

  * Fractionated Cyclophosphamide
  * Steroid: prednisone and dexamethasone
* Continuation: 120 weeks

B lymphoblastic lymphoma: Stage I-III (Stratum 1)

* Induction

  * Single dose of Cyclophosphamide
  * Steroid: prednisone
* Continuation: 98 weeks

B lymphoblastic lymphoma: Stage IV or testicular (Stratum 2)

* Induction

  * Fractionated Cyclophosphamide
  * Steroid: prednisone
* Continuation: 98 weeks

Patients with CNS or testicular involvement will receive Consolidation therapy prior to continuation therapy and receive extended maintenance therapy (120 weeks).

Any patient with detectable disease (MRD, bone marrow or biopsy of residual mass) at the end of induction may be considered for reintensification and/or hematopoietic stem cell transplantation (HSCT).

Arms: arm 1: Patients will undergo treatment as described in the intervention section. Interventions include:

* Remission induction: prednisone, vincristine, daunorubicin, PEG-asparaginase (or Erwinia asparaginase), IT-MHA (Methotrexate, hydrocortisone, and cytarabine), cyclophosphamide, cytarabine, thioguanine
* Consolidation: PEG-asparaginase, High-dose methotrexate (HD-MTX), mercaptopurine
* Postremission continuation: Dexamethasone, doxorubicin, vincristine, mercaptopurine, PEG-asparaginase, cyclophosphamide, cytarabine, methotrexate
* Reintensification: dexamethasone, cytarabine, etoposide, PEG-asparaginase, clofarabine, cyclophosphamide
* All patients receive IT-MHA on days 1 and 15. Some patients also receive additional IT-MHA on days 8 and 22.
Interventions: intervention 1: Prednisone intervention 2: Vincristine intervention 3: Daunorubicin intervention 4: PEG-asparaginase intervention 5: Erwinia asparaginase intervention 6: Doxorubicin intervention 7: Cyclophosphamide intervention 8: Cytarabine intervention 9: Thioguanine intervention 10: Clofarabine intervention 11: Methotrexate intervention 12: Mercaptopurine intervention 13: Dexamethasone intervention 14: Hydrocortisone intervention 15: Etoposide
Intervention descriptions: intervention 1: Given orally (PO). intervention 2: Given intravenously (IV). intervention 3: Given IV. intervention 4: Given intramuscularly (IM) or IV. intervention 5: Given IM or IV if allergy occurs with the first or second PEG-asparaginase dose. intervention 6: Given IV. intervention 7: Given IV. intervention 8: Given IV or IT. intervention 9: Given PO. intervention 10: Given IV. intervention 11: Given IV, IM or IT. intervention 12: Given PO. intervention 13: Given PO or IV. intervention 14: Given IT. intervention 15: Given IV.

Protocol documents:
Prot_SAP_000.pdf: 
NHL16
SJCRH
NHL16 CTG# - NCT01451515
Initial version, dated November 11, 2010.  Resubmitted to BPRC February 21, 2011.Resubmitted to CT-
SRC May 17, 2011.  Resubmitted to the IRB June 30, 2011
(IRB Approved: August 4, 2011)
Amendment 1.0, dated September 19, 2011.  Resubmitted to IRB January 25, 2012
(IRB Approved: January 31, 2012).  Activated: May 4, 2012
Amendment 2.0, dated April 8, 2013.  (IRB approved: May 27, 2013)
Revision 2.1, dated June 14, 2013.  (IRB approved: June 28, 2013).  Activated: July 11, 2013
Amendment 3.0, dated May 5, 2014. (IRB approved: June 10, 2014) Activated: July 15, 2014
Revision 3.1, dated March 3, 2015.  (IRB approved: March 27, 2015) Activated: June 3, 2015
NHL16 STUDY FOR NEWLY DIAGNOSED PATIENTS WITH ACUTE 
LYMPHOBLASTIC LYMPHOMA
Principal Investigator
Hiroto Inaba, MD, PhD
Department of Oncology
Co-Principal Investigator
John T. Sandlund, MD
Department of Oncology
Sub-Investigators
Oncology
Monika Metzger, MD
Raul C. Ribeiro, MD
Pharmaceutical Sciences
Jennifer Pauley, PharmD
Pathology
Charles G. Mullighan, 
MBBS(Hons), MSc, MD
John K. Choi, MD, PhD
Radiological Sciences
Sue Kaste, DO
Larry E. Kun, MD
Barry L. Shulkin, MD, MBA
Biostatistics
Cheng Cheng, PhD
Yinmei Zhou, MS
Cancer Prevention and Control
Daniel M. Green, MD 
Melissa M. Hudson, MD
External Scientific Collaborators – National University of Singapore
Dario Campana, MD, PhD.
Elaine Coustan-Smith, MSc
St. Jude Children’s Research Hospital
262 Danny Thomas Place
Memphis, TN  38105
Telephone (901) 595-3300
This is a confidential research document.  No information may be extracted without permission of the Principal Investigator


NHL16
Revision 3.1, dated 03-03-2015
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Protocol version, dated 03-03-2015
Collaborating Sites
Investigator/Institutions Contact Information
Jeffrey Taub, MD
Meret Henry MD
Children’s Hospital of Michigan
3901 Beaubien Blvd.
Detroit, MI 48201
Catherine E. Madigan, M.D.
UCSD School of Medicine
Rady Children's Hospital-San Diego
3020 Children's Way, MC #5035 
San Diego, CA 92123
Kenneth Heym, MD
Cook Children’s Medical Center
Hematology/Oncology
1500 Cooper St.
Fort Worth, TX 76104


NHL16
Revision 3.1, dated 03-03-2015
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Protocol version, dated 03-03-2015
Protocol Summary
NHL16 STUDY FOR NEWLY DIAGNOSED PATIENTS WITH ACUTE LYMPHOBLASTIC 
LYMPHOMA
Principal Investigator: Hiroto Inaba, M.D., Ph.D.
IND holder: Not applicable, non-IND study.  St. Jude is the study sponsor
Brief overview:  This is a phase II clinical trial using risk-adapted therapy.  The treatment is ALL-
based therapy, using multi-agent regimens comprising of induction, consolidation, and continuation 
(maintenance) phases delivered over 24-30 months.  Participants will be classified into 3 treatment 
stratums, based on bone marrow/peripheral blood lymphoma cells involvement at diagnosis and day 8 
for T-lymphoblastic lymphoma and bone marrow/peripheral blood lymphoma cells involvement at 
diagnosis for B-lymphoblastic lymphoma. 
Intervention: Multi-agent chemotherapy based on treatment stratum (Stratum 1, 2, or 3).  Treatment 
will consist of 3 main phases: remission induction, consolidation (only for patients with any CNS 
disease and/or testicular involvement), and continuation 
Objectives:
Primary objective
1. To improve the outcome of children with lymphoblastic lymphoma (LL) who have minimal 
disseminated disease (MDD) equal to or more than 1% at diagnosis by using MDD- and 
minimal residual disease (MRD)- based risk-adapted therapy.
Secondary objectives
1. To determine event-free and overall survival
2. To determine prognostic value of MDD at diagnosis and MRD on day 8 of remission induction
Exploratory objectives
1. To estimate frequency of early T-cell progenitors in LL
2. To evaluate, copy number, gene expression, and mutations in tumor and normal tissues
3. To compare immunophenotyping, MRD, and genomic data between T-LL and T-ALL
4. To estimate and monitor bone mineral density and osteonecrosis
5. To establish prevalence of fertility and cardiac adverse late effects
Criteria for evaluation: The response evaluation will be based on the multidisciplinary (oncologist, 
pathologist and radiologist) interpretation of physical examination, laboratory and diagnostic imaging 
and response criteria listed in Section 12.1 of the protocol.  Toxicity and performance reporting will be 
according to CTCAE Version 4.0.
Study design:   Multi-center, non-randomized phase II study utilizing risk-adapted multi-agent 
chemotherapy.
Study population:  Participants < 21 years of age with newly diagnosed lymphoblastic lymphoma (LL)
Sample size:  72 participants in approximately 10.5 years.
Randomization:  N/A


NHL16
Revision 3.1, dated 03-03-2015
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Protocol version, dated 03-03-2015
NHL16 STUDY FOR NEWLY DIAGNOSED PATIENTS WITH ACUTE LYMPHOBLASTIC 
LYMPHOMA
Data analyses: Outcome of this subset of patients will be analyzed in terms of overall survival (OS) and 
event-free survival (EFS) since diagnosis. Only death will be considered a failure for OS. 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. Kaplan-
Meier estimates of the OS and EFS curves will be computed, along with estimates of standard errors by 
the method of Peto.  Analysis will begin after 2 years of follow up since the completion of therapy of the 
last enrolled patient.
Anticipated primary completion date:  September 2023
Anticipated study completion date:  September 2023
Time frame for primary outcome measure:  September 2023
Data management: Data management and statistical analysis will be provided by the Comprehensive 
Cancer Center clinical research staff (Leukemia/Lymphoma Division) and Biostatistics Department at St. 
Jude Children’s Research Hospital.
Human subjects: The risks to participants will be related to the toxicity of multi-agent chemotherapy.    
Participants will be informed of this and other potential side effects during informed consent.  Adverse 
events will be monitored and reported and treated appropriately.


NHL16
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Table of Contents
1.0
OBJECTIVES........................................................................................................1
1.1
Primary Objective............................................................................................................1
1.2
Secondary Objectives ......................................................................................................1
1.3
Exploratory Objectives ....................................................................................................1
2.0
BACKGROUND AND RATIONALE .................................................................2
2.1
Therapy............................................................................................................................2
2.2
Pharmacologic Studies.....................................................................................................9
2.3
Biologic Studies...............................................................................................................9
2.4
Bone Mineral Density (BMD).......................................................................................13
2.5
Anthracycline Cardiotoxicity.........................................................................................13
2.6
Gonadal and Reproductive Function .............................................................................14
2.7
Inclusion of Women and Minorities..............................................................................15
3.0
ELIGIBILITY CRITERIA AND STUDY ENROLLMENT...........................15
3.1
Inclusion Criteria ...........................................................................................................15
3.2
Exclusion Criteria ..........................................................................................................16
3.3
Recruitment and Screening of Research Participants....................................................16
3.4
Enrollment On Study at St. Jude....................................................................................16
3.5
Enrollment On Study at Collaborating Sites .................................................................16
4.0
RISK CLASSIFICATION ..................................................................................17
4.1
Criteria for Stratum 1 (approximately 70% of patients)................................................17
4.2
Criteria for Stratum 2 (approximately 15% of patients)................................................17
4.3
Criterion for Stratum 3 (approximately 15% of patients)..............................................17
5.0
TREATMENT PLAN..........................................................................................18
5.1
Intrathecal Chemotherapy..............................................................................................18
5.2
Remission Induction Treatment (6 to 7 weeks).............................................................19
5.3
Consolidation Treatment (10 weeks).............................................................................21
5.4
Reintensification Treatment...........................................................................................24
5.5
Continuation Treatment.................................................................................................25
5.6
Hematopoietic stem cell transplantation........................................................................30
6.0
DRUG INFORMATION.....................................................................................31
6.1
Drug Shortages/Unavailability ......................................................................................31
7.0
TREATMENT MODIFICATIONS...................................................................31
7.1
Patients with Down Syndrome ......................................................................................31
7.2
Renal Dysfunction .........................................................................................................32
7.3
Hepatic Dysfunction ......................................................................................................32
7.4
Obesity...........................................................................................................................32
7.5
Testicular Involvement at Diagnosis .............................................................................32
7.6
Vincristine Neurotoxicity ..............................................................................................33
7.7
Venous Thromboembolism ...........................................................................................33
7.8
Osteonecrosis of Bone ...................................................................................................33
7.9
PEG-asparaginase..........................................................................................................34
7.10
TPMT Status and Thiopurine Dosage ...........................................................................34
7.11
Pancreatitis.....................................................................................................................35


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8.0
DOSE MODIFICATIONS DURING CONTINUATION THERAPY ...........35
8.1
Dose Modifications for Inadequate Myelosuppression .................................................36
8.2
Dose Decreases Based on Mercaptopurine Pharmacology ...........................................36
9.0
CONTINGENCY PLANS FOR REFRACTORY DISEASE OR RELAPSE36
9.1
Induction Failures ..........................................................................................................36
9.2
Relapse...........................................................................................................................37
9.3
Emergence of CSF Lymphoblasts During Remission Requiring CNS Radiation.........37
10.0
PHARMACOKINETIC AND PHARMACODYNAMIC STUDIES .............37
10.1
High-Dose Methotrexate (HD-MTX)............................................................................37
11.0
EVALUATIONS, TESTS, AND OBSERVATIONS........................................38
11.1
Pretreatment Evaluation.................................................................................................38
11.2
Required Evaluations, Tests, and Observations During Treatment...............................39
11.3
Suggested Off-Therapy Evaluations..............................................................................41
11.4
Suggested Long-Term Follow-up Evaluations..............................................................41
12.0
EVALUATION CRITERIA ...............................................................................42
12.1
Response Criteria...........................................................................................................42
12.2
Toxicity Evaluation Criteria ..........................................................................................44
12.3
Acceptable Percentage of Missed Doses for Commercially Available Drugs ..............44
13.0
SUPPORTIVE CARE .........................................................................................44
13.1
Fever at Diagnosis .........................................................................................................44
13.2
Metabolic Derangements...............................................................................................45
13.3
Management of Airway Obstruction and Superior Vena Cava Syndrome....................45
13.4
Osteonecrosis of the Bone .............................................................................................45
13.5
Pancytopenias ................................................................................................................46
13.6
Nutritional Supplementation..........................................................................................46
13.7
Drug Interactions ...........................................................................................................46
13.8
Down Syndrome ............................................................................................................46
13.9
Respiratory Syncytial Virus (RSV) Prophylaxis ...........................................................47
14.0 
OFF THERAPY AND OFF STUDY CRITERIA.............................................47
14.1
Off-Treatment Criteria...................................................................................................47
14.2
Off-Study Criteria..........................................................................................................47
15.0
BIOLOGIC STUDIES.........................................................................................48
15.1
Minimal Disseminated Disease (MDD) and Minimal Residual Disease (MRD)..........48
15.2
Early T-cell Progenitor Phenotype ................................................................................48
15.3
Gene Expression Analysis .............................................................................................48
15.4
Copy Number Alteration ...............................................................................................49
15.5
Mutation Analysis..........................................................................................................49
15.6
Genomic Comparison between T-Lymphoblastic Lymphoma and T-ALL ..................49
16.0
STATISTICAL CONSIDERATIONS...............................................................50
16.1
Primary Objective..........................................................................................................50
16.2 
Secondary Objectives ....................................................................................................50
17.0
SAFETY AND ADVERSE EVENT REPORTING REQUIREMENTS........54
17.1
Reporting Adverse Experiences (AEs) and Deaths.......................................................54
17.2
Recording Adverse Events and Serious Adverse Events ..............................................56
17.3
Process for Reporting AEs from Collaborating Sites to St. Jude and from St. Jude to 
Collaborating Sites.....................................................................................................................56


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18.0
INFORMED CONSENT PROCESS .................................................................58
18.1
Consent at Enrollment and Post-Remission Therapy ....................................................58
18.2
Consent at Age of Majority ...........................................................................................59
18.3
Consent when English is Not the Primary Language ....................................................59
19.0
DATA COLLECTION, STUDY MONITORING AND CONFIDENTIALITY
60
19.1
Data Collection ..............................................................................................................60
19.2
Data Collection Instructions for Collaborating Sites.....................................................60
19.3
Study Monitoring...........................................................................................................60
19.4
Confidentiality ...............................................................................................................61
20.0
REFERENCES ....................................................................................................62
Appendices
APPENDIX I:
TREATMENT SCHEMAS AND SPECIAL LABORATORY TESTS
APPENDIX II: DRUG INFORMATION
APPENDIX III: DEFINITIONS RELATED TO INFECTIOUS DISEASES
APPENDIX IV: TESTS/EVALUATIONS/PROCEDURES PERFORMED FOR STANDARD      
    OF CARE AND FOR RESEARCH
 


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1.0
OBJECTIVES
1.1
Primary Objective
To improve the outcome of children with lymphoblastic lymphoma who have 
minimal disseminated disease (MDD) equal to or more than 1% at diagnosis by using 
MDD- and minimal residual disease (MRD)– based risk-adapted chemotherapy.
1.2
Secondary Objectives
1.2.1
To estimate the event-free survival and overall survival of children with 
lymphoblastic lymphoma who are treated with MDD- or MRD-based risk-
directed therapy.
1.2.2
To evaluate the prognostic value of levels of MDD at diagnosis and MRD 
on day 8 of remission induction.
1.3
Exploratory Objectives
1.3.1
To estimate the frequency of early T-cell progenitors in lymphoblastic 
lymphoma.
1.3.1
To evaluate copy number, gene expression, and mutations in tumor and 
normal tissues of patients.
1.3.2
To compare the immunophenotyping, MRD, and genomic data between T- 
lymphoblastic lymphoma and T-acute lymphoblastic leukemia (ALL).
1.3.3
Bone mineral density (BMD) and osteonecrosis
1.3.3.1 To prospectively estimate BMD at diagnosis and at end of therapy 
and correlate with risk factors for potential BMD deficits in pediatric 
patients with NHL.
1.3.3.2 To prospectively monitor osteonecrosis and correlate with risk 
factors for potential osteonecrosis in pediatric patients with NHL.
1.3.4
Fertility late effects
To establish the prevalence of gonadal and germ cell dysfunction in 
children treated with this regimen. 
1.3.5
Cardiac late effects
To establish the prevalence and severity of cardiac toxicity associated with 
this regimen.


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2.0
BACKGROUND AND RATIONALE
2.1
Therapy
2.1.1
Patients with advanced-stage lymphoblastic lymphoma
The majority of successful regimens designed to treat advanced-stage lymphoblastic 
lymphoma are derived from regimens designed to treat ALL. They are multiagent 
regimens comprising induction, consolidation, and maintenance phases delivered over 
18–30 months. Although involved field irradiation of the primary tumor site was included 
to treat residual mediastinal masses in earlier trials, it is generally not recommended in 
contemporary protocols due to associated late effects.
The Children Cancer Study Group (CCSG) performed an important randomized clinical 
trial to compare the cyclophosphamide-based 4-drug regimen COMP and the 10-drug 
LSA2L2 regimen.1-3 COMP was a lymphoma-based regimen and LSA2L2 was designed 
for ALL therapy. Outcomes of patients with stage 3 or 4 disease were significantly 
related to treatment arm and histology. The LSA2L2 regimen (ALL approach) was 
superior to COMP for lymphoblastic lymphoma [5-year event-free survival (EFS) 64% 
vs. 35%], whereas the COMP regimen was superior to LSA2L2 for Burkitt lymphoma (5-
year EFS 50% vs. 29%).
The early St. Jude study Total X-high risk demonstrated the survival efficacy of the 
addition of cytarabine and teniposide to an otherwise standard antimetabolite-based ALL 
regimen.4 Patients enrolled on the more recent St. Jude study NHL 13, which was based 
on our regimen for childhood T-lymphoblastic leukemia, had a 5-year EFS of 82.9% and 
overall survival (OS) of 90.2%.5 The regimen included induction, consolidation, 
continuation, and reinduction phases and used high-dose methotrexate (HD-MTX) and 
etoposide. Epipodophyllotoxins have also been used in other protocols,6,7 but have been 
omitted from recent regimens because of the risk of secondary leukemia.
There has been continued controversy about the role of HD-MTX in the management of 
advanced-stage lymphoblastic lymphoma. Excellent results were achieved with use of the 
LMT81 regimen of the French cooperative group (SFOP) when multiple courses of HD-
MTX (3g/m2/course) were added onto an LSA2L2 backbone.8 The BFM 90 regimen 
included 4 courses of HD-MTX (5g/m2/dose) as a consolidation phase and produced one 
of the best outcomes to date (5-year EFS for stage III 90% and stage IV 95%).9 The 
Pediatric Oncology Group (POG) 9404 regimen, which examined the role of HD-MTX in 
a backbone of intensive doxorubicin and weekly L-asparaginase, was terminated early 
because of an inferior outcome for children with T-ALL in the arm without HD-MTX.10 
Although the POG study was not powered to examine the impact of HD-MTX in 
advanced-stage precursor T-lymphoblastic lymphoma, the 5 year-EFS was higher among 
patients not receiving HD-MTX (87.8%) than those receiving it (78.1%) (p=0.1057). In 
contrast, a recently completed Children’s Oncology Group (COG) study (A5971) 
examining the role of HD-MTX in a BFM backbone reported no significant difference 


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between 3-year EFS of patients receiving  (84.5%) or not receiving HD-MTX (82.7%) 
(p=0.93).11 
Asparaginase is thought to be an important component of effective lymphoblastic 
lymphoma therapy. The POG 8704 study demonstrated a survival advantage for patients 
who received an additional 20 weekly doses of L-asparaginase after consolidation 
therapy.6 In the Dana-Farber Consortium Protocol 91-01 ALL study, patients who 
received at least 26 weeks of asparaginase had a significantly better outcome than those 
who received 25 or fewer weeks of asparaginase.12 Anthracyclines are also thought to be 
important in the treatment of precursor T-cell ALL and lymphoblastic lymphoma,13 and 
the use of anthracyclines in reinduction (delayed intensification) phases may also 
improve outcome, a strategy used in the BFM regimens, COG A5971, and St. Jude Total 
studies.9,11,14
Prophylactic cranial irradiation was not used in BFM 95, but the outcome of patients on 
BFM 95 was not inferior to that of patients on BFM90/86 therapies.15 St. Jude NHL13 
included intensive intrathecal (IT) chemotherapy for central nervous system (CNS) 
therapy and excluded prophylactic cranial radiation.5 St. Jude TOTXV14 and the Dutch 
Childhood Oncology Group (DCOG) ALL-916 studies showed that cranial irradiation can 
be safely eliminated from ALL treatment if effective risk-directed chemotherapy and IT 
therapy is given. The 5-year cumulative risk of isolated CNS relapse in patients in these 
studies was 2.7% and 2.6%, respectively, which is within the range (1.5% to 4.5%) of 
risk of CNS relapse observed in clinical trials that use prophylactic cranial irradiation. 
The treatment regimen that we have developed for NHL16 is based on the knowledge 
acquired from previous trials and from new evidence indicating that minimal 
disseminated disease (MDD) at diagnosis as measured by flow cytometry is 
prognostically important. In NHL 16, we will adopt the modified St. Jude frontline ALL 
protocol TOTXVI approach. PEG-asparaginase will be given every 2 weeks for 30 weeks 
(15 doses) without interruption (36 weeks and 18 doses for patients who have CNS 
disease and/or testicular involvement and receive consolidation therapy). Fractionated 
cyclophosphamide will be given to patients with MDD ≥1% at diagnosis and any CNS 
and/or testicular involvement. Patients with T-lymphoblastic lymphoma who had MDD 
≥1% at diagnosis and positive day 8 MRD (≥0.01%) will receive dexamethasone instead 
of prednisone during induction on days 15-28. HD-MTX will not be used for patients 
who do not have CNS disease and/or testicular involvement.  For patients with CNS 
disease and/or testicular involvement, 4 doses of HD-MTX will be used after remission-
induction therapy. No cranial or craniospinal radiation or residual mass irradiation will be 
used. Treatment will be completed in 24 months (98 weeks of continuation therapy) for 
patients with MDD <1% at diagnosis and in patients with MDD ≥1% but with negative 
MRD on day 8. Patients with MDD ≥1% and positive MRD on day 8 or those with CNS 
disease and/or testicular involvement will receive 22 additional weeks of continuation 
therapy for a total of 120 weeks.


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2.1.2
Patients with limited-stage disease
Because of the rarity of early-stage lymphoblastic lymphoma, most of the published 
outcome data combine cases of precursor B- and precursor T-lymphoblastic lymphoma. 
In a study by Link et al., patients with limited-stage disease were randomized to receive 
the same 9 weeks of CHOP chemotherapy with or without the 24-week maintenance 
phase.17 This study demonstrated that the maintenance phase could be safely eliminated 
for patients with Burkitt or diffuse large cell lymphoma, but that maintenance benefited 
those with lymphoblastic lymphoma. Patients with B-precursor lymphoblastic lymphoma 
on NHL-BFM 86 and 90 were treated with either an intensive “ALL-type” or shorter 
“Burkitt lymphoma–type” regimen.18  The ALL-type approach, which was similar to that 
used in T-lymphoblastic lymphoma (BFM-90), was superior to the short-pulse Burkitt 
lymphoma–type strategy. 
The COG A5971 study used uniform ALL-based therapy to treat patients with localized 
lymphoblastic lymphoma; most patients (79%) with localized disease had a pre-B 
immunophenotype.19  With 24 months of CCG BFM therapy without the 4 additional day 
28 IT therapies with methotrexate during maintenance, 5-year EFS and OS rates were 
85% and 94%, respectively. EFS rates were similar to those of patients with advanced 
disease, which supports the need for intensive treatment in this population.
In NHL16, patients with limited-stage lymphoblastic lymphoma will be treated by the 
same strategy used for those with advanced-stage disease, except that high-dose 
cytarabine will not be given in reinduction II. PEG-asparaginase will be given every 2 
weeks for 30 weeks (15 doses) without interruption. Fractionated cyclophosphamide will 
be given only to patients with MDD ≥1% at diagnosis. No high-dose MTX will be given. 
Treatment will be completed in 24 months (98 weeks of continuation therapy) in patients 
with MDD <1% at diagnosis and patients with MDD ≥1% and negative MRD on day 8. 
Patients with MDD ≥1% and positive MRD on day 8 will receive 120 weeks of 
continuation therapy.
2.1.3
Remission induction
Remission induction therapy will consist of 3 weeks of prednisone, vincristine, 
daunorubicin, and PEG-asparaginase, followed by 2 weeks of cyclophosphamide, 
cytarabine, thioguanine, and PEG-asparaginase combinations. This remission induction 
regimen is similar to that used in the St. Jude ALL TOTXVI study, except for the 
following modifications: 
(a) Intramuscular PEG-asparaginase will be given every 2 weeks during induction 
without interruption.
(b) Cyclophosphamide therapy will be intensified in patients with MDD ≥1% or 
morphologic BM involvement at diagnosis. Fractionated cyclophosphamide is 
widely used in adult ALL protocols, and has proven safe and effective in children 
with Burkitt leukemia/lymphoma and relapsed ALL.


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(c) Patients with MDD ≥1% and detectable MRD on day 8 will receive 
dexamethasone instead of prednisone during days 15–28 of remission induction 
therapy. The use of dexamethasone during induction therapy has been associated 
with superior outcome in patients with T-ALL in the ALL 2000 Berlin-Frankfürt-
Münster/Associazione Italiana Ematologia Oncologia Pediatrica (BFM/AIEOP) 
study.20 
2.1.4 Consolidation therapy
A recently completed COG study (A5971) examining the role of HD-MTX in a BFM 
backbone reported no significant difference between 3-year EFS of patients receiving  
(84.5%) or not receiving HD-MTX (82.7%) (p=0.93).11 On this basis, patients in NHL 16 
who do not have CNS disease and/or testicular involvement will not receive consolidation 
therapy with HD-MTX and will immediately proceed to continuation therapy. 
For patients with CNS disease and/or testicular involvement, consolidation therapy will 
consist of HD-MTX (average of 5 g/m2 over 24 h) given every alternate week for 4 doses 
with leucovorin rescue, together with IT treatment plus concomitant daily 
mercaptopurine (50 mg/m2) as well as PEG-asparaginase every 2 weeks. The feasibility 
and effectiveness of HD-MTX at 5 g/m2 have been documented in large numbers of 
patients treated in BFM and St. Jude Total studies.14,21 
Intercourse targeting of HD-MTX in the standard- and high-risk arms in TOTXV resulted 
in 23% of courses being below, 62% being within, and 15% being above the target range 
of 65 µM ± 20%. Also, an acceptably low proportion of courses (15%) were associated 
with “delayed excretion” (42-h plasma MTX concentration >1.0 µM). Targeting the 
standard- and high-risk arms avoided extreme exposures relative to simulated 
conventional dosing:  3% versus 0% with steady-state concentrations <40% of the target 
and 3% versus 10% with steady-state-concentrations >40% of the target for targeted and 
simulated conventional dosing, respectively. The median 42-h concentration in the 
standard- and high-risk arms was 0.54 µM, which is close to that reported (0.43 µM) by 
the BFM group. Moreover, the leucovorin rescue administered in the TOTXV and the 
BFM studies was similar, but toxicity was substantially lower in TOTXV (~4% grade 3 
or 4 mucositis) than the BFM study (44% grade 3 or 4 mucositis).  Thus, it appears that 
there may be more benefit in avoiding extremes of exposure in the standard- and high-
risk arms than the low-risk arm, even though target concentrations are better achieved in 
the low-risk arm. 
For NHL16, HD-MTX will be targeted in order to continue to avoid unacceptably low 
concentrations (albeit in a small percentage of courses), minimize unacceptably high 
concentrations, avoid gastrointestinal (GI) toxicity, and maintain the majority of courses 
within the desired target range. By using this approach in TOTXV, only 5.1% of courses 
were associated with grade 3-4 mucositis (compared to 44% of courses with administration 
of 5 g/m2 HD-MTX without targeting in the BFM study) in patients with ALL.


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One of our earlier studies has shown that for targeting intercourse HD-MTX, it is not 
possible to keep all courses within ±20% of the target, as achievable for intra-course HD-
MTX targeting.22 We modified TOTXV to allow intra-course targeting of HD-MTX 
when possible, but have been able to target only a few cases because it is logistically 
difficult to start HD-MTX early enough in the day to allow feasible intra-course 
targeting. However, according to our calculations based on simulations that used the 
previous MTX clearance along with a 2-h MTX plasma concentration to target steady-
state concentrations, 1% of courses would be below, 91% would be within, and 8% 
would be above the target range. Thus, for patients who have experienced renal 
dysfunction, require concurrent drugs that might affect MTX clearance, or who are 
otherwise unstable, we will employ intra-course targeting of HD-MTX.
2.1.5
Continuation treatment
Continuation therapy will start after remission induction therapy for patients without 
CNS and/or testicular involvement and after consolidation therapy for patients with 
CNS and/or testicular involvement.  
The continuation treatment for NHL 16 will incorporate effective treatment components 
of the most successful clinical ALL trials to date. In randomized trials of ALL, 
dexamethasone was superior to prednisone in reducing CNS relapse and improving EFS,  
partly because it has a better CNS penetration.23,24 Intensifying asparaginase therapy 
during the early phase of treatment improved outcome for all risk groups in the DFCI 
studies.12 
PEG-asparaginase is increasingly used in frontline ALL regimens. In NHL16, patients 
without CNS disease and/or testicular involvement will receive PEG-asparaginase every 
2 weeks for a total of 15 doses during the first 30 weeks (until week 23 of continuation 
therapy). We will evaluate the efficacy and feasibility of this approach. Patients who 
received consolidation therapy (patients with CNS and/or testicular disease) will receive 
PEG-asparaginase for a total of 18 doses for the first 36 weeks (until reinduction II, week 
19). Although the optimal dose of different preparations of asparaginase is not firmly 
established, similar EFS has been reported with PEG-asparaginase 2500 units/m2 and 
native L-asparaginase at 6000 units/m2 for 6 doses. Hence, for PEG-asparaginase, the 
dose of 2500 units/m2 has been widely adopted.
As in TOTXV,14 use of epipodophyllotoxins will be limited to patients with high-risk 
lymphoma [biopsy-proven detectable disease by positron emission tomography / 
computed tomography (PET/CT) scan, bone marrow morphology, or MRD (≥0.01%) of 
bone marrow or peripheral blood at the end of induction or thereafter] in NHL16 to 
decrease the risk of therapy-related leukemia. Cyclophosphamide and anthracyclines will 
be used to intensify treatment. However, the total cumulative dose of cyclophosphamide 
will be limited to 4.0 (no fractionation) to 4.2 gm/m2 (fractionation) for reducing the 
problem of sterility (especially in boys). Anthracycline cumulative dosage will be limited 
to 230 mg/m2, as this dosage is associated with a very low risk of cardiomyopathy. After 


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week 61, all patients will receive daily mercaptopurine and weekly methotrexate until 
end of therapy.
Reinduction treatment is an integral component of most contemporary ALL trials, with 
benefits extending to low-risk cases.  A CCG study showed that an augmented BFM 
regimen (equivalent to the use of double reinduction) can even abolish the adverse 
prognostic impact of poor early response.25  Hence, in NHL16, patients will receive 2 
courses of reinduction but those with limited-stage B-lymphoblastic lymphoma will not 
receive high-dose cytarabine.
The majority of patients will receive 98 weeks of continuation therapy. Patients with 
MDD ≥1% at diagnosis as well as the presence of any detectable lymphoma blasts by 
MRD study (≥0.01%) on day 8 or thereafter, any CNS involvement (CNS-2 and 3, and 
traumatic tap with blasts), and testicular involvement are an indication that 120 weeks of 
continuation therapy is required.
2.1.6
Rationale for modifications in mercaptopurine administration (Revision 3.1)
Prior studies assessing the pharmacological and therapeutic impact of giving oral 
mercaptopurine (MP) with food or with dairy products, or giving 6MP at different times of 
day have produced variable results.  All of the early studies enrolled small numbers of 
patients and revealed trends in differences in peak plasma concentrations of parent drug or 
plasma area-under-the-concentration-time curve (AUC), but these results were not 
statistically significant26-28.  Other studies29,30 reported statistically significant differences in 
time of maximum drug concentration in plasma (tmax)  and  AUC in the fasting state of 
parent drug29 or changes in ALL disease free survival30 associated with time of day of oral 
6MP administration (with better results reported for nighttime drug administration in that 
the risk of relapse was 4.6 times greater with the morning administration schedule).  
However, these older studies did not assess these variables in the context of treatment 
protocols that utilize erythrocyte thioguanine nucleotides (TGN) levels to guide therapy 
adjustments, nor did they include thiopurine dosing as part of multivariate analyses for 
outcome predictors.  A more recent study of 532 patients by Schmiegelow, et al used a 
Cox multivariate model to show that the circadian schedule (morning vs. evening vs. 
mixed) of MTX/6MP was not of prognostic significance for the risk of relapse, and the 
10-year cumulative relapse risk was below 20% in all groups31. 
A separate recent study assessed the effects of “pill-taking” habits on treatment 
adherence, erythrocyte TGN levels & relapse risk in 441 children enrolled on the COG 
AALL03N1 study32.  This study reported no association between relapse risk and 
whether 6MP was taken with food (p=0.5), with dairy (p=0.2), whether tablets were 
swallowed whole vs. crushing/chewing (p=0.7); iv), or time of day: evening/night vs. 
morning/mid-day (p=0.9), varying times vs. non-varying times (p=0.9). The 6MP taking 
habits were also not associated with DI- and age-adjusted TGN levels.   The authors 
concluded that the commonly practiced restrictions concerning administration with food 
or at bedtime did not significantly influence outcome in their protocol and patient cohort.


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Based on these larger and newer studies, that include more careful attention to 6MP dosing 
than was true in the earlier studies, and on the fact that 6MP dose is adjusted to desired 
blood counts, we propose to lift the restrictions concerning administering MP at bedtime 
and on an empty stomach to allow patients to take 6MP at a time of day which is most 
likely to yield full adherence to the prescribed daily dosing of 6MP.  As for any daily drug, 
we recommend that parents administer and/or patients take 6MP at a consistent time every 
day. We also strongly recommend that erythrocyte TGN levels continue to be monitored to 
guide 6MP therapy (detect non-adherence and/or inappropriate dosing). Likewise, TPMT 
phenotype/genotype should continue to be assessed for each patient to guide the selection 
of optimal 6MP dosages for each patient.  Finally, ALL continuation therapy should 
continue to be guided by measurement of WBC throughout therapy, with dosage adjusted 
made as stipulated in the primary ALL treatment protocol26-34. 
2.1.7
Subclinical CNS treatment
Since CNS irradiation can induce serious long-term sequelae such as growth retardation, 
intellectual impairment, and brain tumors, and in view of the excellent CNS control 
achieved in TOTXV and NHL 13,5,14 CNS irradiation will be eliminated in NHL16.
The overall 5-year cumulative risk of CNS relapse was 2.7% in TOTXV, which is 
comparable to that reported by studies still using preventive CNS irradiation.14 This 
success is attributed to early intensification of IT treatment (especially in patients at high 
risk of relapse) and effective systemic treatment, including the use of dexamethasone.  In 
NHL16, IT treatment will be intensified during induction treatment, with 2 additional IT 
treatments on days 8 and 22 for patients with any T-lymphoblastic lymphoma, advanced 
stage (stages III and IV) B-lymphoblastic lymphoma, or with any amount of leukemic 
blasts identifiable in the cerebrospinal fluid at diagnosis (including those with 
cerebrospinal fluid contaminated with lymphoma blast cells due to a traumatic lumbar 
puncture). Patients with any CNS involvement and testicular involvement will receive 
consolidation therapy with 4 courses of HD-MTX and triple intrathecal chemotherapy 
(IT-MHA). During continuation therapy, patients with limited stage (stages I and II) B-
lymphoblastic lymphoma with CNS-1 status will receive 14 (total 16) and those with T-
lymphoblastic lymphoma and advanced stage (stages III and IV) B-lymphoblastic 
lymphoma with CNS-1 status will receive 19 (total 23) doses of IT-MHA. Patients with 
any CNS involvement (CNS-3 status, CNS-2 status, traumatic tap with blasts), or 
testicular involvement will receive 17 (total 25) doses of IT therapy.
As in TOTXVI, preventive CNS irradiation will be eliminated altogether in this study, 
except in rare cases in who during continuation treatment have morphologic evidence of 
lymphoblasts in the CSF, confirmed by immunologic testing (i.e., TdT) on 2 separate 
occasions. We expect these events to be very rare; no patient had slow clearance of CSF 
blasts during remission induction in TOTXV.14
Patients who during continuation treatment have morphologic evidence of lymphoblasts in 
the CSF, confirmed by immunologic testing (i.e., TdT) on 2 separate occasions will be 
managed according to guidelines given in section 9.3.


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2.2
Pharmacologic Studies
2.2.1
Germline genetic polymorphisms
The thiopurine methyltransferase (TPMT) gene exhibits genetic polymorphism, with <1% 
of the population homozygous and 10% heterozygous for the deficiency. We have used 
TPMT status to individualize dosages for continuation therapy since 1991 in patients with 
ALL enrolled at St. Jude. For NHL 16, we will assess patients for TPMT phenotype and 
genotype, and use these data (along with data on clinical tolerance of chemotherapy and 
measurements of active thiopurine metabolites in red blood cells) as part of our algorithm 
to determine dosage adjustment during continuation therapy. Also, 6-mercaptopurine will 
be given instead of thioguanine during remission induction for patients with homozygous 
or heterozygous TPMT polymorphisms.
2.3
Biologic Studies
2.3.1
Minimal disseminated disease and minimal residual disease
Approximately 15% of children with T-lymphoblastic lymphoma can have disease 
dissemination at diagnosis.35 Until recently, it was unclear whether the remaining patients 
have submicroscopic systemic disease, and, if so, the prognostic importance of this 
finding. We developed a flow cytometric method that allows the detection of 1 T-
lymphoma cell in 10,000 normal cells and used it to examine bone marrow and peripheral 
blood samples collected at diagnosis from 99 children with T-LL enrolled in the COG 
A5971 study, as well as 174 peripheral blood samples collected from 48 patients during 
remission induction therapy.35  We detected T-lymphoma cells in 71 of the 99 (71.7%) 
diagnostic samples, ranging from 0.01% to 31.6% (median, 0.22%) of bone marrow 
mononuclear cells. Studies in bilateral aspirates agreed well with these diagnostic results. 
High levels of disease dissemination by flow cytometry were significantly associated 
with a poorer outcome: 2-year EFS was 68.1% ± 11.1% for patients with ≥1% 
lymphoblasts versus 90.7% ± 4.4% for the remaining patients (P = 0.031). In this study, 
chemotherapy was not modified based on lymphoma cell involvement at diagnosis. T-
lymphoma cells were as prevalent in peripheral blood as they were in bone marrow at 
diagnosis; monitoring of residual T-lymphoma cells in peripheral blood during remission 
induction therapy was able to identify patients with slow disease clearance and persistent 
disease. In summary, these results demonstrate that more than 66% of children with T-
lymphoblastic lymphoma have systemic disseminated disease at diagnosis, which is 
much higher than previously thought. Therefore, measurements of disease dissemination 
at diagnosis might provide useful prognostic information, which can be further refined by 
monitoring response to therapy through peripheral blood testing. In NHL16, we will use 
the same flow cytometry–based methodology to measure MDD at diagnosis and monitor 
MRD on day 8 of remission induction therapy.


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2.3.2
Early T-cell progenitor phenotype
We have hypothesized that T-ALL originating from early T-cell precursors (ETPs), a 
recently defined subset of thymocytes that retain stem cell–like features,36-38 will respond 
poorly to lymphoid cell–directed therapy.39 We studied leukemic cells collected at 
diagnosis from patients to identify cases with ETP features and determine their clinical 
outcome. Leukemic cells from 239 patients with T-ALL enrolled at St. Jude and in the 
Italian national study AIEOP ALL-2000 were examined by gene expression profiling, 
flow cytometry and, single nucleotide polymorphism array analysis.39  Probabilities of 
survival and treatment failure were calculated for subgroups considered to have ETP-ALL 
or typical T-ALL. Of the 239 patients, 30 (12.6%) had leukemic lymphoblasts with an 
ETP-related gene expression signature or its associated distinctive immunophenotype 
(CD1a, CD8–, CD5weak with stem-cell/myeloid markers). Cases of ETP-ALL showed 
increased genomic instability. Patients with this form of leukemia had very high rates of 
remission failure or hematologic relapse: 72% (95% confidence interval, 40%–100%) at 
10 years versus 10% (4%–16%) for typical T-ALL patients treated at St. Jude and 57% 
(25%–89%) at 2 years versus 14% (6%– 22%) for patients treated in the AIEOP trial.  
These results indicate that ETP-ALL is a distinct, previously unrecognized, pathobiologic 
entity that confers a dire prognosis when standard intensive chemotherapy is used.  On the 
basis of these results, ETP-ALL has been classified as “very-high-risk ALL” in TOTXVI. 
While studying MDD in patients with T-lymphoblastic lymphoma enrolled in the COG 
A5971 study, we noticed that disseminated cells in 4 of 54 (7.4%) cases studied with a 
full panel of antibodies suitable to identify ETP-ALL expressed the ETP phenotype; that 
is, cells were CD1a and CD8 negative, had low expression of CD5, and expressed stem 
cell- and myeloid-associated antigens.  Moreover, a survey of the limited 
immunophenotypic data collected on 134 primary tumors from patients enrolled in the 
same trial identified that 15 tumors were negative for CD1a and CD8 and are potential 
ETP candidates.  These results suggest that ETP malignancy can present as T- 
lymphoblastic lymphoma, leading us to hypothesize that most systemic relapses in 
children and adolescents with this disease occur in those with the ETP phenotype. In 
NHL16, we will systematically study T-lymphoma cells at diagnosis for the cell marker 
panel for ETP definition and determine the response to therapy and clinical outcome of 
patients with ETP-phenotype.
2.3.3
Gene expression analysis, copy number alteration, and mutation analysis in T-
lymphoblastic lymphoma and comparison with T-ALL
Data on genetic analyses, including gene expression, copy number alteration, and mutation 
analysis for T-lymphoblastic lymphoma, are very limited mainly because of the shortage of 
adequate vital tumor samples available.40 The comparison of T-lymphoblastic lymphoma 
and T-ALL profiles is difficult because of differences in the microenvironment of cells. In 
T-ALL, samples for analysis are readily available because the bone marrow or even blood 
samples can be used to isolate RNA or DNA. In contrast, in T-lymphoblastic lymphoma, 
RNA or DNA from malignant cells must be extracted from rarely available tumor biopsies 
(lymph nodes or mediastinal mass) or malignant effusions. 


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Raetz et al. conducted a DNA microarray analysis of the gene expression profiles of T-
lymphoblastic lymphoma and T-ALL samples obtained from Children's Oncology Group 
(COG) tumor banks.41 Unsupervised hierarchic clustering of all samples showed 
complete segregation of T-lymphoblastic lymphoma and T-ALL into distinct clusters. 
Next, a significance analysis of microarrays (a supervised statistical approach), was used 
to identify the 201 genes that best differentiated T-ALL from T-lymphoblastic lymphoma. 
Sixty-eight of these genes upregulated in T-lymphoblastic lymphoma encoded 
extracellular matrix proteins and adhesion molecules, and it was therefore considered that 
these genes might represent gene expression in intervening stroma cells and not in tumor 
cells. After excluding these 68 genes, a reanalysis was performed and 133 genes were 
identified that were expressed differentially in T-lymphoblastic lymphoma and T-ALL 
samples. Genes representing several functional groups were differentially expressed in T-
lymphoblastic lymphoma and T-ALL samples, but this set did not include classic T-cell 
differentiation genes, indicating that differences in the maturational stage were unlikely 
to explain the observed differences. In the T-lymphoblastic lymphoma samples, genes 
encoding adhesion molecules and extracellular matrix proteins were upregulated, which 
led the authors to suggest that the overexpression of adhesion molecules may – at least in 
part – occur within the lymphoma cells themselves. In addition, regulatory genes for 
proliferation and apoptosis were differentially expressed (e.g., overexpression of 
CARD10 in T-lymphoblastic lymphoma, which is involved in apoptotic regulation and 
NF-κB activation via BCL10, or MLL overexpression). 
In a second series, samples from 10 children with T-ALL and 8 with T-lymphoblastic 
lymphoma were available for comparative expressed sequence hybridization, which 
allowed identification of chromosomal regions corresponding to differential gene 
expression.42 RNA was isolated from the bone marrow in T-ALL samples or lymph node 
biopsies in T-lymphoblastic lymphoma samples and cohybridized with a reference sample 
of a RNA mixture isolated from 5 reactive lymph node biopsies. A median of 75 
differentially expressed chromosomal regions per case in T-ALL samples and a median of 
37 regions per case in T-lymphoblastic lymphoma samples were obtained. In general, T-
ALL samples showed more regions with downregulated expression (median, 39 regions) 
than with upregulated expression (median, 27 regions). However, in T-lymphoblastic 
lymphoma, there were fewer regions with downregulated expression (median, 6 regions) 
than with upregulated chromosomal expression (median, 27 regions). A significant number 
of genes overexpressed in T-lymphoblastic lymphoma samples were associated with cell 
adhesion functions, thereby possibly contributing to the differences in the clinical 
presentation of pediatric T-lymphoblastic lymphoma and T-ALL.
Schraders et al. used high-resolution single nucleotide polymorphism–based array 
comparative genomic hybridization to analyze copy number alterations in 12 children with 
T-lymphoblastic lymphoma and 7 with precursor B-cell lymphoblastic lymphoma.43 For 
the 12 T-lymphoblastic lymphoma cases, a total of 44 abnormalities were identified, 
resulting in an average of 3.6 genomic abnormalities (2.3 losses and 1.3 gains) per case. As 
observed previously in T-ALL, 92% of cases of T-lymphoblastic lymphoma exhibited 
recurrent deletions of the CDKN2A locus. Also, deletions of RB1 (16%), duplications of 
MYB (16%), and an amplification of ABL1 8% were detected. These results show that as 


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seen for T-ALL, genomic alterations in T-lymphoblastic lymphoma predominantly target 
genes involved in cell cycle progression. The majority (71%) of cases of precursor B-cell 
lymphoblastic lymphoma were characterized by high-hyperdiploidy and closely resembled 
cases of high-hyperdiploid precursor B-cell ALL.
NOTCH1 plays an essential role in T-cell maturation,44 and activating NOTCH1 
mutations have been reported in patients with T-ALL.45 Park et al. reported NOTCH1 
mutations in 6 of 14 (43%) children with pediatric T-lymphoblastic lymphoma, compared 
with 17 of 55 (31%) patients with T-ALL.46 Baleydier et al. reported mutations in 22 of 
41 (54%) patients with T-lymphoblastic lymphoma; of these, 9 pediatric patients were 
younger than 16 years, 6 (67%) of whom had NOTCH1 mutations.47 The prognostic 
relevance of NOTCH1 mutations in the outcome of patients with T-ALL and T-
lymphoblastic lymphoma is still open to debate, as the findings of different study groups 
have been inconclusive.40 In addition to NOTCH1 mutations, recent reports have shown 
that a significant number of patients with T-ALL (11% to 31%) harbor mutations of 
FBXW7.48,49 The FBXW7 locus encodes the E3 ubiquitin ligase FBXW7 (F-box and WD 
repeat domain containing 7), which is able to bind, ubiquitylate, and induce the 
proteasome-mediated degradation of intracellular NOTCH1. It was postulated that 
mutations of FBXW7 lead to reduced protein function and in turn to reduce NOTCH1 
degradation, resulting in increased NOTCH1 signaling. The only study comparing 
FBXW7 mutations in patients with T-lymphoblastic lymphoma and those with T-ALL 
showed that FBXW7 mutations were present in 3 of 14 (21%) children with T-
lymphoblastic lymphoma versus 8 of 55 (14.6%) children with T-ALL.46 Even though 
data are limited, it can be concluded that activating NOTCH1 mutations and FBXW7 
mutations can occur in T-lymphoblastic lymphoma, and their frequency of occurrence is 
likely similar to that of NOTCH1 and FBXW7 mutations in pediatric T-ALL. 
In T-ALL, translocations involving the TCR genes at chromosome 7q34 or 14q11 led to 
the identification of different oncogenes, which become activated when juxtaposed with 
TCR genes.40 These oncogenes include different types of transcription factors, such as 
basic helix-loop-helix (bHLH) genes (MYC, TAL1, TAL2, LYL1 and OLIG2); cysteine-
rich (LIM-domain containing) genes (LMO1 and LMO2); homeodomain genes (TLX1, 
TLX3, or HOXA gene cluster); or the MYB oncogene.40 Information on the presence of 
these oncogenes in T-lymphoblastic lymphoma is very limited. Baleydier et al. quantified 
oncogene expression in 41 patients with T-lymphoblastic lymphoma, including 9 patients 
younger than16 years.47 The predominant oncogene transcripts identified were HOXA9, 
LMO2, LYL1, TAL1 and TLX1, but none of the pediatric patients had TAL1 or TLX1 
overexpression.
The very few cases of T-lymphoblastic lymphoma analyzed limits us from drawing 
conclusions on the differences in the gene expression profiles of children with T-
lymphoblastic lymphoma and T-ALL. To date, no single biologic parameter has been 
identified that clearly distinguishes pediatric T-lymphoblastic lymphoma from T-ALL.


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2.4
Bone Mineral Density (BMD)
Deficits in BMD have been well documented among childhood ALL survivors and arise 
from the interaction of multiple factors.  Approximately 10% of children have BMD 
deficits at the time of diagnosis of ALL and more than 67% develop them during therapy. 
In a study by Strauss et al., BMD deficits were reported in up to 63% of survivors of 
pediatric ALL after completion of therapy, and were associated with a 5-year cumulative 
incidence of fracture of 28% ± 3%.50 Risk factors for developing BMD deficits include  
age at diagnosis ≥9 years;50 treatment with corticosteroids (both prednisone51 and 
dexamethasone50) and methotrexate;51,52 endocrinopathy associated with radiation 
(growth hormone deficiency, hypogonadism, and hyperthyroidism);53,54 and health 
behaviors such as  inadequate intake of calcium and vitamin D,55 lack of weight-bearing 
exercise,55,56 smoking and alcohol use.57,58  However, BMD changes in patients with 
lymphoblastic lymphoma have not been extensively studied.  Therefore, we will 
prospectively study BMD changes in this patient population.
Corticosteroids and cytostatic therapy are associated with reduced BMD.59-62 Like 
postmenopausal women, children are particularly at risk for steroid-induced osteoporosis 
because of their more rapid bone turnover.63-65 There are several mechanisms of 
glucocorticoid-induced osteoporosis.  The greatest impact is on the vertebral trabecular 
bone.66  Glucocorticoids decrease osteoblastic replication, differentiation, and lifespan by 
inhibiting genes for type 1 collagen, osteocalcin, insulin-like growth factors, bone 
morphogenetic proteins, receptor activator of nuclear factor kappa-B ligand (RANKL), 
and transforming growth factor .67 Glucocorticoids inhibit calcium absorption and 
prevent 1 -hydroxylation of vitamin D in the kidney to form the active metabolite 1,25-
dihydroxyvitamin D, further impairing calcium metabolism. Glucocorticoids directly 
inhibit many hormones and factors important in calcium accretion of bone.59,64,65,68 They 
inhibit the expression of the vitamin D receptor in bone and the production of osteocalcin 
(the major bone matrix protein) and decrease local production of cytokines (which 
normally inhibit bone resorption).64,65,68 Glucocorticoids inhibit osteoblastic activity and 
reduce the renal resorption of calcium. This effect can result in hypercalciuria, and, in 
turn, increase the parathyroid hormone, which further stimulates calcium loss from bone. 
To further understand the pathophysiology of BMD loss in children undergoing NHL16 
therapy, we will obtain serum calcium; serum magnesium; plasma 25-hydroxyvitamin D; 
osteocalcin N-MID; N-Telopeptide with creatinine; bone specific alkaline phosphatase; 
parathyroid hormone; and spot urine collection for magnesium, creatinine, calcium, and 
calcium/creatinine ratio.  If the calcium:creatinine ratio exceeds 0.2, then a 24-h urine 
collection will be obtained for creatinine, calcium, and calcium/creatinine ratio.
2.5
Anthracycline Cardiotoxicity
Although anthracyclines (e.g., doxorubicin, daunorubicin) have contributed significantly 
to childhood cancer survival, they confer an excess risk of asymptomatic left ventricular 
dysfunction, cardiomyopathy, congestive heart failure, and death.69-73 Anthracycline 
cardiotoxicity results in loss of cardiac myocytes, which impedes myocardial 


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development.74 Unfortunately, myocardial effects can be harmful, asymptomatic,71-75 and 
progressive.76  Cardiotoxicity has been reported at all dose levels, but the risk increases 
with higher cumulative doses, younger age at first exposure, time from exposure, and 
female sex.70-73,76  As many as 5% of at-risk survivors develop congestive heart failure 15 
years after treatment.70  The effects may be asymptomatic in up to 57% of survivors, 
becoming apparent only with other physiologic stressors such as infection or 
pregnancy.71,73 
Children exposed to anthracycline agents are at increased risk for cardiac toxicity, which 
may become more clinically significant as they age. Late-onset anthracycline toxicity 
(occurring more than 1 year after therapy) generally manifests as left ventricular 
dysfunction. Although subclinical cardiac changes after anthracycline therapy are 
commonly reported, symptomatic disease is seen only occasionally, particularly in 
children treated on protocols that proactively restrict anthracycline cumulative doses.70,73 
Because most at-risk patients are asymptomatic, ongoing monitoring for late cardiac 
complications is critical. At a minimum, a baseline electrocardiogram and 
echocardiogram is recommended after the completion of therapy, with serial follow-up 
and cardiac referral as indicated based on age at treatment and cumulative cardiotoxic 
exposures.77 The cumulative dosage of anthracycline in NHL 16 will be limited to 230 
mg/m2, as this dosage is associated with a very low risk of cardiomyopathy. 
Recommended off-therapy follow-up for late cardiac toxicity is as follows.
Recommended off-therapy follow-up for late cardiac toxicity  
Age at Treatment
Frequency of Echocardiographic Screening by 
Doxorubicin Dose
<1 year
Every year
1 to 4 years
Every 2 years
>5 years
Every 5 years
2.6
Gonadal and Reproductive Function
Among agents used to treat children with non-Hodgkin lymphoma, alkylating agents 
confer a dose-related risk of gonadal toxicity.  Because they divide faster, male germ 
cells (and their supporting Sertoli cells) are more vulnerable to toxicity from cancer 
therapy than the testosterone-producing Leydig cells.78  Leydig cell failure after 
radiotherapy is dose dependent and inversely related to age at treatment.  Thus, infertility 
is more common than androgen insufficiency after treatment for cancer.  Treatment with 
combinations of alkylating agents or cumulative doses of cyclophosphamide exceeding 
7.5 g/m2 increases the risk of germ cell dysfunction.79-81  Contemporary treatment 
protocols for non-Hodgkin lymphoma attempt to restrict these exposures in an effort to 
preserve reproductive function. In the NHL 16 study, the total cumulative dose of 
cyclophosphamide will be limited to between 4.0 (no fractionation) and 4.2 g/m2 
(fractionation). Androgen insufficiency as a result of chemotherapy-related damage to 
Leydig cells occurs only occasionally. In fact, most males experience normal puberty and 
are capable of producing normal adult levels of testosterone. Appropriate screening for 
signs and symptoms of androgen insufficiency should be performed annually for 


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survivors of cancer. The Children’s Oncology Group (COG) Long-Term Follow-Up 
Guidelines also recommend checking baseline serum luteinizing hormone (LH), follicle 
stimulating hormone (FSH), and testosterone levels at age 14 years and as clinically 
indicated in patients with evidence of delayed puberty or androgen insufficiency. In 
young men at risk for infertility, semen analysis remains the most accurate noninvasive 
method for evaluating germ cell function.
In contrast to male physiology, injury to the female germ cells results in both infertility 
and endocrine dysfunction.78 Because females have a fixed number of primordial follicles 
at birth, which steadily declines with age, the risk for therapy-related ovarian failure and 
infertility is directly related to age. Thus, pre-pubertal girls, having a greater reserve of 
follicles, are at lowest risk for these complications.78 Female children and adolescents 
treated with the cumulative doses of alkylators prescribed in regimens for non-Hodgkin 
lymphoma are at relatively low risk for both gonadal or germ cell dysfunction.  
Evaluation for gonadal failure and infertility centers on a good history (to identify 
irregular or absent menses, history of pregnancy, or difficulty conceiving) and an annual 
physical examination, with specific attention to Tanner staging. The COG currently 
recommends checking baseline serum LH, FSH, and estradiol levels at age 13 years and 
when clinically indicated for menstrual irregularity, delayed puberty, or symptoms of 
estrogen insufficiency. Although low cumulative doses of alkylators would most likely 
preserve fertility, risk and option for gamete preservation need to be discussed with 
patient and family.
2.7
Inclusion of Women and Minorities
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.
3.0
ELIGIBILITY CRITERIA AND STUDY ENROLLMENT 
3.1
Inclusion Criteria
3.1.1
Diagnosis of newly diagnosed lymphoblastic lymphoma (patients must 
have <25% tumor cells in bone marrow by morphology)
3.1.2
Age ≤ 21 years
3.1.3
Limited prior therapy, including systemic glucocorticoids for 1 week or 
less, 1 dose of vincristine, emergency radiation therapy to the 
mediastinum, and 1 dose of IT chemotherapy. Other circumstances must 
be cleared by PI or co-PI.
3.1.4
Written, informed consent and assent following guidelines of the 
Institutional Review Board, National Cancer Institute (NCI), Food and 
Drug Administration (FDA), and Office of Human Research Protections 
(OHRP).


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3.2
Exclusion Criteria
3.2.1
Participants with prior therapy, other than therapy specified in 3.1.3.
3.2.2
Participants who are pregnant or lactating.
3.2.3
Inability or unwillingness of research participant or legal 
guardian/representative to give written informed consent. 
3.3
Recruitment and Screening of Research Participants
Research participants will be recruited by study investigators through regular clinical 
practice at St. Jude.  It is anticipated that additional sites will be added as new 
collaborations are established.
3.4
Enrollment On Study at St. Jude
A member of the study team will confirm potential participant eligibility as defined in 
Section 3.1-3.2, complete and sign the ‘Participant Eligibility Checklist’.  The study team 
will enter the eligibility checklist information into the Patient Protocol Manager (PPM) 
system. Eligibility will be reviewed, and a research participant-specific consent form and 
assent document (where applicable) will be generated. The complete signed 
consent/assent form(s) must be faxed or emailed to the CPDMO at 
 to complete 
the enrollment process.
The CPDMO is staffed 7:30 am-5:00 pm CST, Monday through Friday. A staff member 
is on call Saturday, Sunday, and holidays from 8:00 am to 5:00 pm.  Enrollments may be 
requested during weekends or holidays by calling the CPDMO “On Call” cell phone 
 or referencing the “On Call Schedule” on the intranet).
3.5
Enrollment On Study at Collaborating Sites
Collaborating Site research participants should be registered at St. Jude within 24 hours 
of enrollment at the site.  The completed Eligibility Checklist and entire signed Informed 
Consent should be faxed to 
.  Please call 
 if confirmation of 
the enrollment information is needed. The Protocol Eligibility Coordinator will then 
register the research participant in the Patient Protocol Manager (PPM) system.  The 
CPDMO is staffed 7:30 am-5:00 pm CST, Monday through Friday. A staff member is on 
call Saturday, Sunday, and holidays from 8:00 am to 5:00 pm.


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4.0
RISK CLASSIFICATION
Patients will be classified into 1 of 3 categories on the basis of the bone 
marrow/peripheral blood lymphoma cells involvement at diagnosis and day 8 for T-
lymphoblastic lymphoma and bone marrow/peripheral blood lymphoma cells 
involvement at diagnosis for B-lymphoblastic lymphoma as well as CNS and testicular 
involvement. The criteria and the estimated proportion of patients in each risk category 
(based on data from COG A5971 study) are provided below.
4.1
Criteria for Stratum 1 (approximately 70% of patients) 

Minimal disseminated disease (MDD) <1% at diagnosis in T-
lymphoblastic lymphoma

No bone marrow involvement microscopically at diagnosis in B-
lymphoblastic lymphoma
Patients should NOT have:

Any CNS involvement: CNS-3 status (i.e., ≥5 WBC/L of CSF with 
blasts or cranial nerve palsy), CNS-2 status (<5 WBC/L of CSF with 
blasts) or traumatic LP (>10 RBC/L of CSF with blasts)

Overt testicular involvement (evidenced by ultrasonogram).
4.2
Criteria for Stratum 2 (approximately 15% of patients)

MDD ≥1% and MRD negative (<0.01%) on day 8 in T-lymphoblastic 
lymphoma

Bone marrow involvement microscopically present at diagnosis in B-
lymphoblastic lymphoma

Any CNS involvement: CNS-3 status (i.e., ≥5 WBC/L of CSF with 
blasts or cranial nerve palsy), CNS-2 status (<5 WBC/L of CSF with 
blasts) or traumatic LP (>10 RBC/L of CSF with blasts) but does not 
fulfill the criteria of stratum 3

Overt testicular involvement (evidenced by ultrasonogram) but does not 
fulfill the criteria of stratum 3
4.3
Criterion for Stratum 3 (approximately 15% of patients)

Any patients with MDD ≥1% and MRD positive (≥0.01%) on day 8 in T-
lymphoblastic lymphoma
Any patient with detectable disease [MRD (≥0.01%), morphology and imaging 
(biopsy proven)] at the end of induction or thereafter may be considered for 
reintensification therapy and hematopoietic stem cell transplantation (HSCT) – 
See Section 5.4 and 5.6 for further details.


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5.0
TREATMENT PLAN
Treatment will consist of 3 main phases: remission induction, consolidation (only for 
patients with any CNS disease and/or testicular involvement), and continuation. 
5.1
Intrathecal Chemotherapy 
As a traumatic lumbar puncture at diagnosis may result in a poor 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.  IT-MHA will be administered immediately after cerebrospinal fluid is collected 
for diagnosis, as per the following age-dependent dosage chart: 
Age (months)
Methotrexate (mg)
Hydrocortisone (mg) Cytarabine (mg) Volume (mL)
<12
6
12
18
6
12-23
8
16
24
8
24-35
10
20
30
10
≥36
12
24
36
12
Frequency and total number of IT-MHA treatments for remission induction are 
determined on the basis of patients’ risk of CNS relapse as follows:

All patients will receive IT-MHA treatment on days 1 and 15.

Patients with any of the following features will receive additional IT-MHA 
treatment on days 8 and 22:
-
Any T-lymphoblastic lymphoma
-
Advanced stage (Stages III and IV) B-lymphoblastic lymphoma 
-
Any CNS involvement: CNS-3 status (i.e., ≥5 WBC/L of CSF with blasts 
or cranial nerve palsy), CNS-2 status (<5 WBC/L of CSF with blasts) or 
traumatic LP (>10 RBC/L of CSF with blasts)
-
Testicular involvement (evidenced by ultrasonogram).
[Patients with limited stage (Stages I and II) B-lymphoblastic lymphoma will not receive 
IT-MHA on days 8 and 22.]
Leucovorin rescue (5 mg/m2/dose, max 5 mg) PO will be given 24 and 30 h after each IT-
MHA during induction.
Plasma methotrexate levels will be monitored (starting 24 h after IT therapy and until 
level becomes undetectable) in patients with renal dysfunction or extra fluid in third 
space, and rescue with leucovorin initiated according to pharmacist recommendation.


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5.2
Remission Induction Treatment (6 to 7 weeks)
Remission induction treatment will begin with prednisone, vincristine, daunorubicin, 
PEG-asparaginase and IT-MHA treatment, followed by cyclophosphamide plus 
cytarabine plus thioguanine.  Daunorubicin may be delayed in patients with febrile 
neutropenia, evidence of mucositis or increased hyperbilirubinemia (i.e., total bilirubin 
≥2.0 mg/dL and direct bilirubin >1.4 mg/dL).  Patients with mucositis will be evaluated 
for herpes simplex infection and treated with acyclovir or famciclovir if infection is 
confirmed. Prednisone is replaced by dexamethasone on day 15 in patients with T-
lymphoblastic lymphoma having MDD ≥1% at diagnosis and MRD positive (≥0.01%) on 
day 8 (If the day 8 MRD result is not available by day 15, change to dexamethasone as 
soon as positive MRD is reported). For patients with heterozygous or homozygous TPMT 
genotype, 6-mercaptopurine is used instead of thioguanine. 
5.2.1
Drug dosages (See Section 5.2.1.1 for dosing of infants and sections 7.0 and 8.0 
for treatment and dose modifications) 
Patients with T-lymphoblastic lymphoma having  MDD <1% at diagnosis or patients with B-lymphoblastic 
lymphoma  with no bone marrow involvement microscopically (No CNS or testicular involvement) (Stratum 1)
Agent(s)
Dosages and Routes
No. of Doses
Schedules
Prednisone1 or prednisolone1
40 mg/m2/day PO 
(divided t.i.d.)
84
Days 1–28
Vincristine
1.5 mg/m2  IV (max 2 
mg)
4
Days 1, 8, 15, 22
Daunorubicin2
25 mg/m2   IV
2
Days 1, 8
PEG-asparaginase
2500 units/m2 IM or IV
3 
Day 3, 15, 29
Cyclophosphamide3
1000 mg/m2 IV 
1
Day 22
Cytarabine
75 mg/m2/dose IV 
8
Days 23–26, 30–33
Thioguanine 
(6-mercaptopurine for patients 
heterozygous or homozygous for 
TPMT)
60 mg/m2/dose  PO
14
Days 22–35
Patients with T-lymphoblastic lymphoma having MDD ≥1% at diagnosis and MRD negative on day 8 
(<0.01%), patients with B-lymphoblastic lymphoma with bone marrow involvement microscopically at 
diagnosis, or patients with CNS involvement and/or testicular involvement (Stratum 2) 
Agent(s)
Dosages and Routes
No. of doses
Schedules
Prednisone1 or prednisolone1
40 mg/m2/day PO 
(divided t.i.d.)
84
Days 1–28
Vincristine
1.5 mg/m2  IV (max 2 mg)
4
Days 1, 8, 15, 22
Daunorubicin2
25 mg/m2   IV
2
Days 1, 8
PEG-asparaginase
2500 units/m2 IM or IV
3 
Day 3, 15, 29
Cyclophosphamide3
300 mg/m2 IV 
4
Q12 h on Days 22, 23
Cytarabine
75 mg/m2/dose IV 
8
Days 23–26, 30–33
Thioguanine
(6-mercaptopurine for patients 
heterozygous or homozygous for 
TPMT)
60 mg/m2/dose  PO
14
Days 22–35


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Patients with in T-lymphoblastic lymphoma having MDD ≥1% at diagnosis and MRD positive on day 8 
(≥0.01%) (Stratum 3)
Agents
Dosages and Routes
No. of 
Doses
Schedules
Prednisone1 or prednisolone1
40 mg/m2/day PO 
(divided t.i.d.)
24
Days 1–145
Dexamethasone4
10 mg/m2/day PO
 (divided t.i.d.)
42
Days 155–28
Vincristine
1.5 mg/m2  IV (max 2 
mg)
4
Days 1, 8, 15, 22
Daunorubicin2
25 mg/m2   IV
2
Days 1, 8
PEG-asparaginase
2500 units/m2 IM or IV
3 
Day 3, 15, 29
Cyclophosphamide3
300 mg/m2 IV 
4
Q12 h on Days 22, 23
Cytarabine
75 mg/m2/dose IV 
8
Days 23–26, 30–33
Thioguanine
(6-mercaptopurine for patients 
heterozygous or homozygous for 
TPMT)
60 mg/m2/dose  PO
14
Days 22–35
1.
Oral prednisone can be substituted with methylprednisolone at 20 mg/m2/day IV (t.i.d.) for patients 
who cannot tolerate the oral medication.
2.
First dose of daunorubicin may be delayed until day 2 in patients with or at high risk of tumor lysis 
syndrome. Second dose of daunorubicin could be delayed by up to 1 week if clinically indicated.
3.
See 5.2.3.2 for the criteria of starting cyclophosphamide plus thioguanine on day 22.
4.
Oral dexamethasone can be substituted with IV dexamethasone.
5.
If day 8 MRD result is not available by day 15, change to dexamethasone as soon as positive MRD is 
reported.
5.2.1.1 Dose adjustment for infants
Exception for vincristine, doses of all other drugs given to infants (<1 year old) will be 
based on body surface area.  For infants younger than 1 month or infants younger than 3 
months who were born significantly prematurely, doses of daunomycin, asparaginase, 
methotrexate, thiopurines, cyclophosphamide, and cytarabine will be reduced by 50%.  
The vincristine dose for patients younger than 1 year or less than 10 kg in weight will be 
0.05 mg/kg/dose.
5.2.2
Dose modifications for remission induction
See section 7.0 for treatment modifications for vincristine, daunorubicin, and PEG-
asparaginase and section 7.10 for modification of thiopurine dosing based on TPMT 
status.  After day 22 treatment, cytarabine and thioguanine may be held if patient 
develops febrile neutropenia or grade 3 or 4 mucositis.  If C-reactive protein is normal, 
fever subsides, cultures are not significant and mucositis resolves, cytarabine and 
thioguanine may be resumed.  Doses may be completely omitted if the patient is beyond 
day 30 of remission induction (i.e., half or more doses of thioguanine and cytarabine have 
been given), allowing early bone marrow recovery and early initiation of consolidation 
therapy.


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5.2.3
Bone marrow/peripheral blood evaluations
5.2.3.1 Day 8
A peripheral blood MRD will be done on day 8 of remission induction to assess response 
in T-lymphoblastic lymphoma.  In patients with MDD ≥1% at diagnosis, the presence of 
detectable lymphoma blasts by MRD study (≥0.01%) on day 8 is an indication for 
Stratum 3 therapy and 120 weeks of continuation therapy. 
5.2.3.2 Day 22
For neutropenic patients, the treatment may be delayed for 3 to 7 days to allow some 
degree of hematopoietic recovery if APC (ANC + monocyte) <300/mm3.
5.2.3.3 Disease response at end of remission induction
Imaging by PET/CT and morphologic evaluation of bone marrow as well as MRD studies 
of bone marrow and peripheral blood  (T-lymphoblastic lymphoma only) will be 
performed on days 38–42 of remission induction, depending on when ANC has recovered 
to >300/mm3, WBC to >1000/mm3, and platelet count to >50×109/L.  If the date falls on a 
weekend or holiday, the procedure will be performed on closest working day.  Any 
patient with evidence of disease [imaging (biopsy proven) or BM morphology] or 
detectable MRD at the end of induction or thereafter may be considered for 
reintensification therapy and HSCT.
5.3
Consolidation Treatment (10 weeks)
Consolidation therapy will be considered only for patients with any positive CNS disease 
or testicular involvement.
5.3.1
Drug dosages 
Agent
Dosage and Route
No. of Doses
Schedule
PEG-asparaginase
2500 units/m2 IM or IV
5
Day 1, 15, 29, 43, 57
High-Dose 
Methotrexate
(HD-MTX)
5000 mg/m2 or 
targeted 65 μM 
4
Days 8, 22, 36, 50
Mercaptopurine
50 mg/m2/day 
70
Days 1-70
When ANC of >300/mm3, WBC of  1000/mm3, and platelet count of  50 × 109/L are 
reached, consolidation treatment will be started, consisting of PEG-asparaginase (every 
alternate week for 5 doses), HD-MTX (every alternate week for 4 doses, not concurrent 
with PEG-asparaginase), daily mercaptopurine, and IT chemotherapy (on the same days 
as HD-MTX) (see section 5.3.4).   See section 5.3.5 on interim continuation treatment 
and section 7.0 for dose adjustments.


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5.3.2
Mercaptopurine administration
Mercaptopurine should be given daily at a consistent time that maximizes adherence with 
the prescribed treatment.  If a dose is inadvertently missed, then it should be given as soon 
as the omission is noted, as long as it is at least 6 hours prior to the next scheduled dose.  
For patients in whom HD-MTX treatment is delayed, mercaptopurine may be continued 
until 14 days after the last course of HD-MTX.  Mercaptopurine may be held in the 
presence of ANC <300/mm3, WBC <1000/mm3, platelet count <50,000/mm3, or grade 3 or 
4 mucositis.  Dosage of mercaptopurine in subsequent courses may be reduced to 25 
mg/m2/day in patients who have prolonged neutropenia after HD-MTX and mercaptopurine 
treatment.  See section 7.10 for modifications of mercaptopurine based on TPMT status.
5.3.3
HD-MTX administration
HD-MTX at 5 g/m2 (or a dose targeted to achieve a steady-state plasma concentration of 
65 M) will be administered IV over 24 h.  The subsequent dose of HD-MTX, 
mercaptopurine, and IT treatment will be delayed if ANC is <300/mm3, WBC is 
<1000/mm3, platelet count is <50 × 109/L, SGPT is >500 U/L, total bilirubin is >2 mg/dL 
and direct bilirubin is >1.4 mg/dL, or mucositis is present. Sodium bicarbonate may be 
given orally at 1 g/m2 every 6 h or IV with prehydration fluid starting the day before HD-
MTX.  For patients with Down syndrome, dosages of HD-MTX will be modified (see 
section 7.1.1).
The results from TOTXV suggest that a dose of 5 g/m2 can achieve the targeted 
concentration of 65 M ± 20% in only 62% of the courses (see section 2.1.4 for details and 
rationale).  In NHL16, clearance will be estimated from the plasma concentrations up to 48 
h from methotrexate infusion, using nonlinear curves fitting and a Bayesian estimation 
strategy based on predictive characteristics (such as serum creatinine and SGPT) as 
implemented in ADAPT. Of the total dose, 10% will be administered as a loading dose 
over 1 h and the remainder over 23 hours.
5.3.3.1 Pre-hydration
At least 2 h before HD-MTX administration, pre-hydration IV fluid (D5W + 40 mEq 
NaHCO3/L + 20 mEq KCl/L) will be administered at the rate of 200 mL/m2/h.  At start of 
pre-hydration, 1 IV dose of NaHCO3 (unless otherwise clinically indicated, 25 mEq/m2) 
diluted in 50 mL D5W will be given over 15 min. Pre-hydration fluid may also be given 
overnight at a rate of at least 125 mL/m2/h.  HD-MTX treatment will follow if urinary pH 
is ≥6.5; exceptions must be cleared by the Pharmacokinetics Service and the attending 
physician.
5.3.3.2 HD-MTX infusion
Methotrexate loading dose will be given over 1 h, followed immediately by maintenance 
infusion over 23 h.  During the methotrexate infusion, patients will receive hydration 
fluid with D5W + 40 mEq/L NaHCO3 + 20 mEq KCl/L at 100–150 mL/m2/h.  Urine pH 


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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 PO every 6 to 8 h) may be given if systemic alkalosis limits 
the administration of bicarbonate for urinary alkalinization.  Patients with evidence of 
renal dysfunction or delayed clearance during the methotrexate infusion may receive a 
methotrexate infusion of less than 24 hours.  Blood samples for methotrexate 
pharmacokinetics will be drawn according to procedures in section 10.1.
5.3.3.3 Leucovorin rescue 
Leucovorin (15 mg/m2 PO or IV) will be started 42 h after beginning methotrexate and 
repeated every 6 h for a total of 3 doses, as described by Reiter et al.82  The dosage of 
leucovorin will be increased in patients with high plasma methotrexate concentrations (>1 
M at 42 h) 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-h 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 be continued on leucovorin for 5 (rather than 3) doses; for those with 
early toxicity, leucovorin should be initiated at 36 h with subsequent methotrexate; if 
toxicity recurs, the baseline leucovorin dosage should also be increased.  
5.3.4
Intrathecal (IT) chemotherapy 
All patients will receive IT-MHA therapy every alternate week for 4 doses on days 8, 22, 
36, and 50 (dosages are based on age, according to guidelines in section 5.1). IT 
treatment should be given on the same day as HD-MTX.  If there is more than a 12-h gap 
between IT and HD-MTX administration, the PI or the Pharmacokinetics Service should 
be contacted.
5.3.5
Interim continuation treatment
Interim continuation treatment will be given to the occasional patients who, after 
attaining complete remission, are deemed unable to tolerate HD-MTX.  Specific criteria 
for the use of 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; other unforeseen reasons may also warrant 
temporary withholding of HD-MTX.
Interim treatment will consist of oral mercaptopurine 75 mg/m2 per day (50 mg/m2 per 
day in those with ANC <500/mm3) and intravenous methotrexate 40 mg/m2 per week; IT 
may be given every other week during this period of time and continued during the 
subsequent HD-MTX treatment for a total of 4 doses.  HD-MTX will be started when the 
patient’s physical condition allows.  In the event that the interim therapy is longer than 4 
weeks, an extra IT treatment may be given with the last course of HD-MTX. Patients 
with a defective TPMT status may receive lower doses of mercaptopurine. Interim 
continuation therapy can be considered in other phase of treatment if necessary.


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5.4
Reintensification Treatment
Options for patient with detectable disease by PET/CT scan (biopsy proven), bone 
marrow morphology, or MRD of bone marrow or peripheral blood at the end of induction 
or thereafter.
Patients with detectable disease by PET/CT imaging (biopsy proven), MRD, or 
morphologic disease at the end of induction or thereafter may receive reintensification 
therapy and will then be offered the option of transplant. This treatment will attempt to 
maximize lymphoma cell kill before allogeneic HSCT.  When marrow is recovered (i.e., 
ANC 300/mm3, WBC 1000/mm3 and platelet count  50×109/L) after a course of 
reintensification, imaging, MRD and morphologic studies will be repeated.
Reintensification may be repeated if there was apparent benefit with the first course. This 
decision will also depend on HSCT planning by primary MD and BMT division MD. 
Patients deemed unsuitable for the transplant, those who decline the procedure, or those 
for whom donors have not yet been identified will remain on study and receive 
subsequent chemotherapy as scheduled.  
The treatment scheme and dosage of chemotherapy are summarized below. 
Agent
Dosage and Route
No. of 
Doses
Schedule
Dexamethasone
20 mg/m2/day PO or IV (divided 
t.i.d)
18
Days 1–6
Cytarabine
2000 mg/m2, 3-h IV infusion 
every 12 h
4
Days 1–2
Etoposide
100 mg/m2, 1-h IV infusion every 
12 h
5
Days 3–5
IT-MHA
See section 5.1 for age-specific 
dose
1
Day 5
PEG-asparaginase
3000 units/m2 IM or IV
1
Day 6
Patients with suboptimal response to reintensification may receive 1 or 2 cycles of 
clofarabine/cyclophosphamide/etoposide/dexamethasone:
Agent
Dosage and Route
No. of 
Doses
Schedule
Clofarabine
40 mg/m2/day, 2-h IV infusion
5
Days 1–5
Etoposide
100 mg/m2/day, 2-h IV infusion
5
Days 1–5
Cyclophosphamide
300 mg/m2/day, 30–60 min IV infusion
5
Days 1–5
Dexamethasone
8 mg/m2/day (divided t.i.d)
15
Days 1–5
All dosages given to infants (<1 year old) will be based on body surface area.  For infants 
<1 month old or for infants <3 months of age born significantly prematurely, a 50% 
reduction in dosages of asparaginase, cyclophosphamide, cytarabine, clofarabine and 
etoposide will be made.


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Protocol version, dated 03-03-2015
5.5
Continuation Treatment 
(98 Weeks for Stratums 1 and 2 and 120 Weeks for Stratum 3 and Patients with any CNS 
Disease and/or Testicular Disease).  Post-remission continuation treatment will be 
initiated after the completion of remission induction (consolidation for patients with CNS 
and/or testicular disease) if ANC is 300/mm3, WBC is 1000/mm3, and platelet count is 
50×109/L as well as no evidence of grade 3 or 4 mucositis.  
Week
All Stratums
1
DEX+DOX+VCR+MP + PEG-ASP
2
MP 
3
 MP + PEG-ASP
4
DEX + DOX + VCR + MP 
5
MP + PEG-ASP
6
MP
73
1Reinduction I
83
Reinduction I
93
Reinduction I
10
MP 
11
DOX + VCR +MP + PEG-ASP
12
MP
13
MP + PEG-ASP
14
DEX + DOX + VCR +6MP 
15
MP + PEG-ASP
16
MP 
173,4
1Reinduction II
183,4
Reinduction II
193,4
Reinduction II
204
No chemotherapy (MP + MTX for stages I and II B–lymphoblastic lymphoma)
Note: DEX, dexamethasone; DOX doxorubicin; VCR, vincristine; MP, 6-
Mercaptopurine; PEG-ASP, PEG-asparaginase.  See 5.5.3 for intrathecal therapy 
schedule.
1. MRD study in peripheral blood.
2. Any patient with detectable MRD at week 17 can receive reintensification 
treatment after reinduction II and HSCT can be considered (see section 
5.4). 
3. See section 5.5.2 for details on reinduction treatment.
4.  See 5.5.2.3 for patients with stages I and II B-lymphoblastic lymphoma.
Dexamethasone, vincristine, and asparaginase will be given regardless of blood counts, 
provided that the patient is clinically well. Doxorubicin, mercaptopurine and 
methotrexate will be held if WBC ≤1000/mm3 or ANC ≤300/mm3. Doxorubicin, 
mercaptopurine and methotrexate will be reduced for WBC <1500/mm3, or if WBC and 
ANC not increase by at least 2 folds a week after the start date of dexamethasone pulse 
(see section 7.0 for other dose modifications).  *Mercaptopurine should be given daily at 


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a consistent time that maximizes adherence with the prescribed treatment.  If a dose is 
inadvertently missed, then it should be given as soon as the omission is noted, as long as 
it is at least 6 hours prior to the next scheduled dose.
5.5.1
Drug dosages, schedules, and routes for continuation therapy for Weeks 1 to 6 
and Weeks 10 to 16 
Agent
Schedule
Dexamethasone 
12 mg/m2 for 5 days, Days 1-5
Doxorubicin
30 mg/m2 IV, Day 1
Vincristine
2 mg/m2 IV push (max. 2 mg), Day 1(0.05 mg/kg 
for patients <1 year of age or <10 kg in weight)
Mercaptopurine
50 mg/m2 PO daily for 7 days, Days 1-7
PEG-asparaginase
2500 units/m2 IM or IV, Day 1
See section 5.2.1.1 for dosing for infants.
5.5.2
Reinduction treatment
Reinduction treatment will be started at weeks 7 and 17. Doxorubicin and HD-cytarabine 
will be held if ANC ≤300/mm3 or WBC <1000/mm3. It is preferable to start HD-
cytarabine when WBC ≥1800/mm3 and ANC >300/mm3.
Reinduction treatment will be given twice: at weeks 7–9 and weeks 17–19 for patients 
with all T-lymphoblastic lymphoma and advanced-stage (stages III and IV) B-
lymphoblastic lymphoma. For patients with limited-stage B-lymphoblastic lymphoma 
(stages I and II), reinduction II treatment will not include high-dose cytarabine.\
IT treatment will be followed by leucovorin rescue (5 mg/m2/dose PO, max 5 mg) at 24 
and 30 h only in patients with prior CNS toxicities or in those with WBC < 1500/mm3, or 
ANC < 500/mm3.
5.5.2.1 Reinduction I
Agents
Dosages and routes
# Doses
Schedules
Dexamethasone
8 mg/m2/day PO (divided t.i.d.)
45
Days 1–8, 15–21
Vincristine
1.5 mg/m2/week IV 
0.05 mg/kg for infants <1 year old 
or <10 kg in weight (max 2 mg)
3
Days 1, 8, 15
Doxorubicin
30 mg/m2 IV
2
Days 1, 8
PEG-asparaginase
2500 units/m2  IM or IV
2
Days 1, 15 
Methotrexate + 
hydrocortisone +Ara-C
Age-dependent, IT
(section 5.1)
1
Day 1


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5.5.2.2 Reinduction II for all T-lymphoblastic lymphoma and advanced-stage (stages III 
and IV) B-lymphoblastic lymphoma
Agents
Dosages and routes
# Doses
Schedules
Dexamethasone
8 mg/m2/day PO (t.i.d.)
45
Days 1–8, 15–21
Vincristine
1.5 mg/m2/week IV 
0.05 mg/kg for infants <1year old 
or <10 kg in weight  (max 2 mg)
3
Days 1, 8, 15
PEG-asparaginase
2500 units/m2 IM or IV
2
Days 1, 15
Methotrexate + 
hydrocortisone +Ara-C
Age-dependent, IT
1
Day 1
High-dose cytarabine
2000 mg/m2 IV q 12 h
4
Days 15, 16
5.5.2.3 Reinduction II for limited stage (stages I and II) B-lymphoblastic lymphoma
Agents
Dosages and routes
# Doses
Schedules
Dexamethasone
8 mg/m2/day PO (t.i.d.)
45
Days 1–8, 15–21
Vincristine
1.5 mg/m2/week IV 
0.05 mg/kg for infants <1year old 
or <10 kg in weight  (max 2 mg)
3
Days 1, 8, 15
PEG-asparaginase
2,500 units/m2 IM or IV
2
Days 1, 15
Methotrexate + 
hydrocortisone +Ara-C
Age-dependent, IT
1
Day 1
Mercaptopurine (75 mg/m2 PO daily for 7 days, Days 1–7) and methotrexate (40 mg/m2 
IV or IM, Day 1) will be given in week 20 in this group.
5.5.3
Intrathecal chemotherapy - IT-MHA treatment will be given as follows:

Patients with limited stage (stages I and II) B-lymphoblastic lymphoma with CNS-
1 status (no identifiable blasts in CSF) on weeks 1, 3, 5, 7, 12, 17, 25, 29, 33, 37, 
41, 45, 49, 57, 65, and 73 (total number of treatments 18).

Patients with T-lymphoblastic lymphoma (any stage) and advanced stage (stages 
III and IV) B-lymphoblastic lymphoma with CNS-1 status on weeks 1, 3, 5, 7, 12, 
17, 25, 29, 33, 37, 41, 45, 49, 57, 65, 73, 81, 89, and 98 (total number of 
treatments 23).

Any patient with CNS-3 status, CNS-2 status or traumatic CSF with blasts status, 
or testicular involvement on weeks 3, 7, 12, 17, 25, 29, 33, 37, 41, 45, 49, 57, 65, 
73, 81, 89, and 98 (total number of treatments 25). 
The number of IT treatments for patients with detectable disease after induction will 
depend on whether patients receive HSCT, and, if so, when they receive it.  Leucovorin 
will not be given after IT treatment during continuation treatment unless the patient has 
an adverse reaction with previous IT or methotrexate treatment, e.g., seizure or 
encephalopathy, has renal dysfunction resulting in high plasma methotrexate 
concentration, has Down syndrome and has unacceptable toxicity despite decrease in 
dosage, or has WBC < 1500/mm3 or ANC < 500/mm3.  


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Intrathecal therapy in NHL16
Induction
Consolidation
Continuation Week 1-20
Continuation Weeks 21-98
All Phases
Histology and 
stage
CNS Status
Days
Total
Days
Total
Weeks
Total 
Weeks 
Total
Total
Limited stage 
(stages I and II) 
B-lymphoblastic 
lymphoma
CNS-1
1, 15
2
0
1, 3, 5, 7, 12, 17
6
25, 29, 33, 37, 41, 
45, 49, 57, 65, 73
10
18
T-lymphoblastic 
lymphoma (any 
stage) and 
advanced stage 
(stages III and 
IV) B-
lymphoblastic 
lymphoma
CNS-1
1, 8, 
15, 22
4
0
1, 3, 5, 7, 12, 17
6
25, 29, 33, 37, 41, 
45, 49, 57, 65, 73, 
81, 89, 98
13
23
Any
CNS-3, 
CNS-2 or 
traumatic 
CSF with 
blasts, or 
testicular 
involvement
1, 8, 
15, 22
4
8, 22, 
36, 50
4
3, 7, 12, 17
4
25, 29, 33, 37, 41, 
45, 49, 57, 65, 73, 
81, 89, 98
13
25


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5.5.4
Treatment (weeks 21 to 23)
Week
Treatment
21
 MP +  PEG-ASP1
22
MP1 
23
MP +  PEG-ASP1
Note: MP, 6-mercaptopurine; PEG-ASP, PEG-asparaginase;  Patients who receive 
consolidation therapy will not receive PEG-ASP and weekly MTX will be given instead 
for weeks 21–23.
Mercaptopurine should be given daily at a consistent time that maximizes 
adherence with the prescribed treatment.  If a dose is inadvertently missed, then 
it should be given as soon as the omission is noted, as long as it is at least 6 
hours prior to the next scheduled dose.
5.5.5
Treatment (weeks 24 to end of therapy)
Week
Treatment
24
Cyclo + Ara-C
25
1DEX + VCR
26
MP + MTX
27
MP + MTX
28
Cyclo + Ara-C
29
1DEX + VCR
30
MP + MTX
31
MP + MTX
Note: DEX, dexamethasone; MP, 6-mercaptopurine; Cyclo, cyclophosphamide; Ara-C, 
cytarabine; VCR, vincristine; MTX, methotrexate.  IT MHA (methotrexate + 
hydrocortisone + cytarabine; see section 5.1 for dosage and 5.5.3 for schedule).
Mercaptopurine should be given daily at a consistent time that maximizes adherence with 
the prescribed treatment.  If a dose is inadvertently missed, then it should be given as soon 
as the omission is noted, as long as it is at least 6 hours prior to the next scheduled dose.


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5.5.5.1 Drug dosages, schedules and routes for continuation therapy from week 21 to end 
of therapy
Agent
Schedule
Mercaptopurine
75 mg/m2 PO daily for 7 days, Days 1–7
Methotrexate
40 mg/m2 IV or IM, Day 1
Cyclophosphamide
300 mg/m2 IV, Day 1 between week 21 and 
week 61
Cytarabine
300 mg/m2 IV, Day 1 between week 21 and 
week 61
Dexamethasone
12 mg/m2 PO daily (divided t.i.d.) for 5 days, 
Days 1–5 between week 21 and week 61
Vincristine
2 mg/m2 IV push (max 2 mg), Day 1 between 
week 21 and week 61
(0.05mg/kg for patients <1yr or < 10 kg)
 
PEG-asparaginase1
2500 units/m2 IM, Day 1 in weeks 21 and 23
Patients who receive consolidation therapy will not receive PEG-ASP and weekly MTX 
will be given instead for weeks 21–23.
Mercaptopurine should be given daily at a consistent time that maximizes adherence with 
the prescribed treatment.  If a dose is inadvertently missed, then it should be given as 
soon as the omission is noted, as long as it is at least 6 hours prior to the next scheduled 
dose.
Dexamethasone, vincristine, and asparaginase will be given regardless of blood counts, 
provided that the patient is clinically well.  Cyclophosphamide, cytarabine, 
mercaptopurine and methotrexate will be held if WBC ≤1000/mm3 or ANC ≤300/mm3. 
Mercaptopurine and methotrexate will be reduced for WBC < 1500/mm3, or if WBC and 
ANC do not increase by at least 2 folds a week after the start date of dexamethasone 
pulse. Doses of cyclophosphamide and cytarabine may need to be reduced if patient 
misses 25% of chemotherapy and if the low counts deem to be related to this combination.
The same treatment (weeks 30–37) will be repeated for a total of 4 times, until week 61 
(see section 5.5.3 for IT therapy).  After week 61, Stratums 1 and 2 patients will receive 
daily mercaptopurine and weekly methotrexate until week 98 and Stratum 3 patients and 
those with any CNS disease and/or testicular involvement until week 120. 
5.6
Hematopoietic stem cell transplantation 
Patients who have detectable disease by imaging (biopsy proven), MRD, or morphology 
at the end of induction or thereafter are candidates for allogeneic HSCT.  However, if 
patients or guardians decline this option, or the procedure is deemed unsuitable by the 
attending physician and the PI, the patient will remain on study and continue to receive 
chemotherapy.


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6.0
DRUG INFORMATION 
See Appendix II for information on the individual drugs to be used in this protocol.
6.1
Drug Shortages/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.
7.0
TREATMENT MODIFICATIONS 
7.1
Patients with Down Syndrome
Patients with Down syndrome can be treated on NHL 16, with the following 
modifications:
7.1.1
HD-MTX:  Dosages of HD-MTX will be modified because patients with Down 
syndrome have altered MTX pharmacokinetics and enhanced tissue sensitivity to the 
effects of MTX.  The hydration and alkalinization regimen should be the same as 
outlined in section 5.3.3.  However, the dose of HD-MTX should be 500 mg/m2 (50 
mg/m2 over 1 h and 450 mg/m2 given over 23 h). Baseline leucovorin rescue will begin 
early (at hour 30 at 30 mg/m2 IV q 6 h × 2 doses, followed by 10 mg/m2 IV q6 h × 6 
doses).  If MTX plasma levels are elevated, increased leucovorin rescue will be 
recommended by the Pharmacokinetics Service.  Vigorous hydration should be ensured 
until the 42-h MTX level is known.
7.1.2
Continuation low-dose MTX:  The low-dose weekly MTX (40 mg/m2) should be 
administered at full dosage if possible.  If the patient has severe neutropenia or 
leucopenia (which delays subsequent therapy) or grade 4 mucositis (or mucositis which 
delays subsequent therapy) after being administered 40 mg/m2 low-dose MTX, the 
dosage should be decreased to 30 mg/m2, and  further to 20 mg/m2 and finally to 10 
mg/m2 if necessary.  If 10 mg/m2 is also not tolerated, then leucovorin should be added at 
5 mg/m2 every 6 h for 4 doses, starting 42 h from the MTX dosage, with titration to 
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7.1.3
IT therapy:  IT should be administered as outlined in section 5.1.
7.1.4
Patients with Down syndrome should be closely monitored. Doses should be 
reduced (30% to 50%) as clinically indicated (especially dexamethasone and high-dose 
cytarabine, and for those who have higher than expected toxicity in earlier phases)
7.2
Renal Dysfunction
Subclinical renal impairment (normal serum creatinine but decreased glomerular 
filtration rate) may be present in patients receiving concurrent nephrotoxic drugs (e.g., IV 
acyclovir), which should, if possible, be held during and for 20 h after HD-MTX 
infusions or until adequate MTX clearance has been documented.  Delaying MTX should 
be considered if a patient's serum creatinine indicates renal impairment.
7.3
Hepatic Dysfunction
Anthracyclines and vincristine dosages should be modified in patients with elevated 
direct bilirubin concentrations or other evidence of biliary obstruction.  [More 
conservative criteria will be used for anthracycline treatment during initial remission 
induction (see section 5.2).]
Direct bilirubin 2–4 mg/dL:
50% decrease in dosage 
Direct bilirubin 4–6 mg/dL:
75% decrease in dosage
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.  
HD-MTX should be withheld if there is evidence of existing mucositis or if total bilirubin 
is >2 mg/dL and direct bilirubin is >1.4 mg/dL.
Subclinical hypertransaminasemia (SGPT >500 IU/L) is an indication to delay only HD-
MTX, but not other chemotherapy.
7.4
Obesity
Actual body weight will be used to calculate body surface area in all patients and used for 
dosage calculations (Exception: vincristine dosage will be capped at 2 mg).
7.5
Testicular Involvement at Diagnosis
An ultrasonogram should be performed to differentiate testicular lymphoma involvement 
from hydrocele and to measure the testicular volume.  Overt testicular involvement at 
diagnosis per se is not an indication for testicular irradiation, as many patients can be 
successfully treated with chemotherapy, including HD-MTX. An ultrasonogram should 
again be performed after completion of remission induction.  If testicular size is still 


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abnormally enlarged, the sonogram should be repeated after consolidation treatment with 
HD-MTX and mercaptopurine.  Patients with persistently enlarged testes after 
consolidation treatment will undergo biopsy.  Testicular irradiation (24 Gy) will be 
administered in patients with positive biopsies, after consultation with a radiation 
oncologist. 
7.6
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.  If 
persistent, severe abdominal cramps, gait impairment, severe pain (requiring narcotic 
treatment), or syndrome of inappropriate antidiuretic hormone secretion (SIADH) 
develop, the dose may be reduced to 1 mg/m2.  Vincristine should be withheld only if 
patients develop motor paralysis or typhlitis.
7.7
Venous Thromboembolism 
For patients who develop cerebral or other venous thrombosis during remission 
induction, subsequent treatment will be modified.  Dexamethasone will be omitted from 
weeks 1, 4, and 14 of continuation treatment, and will be given on days 7–14 instead of 
1–8 and 15–21 during reinduction I and II. Low-molecular-weight heparin may be 
required during the first 23 weeks of continuation treatment.  Acute management of 
thrombosis will be as per St. Jude guidelines on the use of thrombolysis and 
anticoagulation. Questions on steroid and asparaginase dosing should be referred to the 
PI or co-PI.  
7.8
Osteonecrosis of Bone 
Total joint MRI exams will be interpreted by the radiologist. If there is evidence of 
epiphyseal or metaphyseal lesions involving any joint or lesions of talus consistent with 
osteonecrosis, the patient will be referred to the orthopedic surgeon, who will evaluate 
symptoms and assess the severity and estimated risk of progression. Physical therapy, 
activity modifications, and surgical procedures will be recommended as needed.  Patients 
with hip, knee and shoulder epiphyseal lesions or talus lesions affecting >30% of weight-
bearing area will have an X-ray of the affected area, and will be assessed as being at 
higher risk for progression. Dexamethasone will be discontinued in symptomatic patients 
with such findings, especially if they are past reinduction II in therapy. Dexamethasone 
dose may be reduced by 50% in asymptomatic patients with such findings, especially if 
they are past reinduction II in therapy. Patients with X-ray findings positive for 
osteonecrosis 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 reevaluated 
by orthopedic follow-up and re-imaging if needed.  If dexamethasone is discontinued, the 


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first choice will be to replace each week’s dosing of dexamethasone with 1 dose of 
methotrexate (40 mg/m2), if tolerated.  See section 13.4 for additional guidelines. 
7.9
PEG-asparaginase 
Patients with allergic reactions to PEG-asparaginase will instead be given Erwinia L-
asparaginase IM or IV. If allergy occurs with the first or second PEG dose and the patient 
requires a dose at day 15 and/or 29 during remission induction, Erwinia L-asparaginase 
will be given at 20,000 units/m2/dose, thrice weekly for 2 weeks (total of 6 doses). After 
remission induction, each dose of PEG will be replaced by Erwinia L-asparaginase at 
30,000 units/m2/dose, twice weekly (3 to 4 days apart) for 4 doses. During 
reintensification, Erwinia L-asparaginase will be given 36,000 units/m2/dose, twice 
weekly (3 to 4 days apart) for 2 doses. 
Asparaginase treatment should be delayed until at least 2 h after IT treatment.  If patients 
become allergic to both forms of asparaginase, methotrexate 40 mg/m2/week should be 
given instead during the week of continuation treatment.
7.10
TPMT Status and Thiopurine Dosage 
Defects in the TPMT enzyme have been linked to acute myelosuppression and to the 
long-term risk of therapy-related AML (t-AML), even in the context of ALL therapy 
consisting primarily of antimetabolites. Studies reporting an association of TPMT defects 
with risk of t-AML used mercaptopurine at a dosage of 75 mg/m2/day, whereas other 
studies on ALL used a starting dosage of 60 mg/m2/day and then titrate up.  Although 
how TPMT status affects 6-mercaptopurine dosage is not fully known, patients with 
TPMT defects have higher concentrations of thioguanine nucleotides, and substitution of 
thioguanine for guanine in DNA can affect topoisomerase II-induced cleavage of DNA in 
the presence and absence of a topoisomerase II inhibitor. Together, clinical and 
preclinical evidence suggests that the 10% of patients who carry a variant TPMT allele 
may be at higher risk for secondary tumors.   Because such patients often require a 
decrease in dosage of thiopurines, and because overall leukemia-free survival has been 
shown to be excellent among patients with TPMT defects (in a setting in which dosage 
was adjusted in about 1/3 of patients with TPMT defects), we recommend that in NHL 
16, patients with a phenotype or genotype consistent with at least 1 variant TPMT allele 
receive no more than 60 mg/m2/day of mercaptopurine or thioguanine, unless it is clearly 
documented that compliance has been good and metabolite levels remain low (<100 
pmol/8 × 108 red cells) (see sections 8.1 and 8.2).  Further changes in mercaptopurine 
dose should be determined on the basis of WBC and ANC counts. As far as possible, 
other anticancer agents should be administered at protocol doses for these patients. A 
blood sample (5 mL) should be drawn along with routine lab work at day 3 of remission 
induction to allow for timely TPMT genotyping.
TPMT genotype will be determined by allele-specific genotyping, directed against the 3 
most common inactivating polymorphisms at positions 238, 460, and 719 of the cDNA, 
which account for >90% of all variant alleles. On the basis of genotyping, patients will be 


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assigned a homozygous wild-type, heterozygous, or homozygous variant TPMT status. 
As specified in section 8.2, levels of 6-thioguanine nucleotides (6-TGN) thiopurine 
metabolite should be measured at the start of reinduction I and TPMT activity in RBCs 
assessed at least by week 17 for all patients.  The threshold for on-therapy, non-
transfused TPMT activity that is considered the upper bounds for heterozygous status (14 
units/mL) is higher than that for off-therapy, non-transfused patients (10 units/mL). The 
ratio of methyl thiopurine metabolites to TGNs can also be used for phenotyping the 
patient if genotype and activity phenotype data are conflicting. If TPMT genotype or 
activity or metabolite measures are consistent with heterozygous status, the patient will 
be considered a heterozygote; using these criteria, approximately 10% of patients are 
expected to be heterozygous or homozygous variants, in agreement with population 
studies for TPMT status, and thus will require decrease in doses of thiopurine on the basis 
of TPMT status. See section 8.2 for additional information on dose modification.
7.11
Pancreatitis
Acute hemorrhagic pancreatitis is a contraindication to continue asparaginase treatment. 
In case of mild to moderate pancreatitis, asparaginase should be withheld until symptoms 
and signs subside and amylase and lipase levels return to normal. For patients with 
abdominal pain that may be due to pancreatitis, serum amylase and lipase levels should 
be measured and an abdominal sonogram or CT scan done. For patients with severe 
pancreatitis (i.e., abdominal pain of 72 h or more, amylase level 3 times or more of the 
upper limit of normal, and sonographic or CT scan showing evidence of pancreatitis), 
asparaginase may be discontinued permanently when the possibility of glucocorticoid- or 
mercaptopurine-induced pancreatitis is excluded. In patients with mild to moderate 
pancreatitis (abdominal pain less than 72 h and amylase and lipase level less than 3 times 
the upper limit of normal), asparaginase should be withheld and resumed once symptoms 
and signs subside.  For asymptomatic patients (no abdominal pain, only elevated amylase 
or lipase levels), management should be discussed with the PI or co-PI. Also, 
management of patients with dexamethasone- or mercaptopurine- related pancreatitis 
should be discussed with the PI or co-PI. 
8.0
DOSE MODIFICATIONS DURING CONTINUATION THERAPY
Dosage of continuation treatment should be titrated to keep WBC between 1800 and 
3000/mm3, ANC between 500 and 1200/mm3 (with the exception of the count one week 
after dexamethasone treatment), and platelet count 50×109/L. Full dose of treatment will 
be administered when WBC 1500/mm3, ANC is 300/mm3 and platelet count 
50×109/L; 30 to 50% dose reduction of mercaptopurine, methotrexate, or both should be 
considered if WBC is between 1000 and 1500/mm3 with ANC 300/mm3 and platelet 
count 50×109/L.
Dexamethasone, vincristine, and asparaginase will be given regardless of blood counts, 
provided that the patient is clinically well. On the weeks of vincristine and 
dexamethasone pulses, mercaptopurine may be reduced by 30% to 50% in patients with 
WBC <1500/mm3 the week after prior dexamethasone pulse. Adjustments of dosages 


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should be made in the following circumstances, with re-evaluation of tolerance and 
toxicities every 8 to 16 weeks.
8.1
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 (>3×109/L) and ANC 
(>1000/mm3) counts should be counseled on compliance, particularly if 6TGN levels are 
<100 pmol/8×108 RBCs.  If the WBC remains high, mercaptopurine and methotrexate 
dosages should be increased by 30% (to 100 mg/m2 for mercaptopurine and 50 mg/m2 for 
methotrexate), using a stepwise approach if needed.  If patients have a TPMT defect, 
mercaptopurine dosage should not be increased unless the 6TGN levels are <100 
pmol/8×108 RBCs. 
8.2
Dose Decreases Based on Mercaptopurine Pharmacology 
6TGN levels will be measured at the start of reinduction I (i.e., week 7) in all patients.  
TPMT activity will be measured at the start of reinduction II (week 17) or earlier if 
TPMT defects are suspected.  TPMT genotype may be used to identify TPMT variant 
alleles. 6TGN and TPMT activity will be measured subsequently in patients with high 
6TGN levels, suspected noncompliance, toxicity-related problems, or high blood counts.
In patients missing 25% of therapy who have 6TGN levels >1000 pmol/8×108 RBCs, 
mercaptopurine dosage will be reduced to achieve a steady-state 6TGN level between 
200 and 1000 pmol/8×108 RBCs; in patients with 6TGN level <1000 pmol/8×108 RBCs, 
both mercaptopurine and methotrexate dosages will be reduced by 30%.
Dosages will be reevaluated every 8–16 weeks.  Other causes of low blood counts will 
also be considered (see section 13.5).
Patients missing less than 25% of therapy and with WBC <3×109/L and ANC <1000 will 
not need any change in dosage, regardless of 6TGN level.  See section 7.10 for 
mercaptopurine dosage adjustments.
9.0
CONTINGENCY PLANS FOR REFRACTORY DISEASE OR RELAPSE
9.1
Induction Failures  
Patients who do not attain complete remission (imaging, morphologic BM exam, or MRD 
studies of BM or PB) after remission induction, consolidation treatment and 
reintensification treatment will be removed from the protocol treatment.  Patients who do 
not achieve a remission after induction therapy, but subsequently attain complete 
remission after consolidation or reintensification treatment, are candidates for allogeneic 
HSCT.


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9.2
Relapse
Patients with any form of relapse (original site, lymph node, bone marrow, testes, 
ovarian, etc.) except that of CNS will be eligible for relapse protocols.  Patients with 
overt CNS relapse (i.e.  5 WBC/L of CSF with blasts) will remain on study and 
receive the treatment outlined in section 9.3.  Patients who have <5 WBC/L of CSF with 
identifiable blasts are not considered to have overt CNS relapse and will be treated as 
outlined in section 9.3.
9.3
Emergence of CSF Lymphoblasts During Remission Requiring CNS Radiation
Therapeutic cranial irradiation will not be given consolidatively to patients with CNS 
disease at diagnosis. Patients with immunologically proven leukemic lymphoblasts in 
CSF (regardless of cell count) during remission on 2 occasions in the study will receive 
therapeutic CNS irradiation after consultation with radiation oncologists and after 
receiving a second remission induction (as detailed in section 5.2), followed by 1 or 2 
cycles of reintensification (as detailed in section 5.4) to consolidate remission after 
induction. Whether 1 or 2 cycles will be given will depend on risk group, time to 
emergence of blasts in CSF, immunophenotype of blasts, and individual patient tolerance. 
In general, patients with early occurrence (<18 months) will receive 2 cycles, but this 
should be discussed with the PI. IT-MHA therapy will be continued every 3 to 4 weeks.
CNS irradiation for patients with CNS relapse will be as follows:  cranial irradiation (24 
Gy in 16 fractions) for patients with <5 WBC/μL of CSF occurring within the first 18 
months of remission; cranial irradiation (18 Gy in 12 fractions) for those with any 
number of leukemic lymphoblasts in CSF after 18 months of initial remission; and 
craniospinal irradiation (24 Gy cranial irradiation in 16 fractions plus 15 Gy spinal 
irradiation in 10 fractions) for patients with >5 WBC/μL of CSF occurring within the first 
18 months of remission. Patients receiving cranial irradiation only should receive 4 or 5 
doses of IT-MHA therapy with leucovorin rescue during irradiation.  Mercaptopurine and 
methotrexate will be withheld for at least 1 week before and during irradiation; systemic 
chemotherapy during irradiation will include dexamethasone and vincristine with or 
without PEG-asparaginase. Continuation treatment will be given for at least 1 year from 
time of relapse (at least 2.5 years, including initial treatment).
10.0
PHARMACOKINETIC AND PHARMACODYNAMIC STUDIES
10.1
High-Dose Methotrexate (HD-MTX) 
Blood (2–3 mL) will be obtained in EDTA tubes (purple top) pre-dose and between 0.5 
and 6 h, 23 h, and 42 h from the start of infusion.  Samples at additional time points will 
be obtained in patients in whom there is clinical suspicion of poor clearance, or in those 
who have high plasma MTX concentration (e.g., >0.5 M at 42 h) in order to adjust 
leucovorin rescue. (Note: blood should be in purple top tube to facilitated nucleic acid 
recovery from the buffy coat).  Collaborating sites should follow local practice for MTX 
monitoring.


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11.0
EVALUATIONS, TESTS, AND OBSERVATIONS
11.1
Pretreatment Evaluation
All participants should be invited to participate in the Tissue Banking Protocol (TBANK) at 
the time of study entry, and the following exams/tests will be conducted: 
All pre-treatment tests are standard of care (except some fertility studies, see Section 11.4)
Complete history and physical exam, 
with careful notation and assessment 
of clinical signs relevant to 
lymphoma
Complete blood count with 
differential
Chemistry profile: glucose, 
electrolytes, blood urea nitrogen 
(BUN), creatinine, lactate 
dehydrogenase (LDH), uric acid, 
bilirubin, SGOT, SGPT, calcium, 
phosphorous, magnesium, total 
protein and albumin.
Lipid screen: Total cholesterol, 
triglycerides, free fatty acids, and 
high-density lipoprotein cholesterol
Plasma 25-hydroxyvitamin D, 
osteocalcin N-MID, urine N-
Telopeptide with creatinine, bone 
specific alkaline phosphatase, 
parathyroid hormone
Thyroid function test (free T4, TSH)
Chest X-ray
Echo (echocardiogram)/EKG 
(electrocardiogram) and/or multiple 
gate acquisition scan (MUGA)
Neck/chest/abdomen/pelvis CT
Positron emission tomography (PET)/CT 
scan
Biopsy/cytology
Bone marrow evaluation: morphology, 
cytochemistry, immunophenotyping, 
cytogenetics, DNA index, molecular 
diagnosis, MRD studies
Peripheral blood MRD study
Lumbar puncture with CSF examination 
(cell count with differential of cytospin 
preparation) 
Other studies as clinically indicated, e.g. 
sickle cell prep, hemoglobin 
electrophoresis, and G6PD screen for 
Black children; varicella titer; Hepatitis 
B antigen; HIV, Epstein-Barr virus 
(EBV), toxoplasma (TOXO), 
cytomegalovirus (CMV), histoplasma, 
and Bartonella titers.


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11.2
Required Evaluations, Tests, and Observations During Treatment 
At diagnosis
Induction & 
Consolidation
Continuation
Reinduction I & II
History and physical 
exam
At diagnosis
q3-7 days 
q4 week
q3-7 day
CBC with differential
At diagnosis
Weekly
Weekly
Weekly
Coagulation screen
At diagnosis
---
---
---
Uric acid, electrolytes, 
calcium phosphorous, 
magnesium
At diagnosis
Before each HD-MTX 
As indicated
Day 1 (Weeks 7 & 17)
Serum glucose, urinalysis
At diagnosis
As indicated
As indicated
As indicated
Bilirubin, SGOT, SGPT, 
total protein, albumin,
LDH, BUN, creatinine
At diagnosis
Before each HD-MTX 
As indicated
Day 1 of Weeks 7, 8, 
9, 17, and 19 
MRD
(see tables below)
At diagnosis
Day 8 
( days 15 and 22)*, and 
end of induction
Week 49*
Week 98 or 120**
Day 1
Weeks 7 & 17*  
Total cholesterol, 
triglycerides, free fatty 
acids, and high-density 
lipoprotein cholesterol
At Diagnosis
 - - - 
After completion of 
therapy (Week 98 or 
120**, or later)
Day 1 of each re-
Induction (Day 1 of 
Weeks 7 and 17)
CSF studies
At diagnosis 
(with first 
intrathecal 
treatment)
With each intrathecal 
treatment
With each intrathecal 
treatment and Week 98 
or 120** 
With each 
intrathecal treatment
Chest X-ray
At diagnosis
As indicated  
As indicated
As indicated
Biopsy/cytology
At diagnosis
Bone marrow aspirate and 
biopsy
At diagnosis
End of induction†
Week 98 or 120**
Day 1 (Weeks 7, 17, 
49)‡
Neck/chest/abdomen/pelv
is CT
At diagnosis
End of induction
Week 98 or 120**
Prior to week 7§
NM PET/CTscan
At diagnosis
End of induction
Week 98 or 120**
Prior to week 7§
EKG and Echo and/or 
MUGA, Troponin T, 
Natriuretic hormone 
levels##
At diagnosis
1 year from enrollment
Week 98 or 120**
Total joint MRI  
(shoulders, elbows, hips, 
knees and ankles: >9 year 
olds only)
- - -
End of induction
After completion of 
therapy (Week 98 or 
120**, or later)
After each reinduction 
phase (Weeks 12-14 
and 22-30)
QCT for bone density
Week 1
- - -
After completion of 
therapy (Week 98 or 
120**, or later)
- - -


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Required Evaluations, Tests, and Observations During Treatment
At diagnosis
Induction & 
Consolidation
Continuation
Reinduction I & II
Plasma 25-
hydroxyvitamin D, 
osteocalcin N-MID, urine 
N-Telopeptide with 
creatinine, parathyroid 
hormone, bone specific 
alkaline phosphatase, 
serum calcium and serum 
magnesium
At diagnosis
- - -
After completion of 
therapy (Week 98 or 
120**, or later)
- - -
Spot urine for 
magnesium, creatinine, 
calcium, and 
calcium/creatinine ratio¶
At diagnosis
- - -
After completion of 
therapy (Week 98 or 
120**, or later)
- - -
PT/OT evaluation (>9 
year olds only)
- - -
- - -
After completion of 
therapy (Week 98 or 
120**, or later)
After each reinduction
TPMT genotype
Day 3 (TPMT genotype)
TPMT and TGN
- - -
- - -
Day 1 of Week 7 
(TGN) and week 
17(TPMT activity)
CYP2D6 genotyping
Day 3
MTX pharmacokinetics
- - -
Each HD-MTX
- - -
Thyroid function
At diagnosis
- - -
As clinically indicated
- - -
Fertility studies##
At diagnosis
- - -
- - -
- - -
Pregnancy test#
At diagnosis
- - -
- - -
- - -
Note: CBC, complete blood count; BUN, blood urea nitrogen; LDH, lactate dehydrogenase; CT, computed 
tomography; MRD, minimal residual disease; PET, positron emission tomography; Echo, echocardiogram; EKG, 
electrocardiogram; MUGA, multiple gate acquisition scan; PT/OT, physical therapy/occupational therapy; TGN, 
thioguanine nucleotide; TPMT, thiopurine methyltransferase; HD-MTX, high-dose methotrexate.
*See tables below for samples required for MRD studies.
** Patients with MDD ≥1% at diagnosis and day 8 MRD positive in T-lymphoblastic lymphoma (Stratum 3), CNS or 
testicular involvement.
†For patients with positive bone marrow at diagnosis only.
‡ Bone marrow aspiration is to be performed if the patient has: 1) circulating blast cells; 2) unexplained 
organomegaly or lymphadenopathy; 3) unexplained bone pain; 4) suspected or documented extramedullary disease; 
or 5) 2 weeks after stopping chemotherapy because of a low ANC or platelet count, the ANC still is <750/μL or the 
platelet count < 100,000/μL.
§ Patients with abnormal imaging evaluations at end of induction.
¶If the calcium: creatinine ratio exceeds 0.2, then a 24-h urine will be collected for creatinine, 
calcium, and calcium/creatinine ratio.
# Applies only to female patients of childbearing potential
## See section 11.4 for details and the timing for long-term follow-up evaluations


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Samples required for MRD studies during remission induction
Time point
T-lineage lymphoma
Diagnosis
BM and PB
Day 8
PB
 (Day 15 if MRD+ on Day 8)
PB
 (Day 22 if MRD+ on Day 15) 
PB
Day 43 (End of induction)
PB
Note: PB, peripheral blood; BM, bone marrow
Samples required for MRD studies post-remission induction
Time point
T-lineage lymphoma 
Day 1 (Weeks 7, 17, 49)
PB
Week 98 or 120 (off therapy)
PB
Note: PB, peripheral blood; ETP, early T-cell precursor.
11.3
Suggested Off-Therapy Evaluations
The recommended follow-up for patients is every 4 months for the first year, every 6 
months for the second year, and then yearly until the patient is in remission for 10 years 
and is at least 18 years old.  Thereafter, patients will become alumni and will be followed 
according to the institution’s policy.  During their follow-up visit, CBC with differential 
and other laboratory studies as clinically indicated will be performed.  It is recommended 
that QCT for bone density be performed at 5 years off-study.
Patients will be considered off therapy 30 days after the last treatment taken.  Adverse 
events will not be reported while patient is off therapy unless they are deemed related to 
therapy by the site PI.  
After attaining continuous, complete remission for 6 years or more, patients treated at St. 
Jude will be invited to participate in a long-term follow-up umbrella protocol and may be 
referred to the After Completion of Therapy (ACT) clinic.
When a patient treated at St. Jude has been in remission for 10 years and is at least 18 
years of age, he/she will become St. Jude alumni and will be followed according to 
institutional policy.
11.4
Suggested Long-Term Follow-up Evaluations
11.4.1 Fertility studies
The following tests and evaluations are recommended to monitor the late effects on 
fertility at pretreatment, 2 years from enrollment, 5 years from enrollment, at Tanner III 
and V (if not already studied)


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Males
Standard of care (SOC)

Pubertal development evaluation (annually)

FSH, LH, and testosterone (annually)
Research (R)

Semen analysis (through Fertility Associates of Memphis)

Inhibin B level
Females
Standard of care (SOC)

Pubertal development evaluation (annually)

FSH, LH, and Estradiol (annually)
Research (R)

Anti-müllerian hormone (AMH)
11.4.2 Cardiac studies
The following tests and evaluations are recommended to monitor the cardiac late effects 
at pretreatment, off therapy, 1 year from enrollment, and 5 years from enrollment:  These 
tests are standard of care:

2D-echocardiogram

Troponin T levels

Natriuretic hormone levels (NT-PRO BNP)
12.0
EVALUATION CRITERIA
12.1
Response Criteria
12.1.1
Complete Response
Complete Response-A (CR-A)
This includes PET negative patients with complete disappearance of all clinical evidence 
of disease by physical examination, by imaging studies, by bone marrow aspirate/biopsy 
(where indicated), and by CSF evaluation (where indicated). Bone marrow must contain 
<5% blasts. For patients with CNS disease, CSF WBC must be <5/μL with no blasts or 
lymphomatous cells present on 2 consecutive taps. MRD must be negative. 


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Complete Response-B (CR-B)
This includes patients who have a >55% decrease in a sum of the products of the two 
greatest perpendicular diameters (SPPD) of the 6 largest dominant nodes or nodal masses. 
These nodes or masses should be selected according to the following features:
a) they should be clearly measurable in at least 2 perpendicular dimensions
b) they should be from as disparate regions of the body as possible
c) they should include mediastinal and retroperitoneal areas of disease whenever 
these sites are involved.
PET must be negative. Bone marrow must contain <5% blasts. For patients with CNS 
disease, CSF WBC must be <5μL with no blasts or lymphomatous cells present on 2 
consecutive taps. MRD must be negative.
Complete Response-C (CR-C)
This group includes those with residual diagnostic imaging abnormality that is biopsy 
negative for lymphoma. MRD must be negative.
Complete Response-D (CR-D)
CR-B criteria with residual PET uptake in a mass that is not safely assessable for biopsy 
in the judgment of clinicians (i.e. risk/benefit ratio is too high). MRD must be negative.
Complete Response-E (CR-E)
Includes patients who are CR-A, CR-B, CR-C, or CR-D but MRD positive.
12.1.2 Partial Response (PR)
This includes patients with a decrease of 30% or more of the SPPD of the 6 largest 
dominant nodes or nodal masses, but not satisfying the criteria for CR-B, CR-C or CR-D. 
Bone marrow must contain <5% blasts. For patients with CNS disease at diagnosis, CSF 
WBC must be less than 5/μL with no blasts or lymphomatous cells present.
12.1.3 Stable Disease (SD)
This includes patients not satisfying the definition of CR-A, CR-B, CR-C, CR-D, CR-E, 
PR, RL or PD.
12.1.4 Relapse (RL)
In patients who have responded completely to therapy (including surgery), RL is 
indicated by the appearance or reappearance of tumor at any site (biopsy proven). 
Reappearance of cranial nerve palsy alone without definitive evidence of CNS 
involvement is not sufficient evidence of CNS relapse.


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12.1.5 Progressive Disease (PD)
In patients with detectable residual disease, PD is indicated by an increase of >25% of the 
SPPD at any site of residual disease compared with immediate prestudy SPPD or to the 
SPPD of best prior response at that site, or the reappearance of tumor in sites of 
involvement (including marrow or CNS) which had responded completely to therapy 
(including surgery), or the appearance of tumor in previously uninvolved sites. 
Reappearance of cranial nerve palsy alone without definitive evidence of CNS 
involvement is not sufficient evidence of CNS relapse.
12.1.6 Treatment Failure
1. Failure to achieve CR-A, CR-B, CR-C or CR-D at week 7 of continuation therapy 
(prior to reinduction I) or after reintensification treatment. There must be 
histopathologic confirmation of disease. (Contact the PI or co-PI if there are 
problems in this confirmation.)
2. Progressive disease at any time.
3. Relapse at any time. There must be histopathologic confirmation of disease 
(Contact the PI or co-PI if there are problems in this confirmation.)
12.2
Toxicity Evaluation Criteria
CTCAE Version 4.0 [available for download from http://ctep.info.nih.gov] will be used 
for toxicity and performance reporting in NHL 16. The toxicities will also be reported on 
the appropriate data collection forms.
12.3
Acceptable Percentage of Missed Doses for Commercially Available Drugs
It is understood that deviations from the protocol should be avoided, except when 
necessary to eliminate an immediate hazard to a research participant. In such case, the 
deviation must be reported to the IRB.   However, it is expected that patients will 
occasionally miss some doses or receive the wrong dose of oral chemotherapy.  
Compliance with oral medication will be captured in the CRIS database and appropriately 
documented in the participants’ medical records.  Appropriately documented doses of 
missed or wrong doses of chemotherapy will not constitute a deviation unless the amount 
in question is over 10% of the expected total dose due in the respective protocol cycles 
(these are specified in the CRIS NHL16 database).   Missed doses do not include doses 
held or reduced for medical reasons (toxicity, illness) and will not be considered protocol 
deviations or violations
13.0
SUPPORTIVE CARE
13.1
Fever at Diagnosis
All patients with fever at diagnosis will be administered broad-spectrum parenteral 
antibiotics until an infectious etiology can be excluded.


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13.2
Metabolic Derangements
It is important to prevent or treat hyperuricemia and hyperphosphatemia with secondary 
hypocalcemia resulting from spontaneous or chemotherapy-induced leukemic cell lysis, 
especially in T-lymphoblastic lymphoma.

Patients with a large lymphoma cell burden should receive hydration and an oral 
phosphate binder (aluminum hydroxide in those with relatively high calcium 
levels and calcium carbonate in those with low calcium levels).  Sevelamer 
(Renagel®) or lanthanum (Fosrenol®) can be used in patients who cannot tolerate 
aluminum hydroxide or calcium carbonate.

Patients with a large lymphoma cell burden with or without hyperuricemia (e.g., 
uric acid 7.5 mg/dl or  6.5 mg/dl in patients younger than 13 years) may be 
treated with rasburicase if they have no history of G6PD deficiency or ongoing 
pregnancy.  Patients with a history of severe allergy (e.g., bronchial asthma 
requiring bronchodilator, atopic eczema), may be enrolled on RASALL. For all 
other patients not at high risk of hyperuricemia, hydration, allopurinol, and 
judicious use of alkalinization (maintaining urine pH between 6.5 and 7.4) may be 
sufficient.  
13.3
Management of Airway Obstruction and Superior Vena Cava Syndrome
Some of these patients will present as acute emergencies. In these patients, the pre-
treatment evaluation will be necessarily curtailed or completed as soon as possible after 
initiation of treatment. Airway obstruction may require emergency institution of therapy 
to reduce obstruction. Two alternative methods may be used as emergency treatment. 
Irradiation to the mediastinal mass (180 rad/dose x 3 doses) may be used, or 
methylprednisolone 20 mg/m² in 4 divided doses for one day. The use of 
methylprednisolone may be accompanied by tumor lysis syndrome, and may cause 
alteration of tumor histology in patients not yet biopsied.
13.3.1 Mediastinal Mass
Attempted resection of a mediastinal mass is not recommended. In most of these patients 
the diagnosis may be established by biopsy of a lymph node in the cervical or 
supraclavicular regions or by cytologic assessment of the pleural fluid.
13.4
Osteonecrosis of the Bone
 
Osteonecrosis of the bone, a known complication of treatment with corticosteroids, can 
occur in approximately 10%–15% of patients, especially those older than 9 years.  This 
devastating complication may result in collapse of the articulating surface, with 
subsequent pain and development of arthritis.  Early detection of small lesions can permit 
intervention, which may prevent pain and irreversible damage of the joints.  In NHL 16, 
all patients 9 years and older will undergo total joint MRI scans of the shoulders, elbows, 


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pelvis/hips and knees after each reinduction phase, at off-therapy date, and as needed 
thereafter.  Patients diagnosed with osteonecrosis (see section 7.8) will be referred to 
orthopedics. Any patient who develops symptoms of joint pain before or between 
scheduled MRI scans should undergo MRI to rule out osteonecrosis or progression of this 
complication.
For patients who require surgical intervention, treatment will vary, based on the degree of 
progression (i.e., observation, core decompression, bone grafting, and resurfacing 
hemiarthroplasty). 
 
13.5
Pancytopenias  
Patients with prolonged (>3 weeks) unexplained anemia (hemoglobin <7 g/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).
13.6
Nutritional Supplementation  
When patients are administered nutritional or vitamin therapies, they should not receive 
more than the recommended daily allowance (RDA) for folic acid with dietary and 
supplement intake, in order to prevent interference with the effectiveness of methotrexate.
13.7
Drug Interactions
Because concurrent use of enzyme-inducing anticonvulsants (e.g. phenytoin, 
phenobarbital, and carbamazepine) with anti-lymphoma therapy has recently been 
associated with inferior EFS, every effort should be made to avoid these agents, as well 
as rifampin, which also induces many drug-metabolizing enzymes.  Gabapentin 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 
azithromycin) may have potent inhibitory effects on drug-metabolizing enzymes, and the 
doses of some anti-leukemic drugs (e.g., vincristine, anthracyclines, steroids, etoposide) 
may need to be reduced in some patients on chronic azole antifungals or antibiotics.  The 
pharmacokinetics Service should be consulted if the long-term use of these interacting 
drugs is unavoidable. 
Penicillin interferes with tubular excretion of methotrexate, and it is recommended that 
an alternative non-penicillin antibiotic be used.
13.8
Down Syndrome
Patients with Down syndrome should be closely monitored for toxicity, and offered 
aggressive supportive care. Methotrexate dosage should be reduced as described in 
section 7.1.1.  Chemotherapy doses may be appropriately reduced to avoid undue 
toxicity. Oral leucovorin (5 mg/m2 q 12 h × 2) should be given 24 h after each IT MHA. 


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A 30% dose reduction of dexamethasone and/or high dose cytarabine should be 
considered for patients with Down syndrome who experience higher than expected 
toxicity during earlier phases of therapy.
13.9
Respiratory Syncytial Virus (RSV) Prophylaxis
All infants should receive prophylaxis for respiratory syncytial virus (RSV) as per current 
institutional policy.
14.0 
OFF THERAPY AND OFF STUDY CRITERIA
14.1
Off-Treatment Criteria
Patients will be taken off NHL16 therapy if any of the following occurs:

Failure to achieve CR-A, CR-B, CR-C or CR-D at week 7 of continuation therapy 
(prior to reinduction I) or after reintensification treatment

Relapse (except CNS)

Second malignancy (e.g., therapy-induced AML or brain tumor)

Development of unacceptable toxicity during treatment (confirmation by PI or co-
PI required)

Patients with severe congenital immunodeficiency (e.g., ataxia telangiectasia) or 
HIV infection will be taken off NHL16 therapy and will receive alternative 
therapy (to prevent excessive toxicities) with curative intent.

Completion of all protocol-prescribed treatment

Decision of participant or family to withdraw from protocol treatment at any time 
for any reason

PI decides that continued protocol treatment is no longer in the patient’s best interest
14.2
Off-Study Criteria
A patient will be taken off NHL16 study if any of the following occurs:

Death

Lost to follow-up

Withdrawal of consent for continued follow-up

Found to be ineligible (e.g., incorrect diagnosis)
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.


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15.0
BIOLOGIC STUDIES
15.1
Minimal Disseminated Disease (MDD) and Minimal Residual Disease (MRD)
Bone marrow and peripheral blood samples, collected in preservative-free heparin, will be 
obtained at diagnosis. Peripheral blood will be used to monitor response to treatment. 
Mononuclear cells, separated on a density step (Accu-Prep, Accurate Chemical, Westbury, 
NY),  will be labeled with phycoerythrin (PE)-conjugated anti-CD5 (Dako, Carpinteria, 
CA) and a mixture of allophycocyanin (APC)-conjugated anti-CD33 and anti-CD19 
(Becton Dickinson, San Jose, CA). After permeabilization with reagent 8E (developed in 
our laboratory from a proprietary formula), cells will be stained with fluorescence 
isothyocyanate (FITC)-conjugated anti-TdT (Supertechs, Rockville, MD) and peridinin 
chorophyll protein (PerCP)-conjugated anti-CD3 (Becton Dickinson). Anti-TdT-FITC 
will be replaced by a FITC-conjugated isotype-matched non-reactive immunoglobulin 
(Becton Dickinson) in control tubes. We will also use 9-color staining including 
antibodies such as anti-CD34-FITC, anti-CD3-PerCP (cytoplasmic), anti-CD19- and anti-
CD33-APC, anti-CD5-PECy7, anti-HLA-Dr-APCCy7, anti-CD4-Pacific Blue, anti-CD8-
AmCyan, anti-CD3-Alexafluor 700 (surface; all from Becton Dickinson), and anti-CD1a- 
(Beckman Coulter, Miami, FL) or anti-CD99-PE (Becton Dickinson). Cells (2-5 x 105 in 
each sample) will be analyzed with a FACSCalibur, FACScanto or LSR II flow 
cytometers (all from Becton Dickinson) as previously described.35 
15.2
Early T-cell Progenitor Phenotype
The early T-cell progenitor (ETP) phenotype is defined by the expression of CD7 and 
cytoplasmic (or surface) CD3, the lack of CD1a and CD8 expression, dim expression of 
CD5, and exprerssion of one or more stem cell/myeloid-associated markers such as 
CD117, CD34, HLA-DR, CD13, CD33, CD11b.39 The expression of this phenotype will 
be determined by flow cytometry in cases with disseminated disease at diagnosis. To this 
end, bone marrow and/or peripheral blood mononucleated cells obtained for studies of 
disseminated disease described in 15.1 will be labeled with antibodies directed against 
the markers that define that ETP phenotype. Cell staining and analysis will be performed 
as described in 15.1 using multiparameter flow cytometry.  
15.3
Gene Expression Analysis
Total RNA will be isolated from tumor tissue by using the TriZOL reagent (Invitrogen, 
Carlsbad, CA). RNA will be quantitated by spectrophotometry using a Nanodrop 
(ThermoScientific, Wilmington, DE), and integrity assessed using a bioanalyzer (Agilent 
Technologies, Palo Alto, CA) to calculate the RNA integrity index. Nondegraded RNA 
samples will be processed for gene expression profiling, using U133 Plus 2.0 gene 
expression arrays (Affymetrix, Santa Clara, CA) or gene and exon arrays, or their 
combination. Briefly, 100 ng of total RNA will be amplified, labeled, fragmented, 
hybridized to arrays, and scanned as per manufacturer’s protocols by the Clinical 
Applications Core Technology (CACT) laboratory at the Hartwell Center for 
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Microarrays Suite v 5.0 (Affymetrix) or equivalent programs. Array quality will be 
assessed by using various metrics such as background, noise, scale factor, present calls, 
and GAPDH/ACTIN 3’/5’ ratios. 
15.4
Copy Number Alteration
Genome wide profiling of DNA copy number alterations and loss-of-heterozygosity 
(LOH) will be performed using Affymetrix SNP 6.0 arrays, or equivalent state-of-the-art 
arrays available at the time of the study. SNP array execution, data processing, and lesion 
calling will be performed by using an analysis pipeline established and subject to ongoing 
modification and refinement at St Jude. Briefly, high-molecular-weight DNA will be 
extracted from tumor and normal tissue (e.g., peripheral blood leukocytes or bone 
marrow aspirates free of tumor) by column-based methods (e.g., DNA blood mini, 
Qiagen) or by organic extraction. DNA will be quantified by spectrophotometry 
(Nanodrop), fluorescence (e.g., PicoGreen, Invitrogen), or their combination, and 
integrity assessed by electrophoretic analysis of DNA (50–100 ng) on a 0.8% agarose gel. 
Samples exhibiting degradation will not be processed further, and, if possible, extraction 
will be repeated. 500ng DNA will be processed for SNP arrays by the CACT laboratory. 
Restriction enzyme digestion, PCR amplification, cleanup, labeling, array hybridization, 
and scanning will be performed as per the manufacturer’s instructions. 
15.5
Mutation Analysis
Mutation analysis will be performed by genomic PCR and Sanger sequencing of whole-
genome amplified DNA (RepliG, Qiagen). Sequence quality assessment and mutation 
detection will be performed as previously described.83 Putative mutations will be 
validated by sequencing of tumor and matched normal DNA (including nonamplified 
DNA if available). 
15.6
Genomic Comparison between T-Lymphoblastic Lymphoma and T-ALL
The investigators have access to SNP array and gene expression data for more than 100 
St. Jude T-lineage ALL samples studied on protocols Total XII, XIII, XV and XVI. Copy 
number data will be directly compared to this data set for (1) lesion type; (2) lesion 
frequency; (3) association of lesions with tumor subtype (defined by clinical, pathologic, 
genetic or microarray analyses); and (4) effect on gene expression identified by local or 
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16.0
STATISTICAL CONSIDERATIONS
16.1
Primary Objective
Improve the outcome of children who have minimal disseminated disease (MDD) equal to 
or more than 1% at diagnosis by using MDD- and minimal residual disease (MRD)–
based risk-adapted chemotherapy.
Accrual:  The institutional trial NHL-13 ran 10 years and enrolled 41 evaluable patients. 
The PI has indicated that NHL-16 will be a multi-institution trial and predicts that the 
accrual rate will be at least double that of NHL-13. We plan to accrue patients for 5–11 
years. Assuming that 7 evaluable patients are enrolled per year, we expect to accrue 72 
evaluable patients in approximately 10.5 years. We expect that approximately 30% of 
patients will have MDD equal or more than 1% at diagnosis; hence, we expect to enroll 
22 evaluable patients for the primary objective.
Analysis:  This is a phase-II clinical trial. Outcome of this subset of patients will be 
analyzed in terms of overall survival (OS) and event-free survival (EFS) since diagnosis. 
Only death will be considered a failure for OS. 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. Kaplan-Meier 
estimates of the OS and EFS curves will be computed, along with estimates of standard 
errors by the method of Peto.84 Two-year EFS and OS, as well as longer term survival 
rates (5 year and 10 year) will be estimated with 95% confidence intervals. 
The objective here is estimation instead of comparison. Comparisons to historical 
controls are considered exploratory. The limited COG A5971 study data show that the 2 
year EFS in this patient subset is 68.1% although chemotherapy was not modified based 
on lymphoma cell involvement at diagnosis.35 The sample size n=22 provides 85% (71%) 
power for a one-sided log-rank test at the 5% level if the true 2 year EFS in the newly 
treated patients is 88.1% (83.1%) compared to the “historical” 68.1% in a simple null 
hypothesis. 
Analysis will begin after 2 years of follow up since the completion of therapy of the last 
enrolled patient.
16.2 
Secondary Objectives
16.2.1 Estimate the event-free survival and overall survival of children with 
lymphoblastic lymphoma who are treated with MDD/MRD based risk-directed therapy.
EFS and OS function estimates of NHL-13 is provided below for background 
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OS and EFS are defined as in Section 16.1; the survival functions will be estimated in the 
same way as described therein. Analysis will begin at the same time as the primary 
objective, i.e., after 2 years of follow up since the completion of therapy of the last 
enrolled patient.
16.2.2 Evaluate the prognostic value of levels of MDD at diagnosis and MRD on day 8 
of remission induction.
Prognostic value of MDD and MRD on day 8 will be evaluated by their associations with 
the risk of relapse. MDD and MRD will be considered as either binary (negative vs. 
positive) or continuous/ordinal variables. Gray’s test for comparing cumulative incidence 
functions (for binary MDD/MRD) and Fine and Gray hazard rate regression modeling 
(for continuous MDD/MRD) will be applied. Death in remission and second malignancy 
are considered as competing risks. Analysis for this aim will begin at the same time as the 
primary objective.
16.3 
Exploratory Objectives
16.3.1 Estimate the frequency of early T cell progenitors in lymphoblastic lymphoma
The proportion of ETP will be estimated by the sample proportion along with the 
binomial distribution–based exact 95% confidence interval. Analysis will begin within 
six (6) months after the last enrollment.


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16.3.2 Evaluate copy number, gene expression, and mutations in tumor and normal 
tissues of patients 
DNA copy numbers and mutations in tumor cells will be detected using established 
methods.85  Differential gene expression profiling between tumor and normal tissues will 
be performed by paired t-tests on log-transformed gene (RNA) expression signals. Levels 
of false-positive and false-negative errors will be assessed by established methods.86-88 
Microarray data will be analyzed by using several complementary approaches. Gene 
expression data will be filtered by excluding probe sets called as absent across all arrays. 
Unsupervised hierarchical clustering will be performed for all probes remaining after this 
filtering, and after selection of probes exhibiting the greatest variation in intensity across 
the dataset (e.g., after using a coefficient of variation or minimal absolute deviation filter 
criterion).  This approach will be used to identify subgroups of cases defined by gene 
expression profiling, and associations between these clusters and clinical, pathologic, and 
genetic variables will be examined. Integrated analysis of copy number alteration and 
local gene expression data will be performed by using a linear regression model to assess 
associations between copy number alterations and local gene expression. The similarity 
between the gene expression profile of T-lymphoblastic lymphoma and T-lineage acute 
lymphoblastic leukemia will be performed using Gene Set Enrichment Analysis or 
alternative statistical methods developed by the Departments of Biostatistics and 
Computational Biology during the course of the study.89-91 
Array data will be processed using Genotyping Console (Affymetrix) or equivalent 
command-line/developer tools (Affymetrix). Contrast QC rates will be used to assess 
quality, arrays called “out-of-bounds” discarded, and arrays repeated. SNP genotyping 
will be performed for not less than 44 arrays per batch, using the Birdseed v2 or an 
equivalent algorithm. Probe-level intensity data will be summarized by using the model-
based expression intensity algorithm implemented in dChip92 or alternative approaches 
developed by Drs. Pounds and Cheng (Biostatistics).85 Raw array data will be normalized 
by using reference normalization or alternative approaches that incorporate correction of 
signal intensity for aneuploidy. Inference of copy number alterations will be performed 
using circular binary segmentation (CBS) implemented in Bioconductor,93,94 and raw 
segmentation outputs compared to array data in dChip. For samples with corresponding 
normal DNA also run on arrays, segmentation will be performed pairwise (tumor vs. 
matched normal). For tumors lacking matched normal samples, segmentation will be 
performed unpaired, in which data from each array will be compared to a pool of within-
batch control samples. For unpaired analyses, somatic (tumor-acquired) lesions will be 
distinguished from inherited copy number variants by comparing lesions to online 
databases of CNVs95 and in-house databases of CNVs acquired from several hundred 
normal/remission SNP arrays. LOH data will be analyzed by using Hidden Markov 
Models (HMM) or equivalent approaches.
Subsequent analysis of copy number data will include manual tallying of recurrent 
lesions and computational approaches to identify regions of significant recurrence (e.g., 


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GISTIC, Beroukhim). Integrated analysis with copy number alterations will be performed 
as described above.
Analysis will begin within six (6) months after the last enrollment.
16.3.3 Compare the immunophenotyping, MRD, and genomic data between T-
lymphoblastic lymphoma and T-acute lymphoblastic leukemia (ALL)
Frequencies of ETP and positive MRD between T-lymphoblastic lymphoma and T-ALL 
will be compared by Fisher’s exact test. Large-scale comparisons of genomic features 
between the 2 diseases will be conducted by statistical tests (rank-sum test for continuous 
or ordinal features, Chi-square or Fisher’s exact test for categorical features), and levels 
of false-positive and false-negative errors will be assessed by established methods.86-88 
Available methods [gene set enrichment analysis (GSEA)89-91] and those developed by 
the Department of Biostatistics and the Department of Computational Biology during the 
course of the study will be applied to detect and compare multigenetic and pathway 
differences between the 2 diseases. Analysis will begin within six (6) months after the 
last enrollment.
16.3.4 Bone mineral density (BMD) and osteonecrosis
16.3.4.1  Prospectively estimate BMD at diagnosis and at end of therapy and correlate with 
risk factors for potential BMD deficits in pediatric patients with NHL.
BMD levels at diagnosis and at the end of therapy will be analyzed by descriptive 
statistics, including mean, standard deviation, median, quartiles, and range. General linear 
models will be applied to assess the associations between BMD and potential risk factors 
for BMD deficits.
16.3.4.2  Prospectively monitor osteonecrosis and correlate with risk factors for potential 
osteonecrosis in pediatric patients with NHL.
Frequency of osteonecrosis will be estimated by using sample proportion and cumulative 
incidence function estimates. Logistic regression and Fine and Gray regression modeling 
will be applied to analyze the association between the risk of osteonecrosis and potential 
risk factors. 
Analysis for this aim will begin at the same time as the primary objective.
16.3.5 Fertility and cardiac late effects 
16.3.5.1 Establish the prevalence of gonadal and germ cell dysfunction associated with 
NHL 16. 
The prevalence of gonadal and germ cell dysfunction will be estimated by the sample 
proportion and an exact 95% confidence interval.


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16.3.5.2  Establish the prevalence and severity of cardiac toxicity associated with 
NHL16.
The same statistics in section 16.3.4.1will be applied to analyze this objective.  Analysis 
for this aim will begin at the same time as the primary objective.
17.0
SAFETY AND ADVERSE EVENT REPORTING REQUIREMENTS
17.1
Reporting Adverse Experiences (AEs) and Deaths 
Only “unanticipated problems involving risks to participants or others” referred to 
hereafter as “unanticipated problems” are required to be reported to the St. Jude 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, only 
adverse events that constitute unanticipated problems are reportable to the St. Jude 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.  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 St. Jude 
IRB, but in no event later than 48 hours after the investigator first learns of the death. 
The following definitions apply with respect to reporting adverse experiences: 
Serious Adverse Event: Any adverse event temporally associated with the subject’s 
participation in research that meets any of the following criteria:

results in death;

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;


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
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: 

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, 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.
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 

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. 
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 
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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. 
17.2
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.  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), 
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.  Grade 3-5 
events will be reported with 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 AE reports generated from the research 
database, and corrections will be made if applicable.  Once the information is final, the PI 
will sign and date these reports, to acknowledge his/her review and approval of the AEs 
as entered in the research database.
17.3
Process for Reporting AEs from Collaborating Sites to St. Jude and from St. Jude 
to Collaborating Sites
Adverse events from collaborating sites will also be reviewed by the PI and discussed in 
study team meetings as described above.  SAE report from collaborating sites for AEs 
that are serious, unexpected, and at least possibly related to protocol treatment or 
interventions will be reported to the site’s 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 the other 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 TRACKS 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.  
At a minimum, Grade 3-5 AEs and expected/unrelated deaths that occur more than 30 
days after last protocol treatment will be reported to all sites via a study progress report at 
the time of continuing review.
FURTHER GUIDELINES FOR REPORTING OF ADVERSE EVENTS AND 
UNANTICIPATED PROBLEMS
To determine whether an adverse event is an unanticipated problem, and therefore 
requires expeditious reporting under 45 CFR part 46, the PI will take into account the 
following:
1. The description of known or foreseeable adverse events and risks in the IRB-
approved research protocol, any applicable investigator brochure, the current 
IRB-approved informed consent document, and other relevant sources of 
information, such as scientific literature, product labeling, and package inserts.
2. Any underlying diseases or conditions of the subject experiencing the adverse 
event.
3. A careful assessment of whether the adverse event is related or possibly related to 
the subject’s participation in the research study.
Particular AEs and SAEs require more prompt reporting to the various governing 
regulatory authorities.  The key to whether a SAE should be reported expeditiously or not 
to the St. Jude IRB is based on its expectedness of the event.  Is this SAE an expected or 
unexpected event?  Expeditious reporting to the various Federal governing regulatory 
authorities is based on the relationship of the unexpected event to the protocol treatment 
and the seriousness of the event.  
Serious adverse events that are identified by the PI or designated sub-investigator as 
expected, regardless of causality are not subject to expedited reporting.  All expected 


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SAEs will be reported to the St. Jude IRB and St. Jude Office of Regulatory Affairs in a 
summary type format on an annual or semi-annual basis or more frequently if requested 
by the IRB, FDA, or PI.
All unexpected SAEs that are at least possibly related to the protocol treatment need 
to be reported to the IRB’s at all participating sites expeditiously.  The nature and 
severity of the event will dictate the exact time frame for expeditious reporting (24 – 48 
hours vs. 10 days).  
Expeditious Adverse Event Reporting Requirements to the St. Jude IRB
All deaths that occur while participants are on active therapy or within 30 
days of protocol therapy OR deaths that are deemed unexpected and at least 
possibly related to study treatment will be reported to the St. Jude IRB 
immediately (within 24-48 hours of notification) using the electronic 
TRACKS system.  Immediate reporting is required even if few event specific 
facts are available at the time of the initial report.  In this case, a complete follow-
up report detailing the event should be submitted to the IRB within 10 days of the 
event.
All life threatening SAEs that are deemed unexpected and at least possibly 
related to study treatment will be reported to the St. Jude IRB as soon as possible 
using the electronic TRACKS system but no later than 24 - 48 hours and followed 
up in with a complete report within 10 working days of the occurrence of the 
event. 
All other unexpected SAEs (not fatal or life threatening) determined to be at 
least possibly related to study treatment will need to be reported to the St. Jude 
IRB within 10 working days of the occurrence.
Follow-up Reports
Follow-up reports for the expedited reports submitted to the St. Jude IRB are required for 
those that are checked as “unresolved” at the time of the report.  Typically, follow-up 
reports should be submitted when the investigator becomes aware of significant new 
information regarding the initial event or subsequent patient status, or when the event has 
completely resolved and any sequelae have been identified and/or resolved.
18.0
INFORMED CONSENT PROCESS
18.1
Consent at Enrollment and Post-Remission Therapy
The process of informed consent for NHL16 will follow institutional policy. The 
informed consent process 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 1 witness who is not a physician.  Initially, informed 


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consent will be sought for the T BANK protocol (research study), blood transfusion (if 
needed), the first IT therapy (if the diagnosis of lymphoma is certain either by referral 
bone marrow smears or blood smears at St. Jude), and treatment with recombinant urate 
oxidase, if needed.  After the diagnosis of lymphoblastic lymphoma is established, we 
will invite the patient to participate in the NHL16 protocol, as well as obtain standard 
medical consent for HIV testing.  
The timeline for various informed consents is indicated in the figure below.
At Presentation:
     TBANK (research study)
     Blood transfusion
     Triple Intrathecal Treatment
Diagnosis of Lymphoblastic Lymphoma Established:
     NHL16 induction therapy (research study)
     HIV testing
Throughout the treatment period, participants and their parents will receive constant 
education from health professionals at St. Jude and are encouraged to ask questions 
regarding alternatives and therapy.  All families have ready access to chaplains, 
psychologists, social workers, and the St. Jude ombudsperson for support, in addition to 
that provided by the primary physician and other clinicians involved in their care.  We 
will also obtain verbal assent from children 7–14 years old and written assent for all 
patients 14 years or older.
18.2
Consent at Age of Majority
The age of majority in the state of Tennessee is 18 years old. Research participants on 
active therapy must be consented at the next clinic visit after their 18th birthday. 
Participants, who have reached age of majority and have completed all protocol-directed 
therapy, will be re-consented with a separate consent specifically for this purpose (AOM 
consent). Participants, who reach age of majority after the 10 year protocol required 
follow-up, will be followed for survival and late effects as per the SJLTFU. A waiver for 
AOM consent will be requested for these participants at St. Jude.
If an affiliate site is located in a state where a different age of majority applies, that 
location must consent the participants according to their local laws. 
18.3
Consent when English is Not the Primary Language
When English is not the patient, 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 


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interpreter or the telephone interpreter’s service will be used to translate the consent 
information. The process for obtaining an interpreter and for the appropriate use of an 
interpreter is outlined on the Interpreter Services, OHSP, and CPDMO websites.
19.0
DATA COLLECTION, STUDY MONITORING AND CONFIDENTIALITY
19.1
Data Collection 
Electronic case report forms (eCRFs) will be completed by the SJCRH 
Leukemia/Lymphoma CRAs. 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 Leukemia/Lymphoma Division, 
working with Dr. Inaba or his designee. All protocol-specific data and all grade 3-5 
adverse events will be recorded by the clinical research associates into the CRIS 
database, ideally within 2-4 weeks of completion of study phase. 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.
19.2
Data Collection Instructions for Collaborating Sites
Collaborating sites will collect data either by using eCRFs via remote electronic data 
entry.  All protocol-specific data and all grade 3-5 adverse events will be recorded by the 
clinical research associates into the CRIS database, ideally within 2-4 weeks of 
completion of study phase.
19.3
Study Monitoring
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 TRACKS. 
Monitoring of this protocol is considered to be in the “moderate” risk category.  The 
Monitoring Plan is outlined in a separate document from this protocol, but has been 
submitted for review and approval by the Clinical Trials Scientific Review Committee 
and the Institutional Review Board.
St. Jude affiliates and domestic collaborating study sites will be monitored on-site by a 
representative of St. Jude at intervals specified in the Data and Safety Monitoring Plan.  


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International collaborators will be monitored according to the study-specific monitoring 
plan.
19.4
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.


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20.0
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Appendix I
Revision 3.1, dated 03-03-2015
IRB approval date: 03-27-2015
Protocol version, dated 03-03-2015
Appendix I:  Treatment/Evaluation Calendars
Remission Induction Pretreatment
See order sheets.  Offer enrollment for institutional tissue banking protocol.
1
LP, ITMHA, 
LV rescue
PRED
VCR
DAUNO**
CT/PET scan
BM
MDD
CSF Studies*
PE, CBC diff, 
Uric Acid,  UA, 
Chem. 18
[1, 2, 3]
2
PRED
PE, CBC 
diff, Uric 
Acid, lytes, 
Ca, P, Mg, 
3
PRED
PEG-ASP
PE, CBC 
diff, Uric 
Acid, 
lytes, Ca, 
P, Mg,
[4, 5] 
4
PRED
PE, CBC diff, 
Uric Acid, 
lytes, Ca, P, 
Mg
5 
PRED
PE, CBC diff, 
Uric Acid, 
lytes, Ca, P, 
Mg,bili, SGPT
6
PRED
PE, CBC 
diff, Uric 
Acid, lytes, 
Ca, P, Mg, 
7
PRED
CBC, diff, 
Uric Acid, 
lytes, Ca, 
P, Mg
8
PRED
VCR
DAUNO**
(*)ITMHA, LV 
rescue
MRD
CSF Studies*
9
PRED 
10
PRED 
11
PRED 
12
PRED 
CBC diff
13
PRED 
14
PRED 
15
LP, ITMHA, 
LV rescue
PRED (DEX 
for Stratum 3†)
VCR
PEG-ASP 
TMP-SMZ
MRD‡
CSF Studies*
16
PRED 
(DEX for 
Stratum 
3†)
TMP-SMZ
17
PRED 
(DEX for 
Stratum 
3†)
TMP-
SMZ
18
PRED (DEX 
for Stratum 
3†)
19
PRED (DEX 
for Stratum 
3†)
CBC diff
20
PRED (DEX 
for Stratum 
3†)
21
PRED 
(DEX for 
Stratum 
3†)
22
 (*)ITMHA, LV 
rescue
PRED (DEX 
for Stratum 3†)
VCR
23
PRED 
(DEX for 
Stratum 
3†)
ARA-C
24
PRED 
(DEX for 
Stratum 
3†)
ARA-C
25
PRED (DEX 
for Stratum 
3†)
ARA-C
TG (6MP#)
26
PRED (DEX 
for Stratum 
3†)
ARA-C 
TG (6MP#)
27
PRED (DEX 
for Stratum 
3†)
TG (6MP#)
28
PRED 
(DEX for 
Stratum 
3†)
TG 


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CYCLO (§)
TG (6MP#)
TMP-SMZ
CSF Studies*
MRD‡
TG 
(6MP#)
CYCLO 
(§)
TMP-SMZ
TG 
(6MP#)
TMP-
SMZ
CBC diff
(6MP#)
29
Stop Prednisone 
(or 
Dexamethasone)
TG (6MP#)
PEG-ASP 
TMP-SMZ
30
ARA-C 
TG 
(6MP#)
TMP-SMZ
31
ARA-C 
TG 
(6MP#)
TMP-
SMZ
32
ARA-C
TG (6MP#)
33
ARA-C 
TG (6MP#)
CBC diff, bili, 
24-hour urine, 
Spot urine
34
TG (6MP#)
35
TG 
(6MP#)
36
TMP-SMZ
37 
TMP-SMZ
38
TMP-
SMZ
39
40
CBC diff 
41
42
MRD
CT/PET 
scan
BM ¶ 
[6]
Notes:
* IT methotrexate + hydrocortisone + cytarabine (ITMHA) all participants Day 1 and 15; (*) 
Participants with the following features will receive additional triple intrathecal treatment on 
days 8 and 22: T-lymphoblastic lymphoma (any CNS status) and B-lymphoblastic lymphoma 
with advanced (stages III and IV) disease (including testicular involvement) or following CNS 
status: CNS-3 status (i.e., >5 WBC/L of CSF with blasts or cranial nerve palsy), CNS-2 
status (< 5WBC/L CSF with blasts), or traumatic status (> 10 RBC/L of CSF with blasts).  
[Patients with limited stage (Stages I and II) B-lymphoblastic lymphoma will not receive 
ITMHA on days 8 and 22.] Leucovorin rescue (5 mg/m2/dose) PO will be given at 24 and 30 
hours after each triple intrathecal treatment during induction.  Follow plasma methotrexate 
levels (starting 24 hours after IT therapy and until levels become undetectable) in patients 
with renal dysfunction or extra fluid in third space, and rescue with leucovorin according to 
PharmD recommendation.  CSF Studies to be done with each ITMHA treatment.
**  First dose of Daunorubicin may be delayed to day 2 in patients with or at high risk of tumor 
lysis syndrome.  Second dose of daunorubicin could be delayed up to one week if clinically 
indicated.
† Patients with in T-lymphoblastic lymphoma having MDD ≥1% at diagnosis and MRD 
positive on day 8 (≥0.01%)
‡ Perform MRD tests if previous MRD is positive.


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IRB approval date: 03-27-2015
Protocol version, dated 03-03-2015
§ Participants with MDD <1% will receive cyclophosphamide 1000 mg/m2 IV Day 22 for 1 
dose; Participants with MDD  > 1% will receive cyclophosphamide 300 mg/m2 every 12 
hours on Days 22-23 for a total of 4 doses.
# For patients with heterozygous or homozygous TPMT genotype 
¶ For patients with positive BM disease at diagnosis only
Special Studies:
(1) CBC with diff required at least every third day for first 7 days, and then at least weekly (2) 
blood chemistries (Chem 18 profile) (3) QCT for bone density (4) TPMT genotype– Sections 
7.10 and 8.0. (5) CYP2D6 genotyping (6) Total joint MRI  
MRD Studies:
Samples required for MRD studies during remission induction
Time point
T-lineage lymphoma
Diagnosis
BM and PB
Day 8
PB
 (Day 15 if MRD+ on Day 8)
PB
 (Day 22 if MRD+ on Day 15) 
PB
Day 43 (End of induction)
PB
Note: PB, peripheral blood; BM, bone marrow
End of Induction response evaluation: Patients will be evaluated with neck/chest/abdomen/pelvis 
CT scan and PET scan. For patient with T-lymphoblastic lymphoma, peripheral blood MRD will 
be performed around day 38-42 of remission induction when ANC has recovered to ≥300/mm3, 
WBC to ≥1000/mm3, and platelet count to ≥50 x 109/L.  If the date falls on a week-end or 
holiday, the procedure may be performed on the closest working day.  For patients with initial 
bone marrow involvement, bone marrow aspirate and biopsy will be performed. Any patient with 
detectable disease [MRD (≥0.01%), morphology and imaging (biopsy proven)] at the end of 
induction or thereafter may be considered for reintensification therapy and hematopoietic stem 
cell transplantation (HSCT).


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IRB approval date: 03-27-2015
Protocol version, dated 03-03-2015
Consolidation
Consolidation therapy will be considered only for patients with positive CNS disease or 
testicular involvement.
1
PEG-ASP 
6MP
CBC, diff,
2
6MP
3
6MP
4
6MP
5
6MP
6
6MP
7
6MP
8
*ITMHA, LV 
rescue
HDMTX #1
6MP
CBC diff, 
[1, 2, 3]
9
6MP,
10
6MP
LV ___ 
mg
11
6MP
LV ___ mg
12
6MP
13
6MP
14
6MP
15
PEG-ASP 
6MP
CBC diff
16
6MP
17
6MP
18
6MP
19
6MP
20
6MP
21
6MP
22
*ITMHA, LV
HDMTX #2
6MP
CBC, diff, 
 [1, 2, 3]
23
6MP
24
6MP
LV ___ 
mg
25
6MP
LV ___ mg
26
6MP
27
6MP
28
6MP
29
PEG-ASP 
6MP
CBC, diff
30
6MP
31
6MP
32
6MP
33
6MP
34
6MP
35
6MP
36
*ITMHA, LV 
rescue
HDMTX #3
6MP
CBC, diff,
[1, 2, 3]
37
6MP
38
6MP
LV ___ 
mg
39
6MP
LV ___ mg
40
6MP
41
6MP
42
6MP
43
PEG-ASP 
6MP
CBC, diff, 
44
6MP
45
6MP
46
6MP
47
6MP
48
6MP
49
6MP


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50
*ITMHA, LV 
rescue
HDMTX #4
6MP
CBC, diff
[1, 2, 3] 
51
6MP
52
6MP
LV ___ 
mg
53
6MP
LV ___ mg
54
6MP
55
6MP
56
6MP
57
PEG-ASP 
6MP
CBC, diff
58
6MP
59
6MP
60
6MP
61
6MP
62
6MP
63
6MP
64
6MP
CBC, diff,
[1]
65
6MP
66
6MP
67
6MP
68
6MP
69
6MP
70
6MP
Notes:
*IT methotrexate + hydrocortisone + cytarabine, to be given on days 8, 22, 36, and 50; IT 
therapy should be given on the same day as HDMTX administration (consult PI or PK if the IT 
and HDMTX become separated by more than 12 hours).
Physical Exam every 3-7 days during Consolidation.  CBC with differential needed weekly.  
Special Studies: 
(1) blood chemistries (Chem 18 profile); (2) CSF Studies with each ITMHA (3) HDMTX 
Pharmacokinetics – Section 10.1


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Protocol version, dated 03-03-2015
(2) TREATMENT SCHEMA and Special Laboratory Tests during Continuation 
Therapy
Week
Special Studies
 1
(*) DEX + DOXO + VCR + 6MP + 
PEG-ASP 
 2
6MP
 3
* 6MP + PEG-ASP 
 4
DEX + DOX + VCR + 6MP 
 5
 (*) 6MP + PEG- ASP
 6
6MP
 7
* Reinduction I**
1, 2‡, 3, 4, 5§, 6§
 8
Reinduction I 
 9
Reinduction I 
10
6MP
11
DOX + VCR + 6MP + PEG-ASP
12
* 6MP
7
13
6MP + PEG-ASP
14
DEX + DOX + VCR + 6MP
15
 6MP + PEG-ASP
16
6MP
17
*Reinduction II**
1, 2‡, 3, 4, 
18
Reinduction II
19
Reinduction II
20 
No Chemotherapy  (6MP + MTX for 
stages I and II B –lymphoblastic 
lymphoma)
21
6MP + PEG-ASP†
22
6MP†
7
23
6MP + PEG-ASP†
24
CYCLO + ARA-C
25
*DEX + VCR
26
6MP + MTX
27
6MP + MTX
28
CYCLO + ARA-C
29
*DEX +VCR
30
6MP + MTX
31
6MP + MTX
32
CYCLO + ARA-C
33
*DEX + VCR
34
6MP + MTX
35
6MP + MTX
36
CYCLO + ARA-C
37
*DEX + VCR
38
6MP + MTX


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Appendix I
Revision 3.1, dated 03-03-2015
IRB approval date: 03-27-2015
Protocol version, dated 03-03-2015
Week
Special Studies
39
6MP + MTX
40
CYCLO + ARA-C
41
*DEX + VCR
42
6MP + MTX
43
6MP + MTX
44
CYCLO + ARA-C
45
*DEX + VCR
46
6MP + MTX
47
6MP + MTX
48
CYCLO + ARA-C
49
*DEX + VCR
2‡
50
6MP + MTX
51
6MP + MTX
52
CYCLO + ARA-C
53
DEX + VCR
54
6MP + MTX
55
6MP + MTX
56
CYCLO + ARA-C
57
*DEX + VCR
58
6MP + MTX
59
6MP + MTX
60
CYCLO + ARA-C
61
DEX + VCR
62
6MP + MTX
63
6MP + MTX
64
6MP + MTX
65
*6MP + MTX
66
6MP + MTX
67
6MP + MTX 
68
6MP + MTX
69
6MP + MTX
70
6MP + MTX
71
6MP + MTX
72
6MP + MTX
73
*6MP + MTX
74
6MP + MTX
75
6MP + MTX
76
6MP + MTX
77
6MP + MTX
78
6MP + MTX
79
6MP + MTX
80
6MP + MTX
81
(*)6MP + MTX


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Appendix I
Revision 3.1, dated 03-03-2015
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Protocol version, dated 03-03-2015
Week
Special Studies
82
6MP + MTX
83
6MP + MTX
84
6MP + MTX
85
6MP + MTX
86
6MP + MTX
87
6MP + MTX
88
6MP + MTX
89
(*)6MP + MTX
90
6MP + MTX
91
6MP + MTX
92
6MP + MTX
93
6MP + MTX
94
6MP + MTX
95
6MP + MTX
96
6MP + MTX
97
6MP + MTX
98¶
(*)6MP + MTX
1, 2, 4, 5, 6, 7, 8, 9, 10, 11 
(Stratums 1 and 2)
99
6MP + MTX
100
6MP + MTX
101
6MP + MTX
102
6MP + MTX
103
6MP + MTX
104
6MP + MTX
105
6MP + MTX
106
6MP + MTX
107
6MP + MTX
108
6MP + MTX
109
6MP + MTX
110
6MP + MTX
111
6MP + MTX
112
6MP + MTX
113
6MP + MTX
114
6MP + MTX
115
6MP + MTX
116
6MP + MTX
117
6MP + MTX
118
6MP + MTX
119
6MP + MTX
120¶
6MP + MTX
1, 2, 4, 5, 6, 7, 8, 9, 10, 11 
(Stratum 3 & pts with CNS 
and/or Testicular disease)


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Revision 3.1, dated 03-03-2015
IRB approval date: 03-27-2015
Protocol version, dated 03-03-2015
DEX = dexamethasone; DOX = doxorubicin; VCR = vincristine; 6MP = mercaptopurine; PEG-
ASP = PEG-asparaginase; CYCLO = cyclophosphamide; ARA-C = cytarabine
IT-MHA Treatment (*) Schedule During Continuation (See Section 5.5.2.3):

Patients with limited stage (stages I and II) B-lymphoblastic lymphoma with CNS-1 status (no 
identifiable blasts in CSF) on weeks 1, 3, 5, 7, 12, 17, 25, 29, 33, 37, 41, 45, 49, 57, 65, and 
73 (total number of treatments 18).

Patients with T-lymphoblastic lymphoma (any stage) and advanced stage (stages III and IV) 
B-lymphoblastic lymphoma with CNS-1 status on weeks 1, 3, 5, 7, 12, 17, 25, 29, 33, 37, 41, 
45, 49, 57, 65, 73, 81, 89, and 98 (total number of treatments 23).

Any patient with CNS-3 status, CNS-2 status or traumatic CSF with blasts status, or 
testicular involvement on weeks 3, 7, 12, 17, 25, 29, 33, 37, 41, 45, 49, 57, 65, 73, 81, 89, and 
98 (total number of treatments 25). 
CBC with differential is needed weekly, Physical Exam every 4 weeks, and Chemistries as 
clinically indicated.
During Re-Inductions I and II: PE required every 3-7 days, CBC weekly, Chem 18 on Day 1 
Weeks 7, 8, 9, 17. 19
Surveillance cerebrospinal fluid examination will be done with each IT treatment
Special Studies:
(1) Total cholesterol, triglycerides, free fatty acids, and high-density lipoprotein cholesterol
(2) Bone marrow aspirate and biopsy
 (3) TPMT activity and TGN – Day 1 Week 7 (TGN) and Week 17 (TPMT activity)
(4) MRD studies; see below
(5) Neck/chest/abdomen/pelvis CT
(6) NM PET 
(7) Total joint MRI (shoulders, elbows, hips and knees and PT/OT evaluation (participants > 9 
years of age) – After each Re-Induction (weeks 12-14 and 22-30, and at End of therapy – Weeks 
98 or 120 or later)
(8) Surveillance cerebrospinal fluid examination (patients with T-lymphoblastic lymphoma, 
advanced stage B-lymphoblastic lymphoma and CNS/testicular involvement will receive IT-
MHA treatment in week 98)
(9) QCT for bone density
(10) Plasma 1, 25-dihydroxyvitamin D, bone specific alkaline phosphatase, serum calcium and 
serum magnesium
(11) Spot urine for magnesium, creatinine, calcium, and calcium/creatinine ratio


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IRB approval date: 03-27-2015
Protocol version, dated 03-03-2015
MRD Studies – Samples required post remission
Time point
T-lineage lymphoma
Day 1 (Weeks 7, 17, 49)
PB
Week 98 or 120 (off therapy)
PB
Note: PB, peripheral blood; ETP, early T-cell precursor.
** See section 5.5.2 for reinduction treatment 
† Patients who receive consolidation therapy will not receive PEG-ASP and weekly MTX will be 
given instead for weeks 21–23.
‡ Bone marrow aspiration is to be performed if the patient has: 1) circulating blast cells; 2) 
unexplained organomegaly or lymphadenopathy; 3) unexplained bone pain; 4) suspected or 
documented extramedullary leukemia; or 5) 2 weeks after stopping chemotherapy because of a 
low ANC or platelet count, the ANC still is <750/μL or the platelet count < 100,000/μL.
§ Patients with abnormal imaging evaluations at end of induction.
¶98 Weeks for Stratums 1 and 2 and 120 Weeks for Stratum 3 and Patients with CNS Disease 
and/or Testicular Disease


NHL16
Appendix II
Revision 3.1, dated 03-03-2015
IRB approval date: 03-27-2015
Protocol version, dated 03-03-2015
APPENDIX II:  DRUG INFORMATION
1. PREDNISONE, PREDNISOLONE
Source and Pharmacology: Prednisone is a synthetic congener of hydrocortisone, the natural 
adrenal hormone.  Prednisone is a white or yellowish crystalline powder.  It binds with steroid 
receptors on nuclear membranes, impairs cellular mitosis, and inhibits protein synthesis.  
Prednisone also has potent anti-inflammatory effects and suppresses the immune system. 
Prednisone is absorbed well orally.  It is converted to prednisolone, the pharmacologically active 
metabolite, in the liver.  Prednisolone is further metabolized to inactive compounds in the liver.  
The metabolites are excreted mainly in the urine.  
Formulation and Stability: Prednisone is available in various strengths as tablets and oral 
solution from multiple manufacturers. All dosage forms can be stored at room temperature. At 
St. Jude, prednisolone oral solution may be substituted for prednisone liquid at equal doses, as it 
is more palatable. 
Supplier: The drug is commercially available.
Toxicity: The side effects of prednisone vary depending on the duration of its use.  Short-term 
use can cause sodium and water retention with associated hypertension, peptic ulcer with 
possible perforation and hemorrhage, increased susceptibility to infections, emotional instability, 
insomnia, increased appetite, weight gain, acne, and hyperglycemia. Side effects more 
commonly associated with prolonged use include cataracts, increased intraocular pressure and 
associated glaucoma, development of a “cushingoid” state, compression fractures, menstrual 
irregularities, suppression of growth in children, secondary adrenocortical, and pituitary 
unresponsiveness, particularly in times of stress as in trauma, surgery or illness, osteoporosis and 
muscle wasting.
Guidelines for Administration: See Treatment and Dose Modification sections of the protocol.
2. VINCRISTINE (Oncovin)
Source and Pharmacology:  Vincristine is an alkaloid obtained from the periwinkle (Vinca 
rosea) plant.  It reversibly binds to microtubule and spindle proteins to cause metaphase arrest.  
Vincristine has poor penetration into the CSF.  It is extensively protein bound (~75%).  
Extensive metabolism occurs in the liver.  Excretion is primarily in the bile.  A dosage decrease 
is recommended in patients with elevated bilirubin (see section 7.3)      
Formulation and Stability:  Vincristine is supplied in multiple-dose 1 mg/mL vials containing 1 
mL, 2 mL and 5 mL. The intact vials should be stored under refrigeration and protected from light.  
Supplier:  The drug is commercially available.
Toxicity:  Dose-limiting toxicity is neurotoxicity, which is characterized by constipation and/or 
paralytic ileus, ptosis, vocal cord paralysis, weakness, jaw pain, abdominal pain, peripheral 


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Appendix II
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Protocol version, dated 03-03-2015
neuropathies, loss of deep tendon reflexes, and “foot drop.”  Peripheral neuropathy is often the 
first sign of neurotoxicity and is initially reversible.  Other toxicities reported include alopecia, 
mild nausea and vomiting, SIADH, myelosuppression, orthostatic hypotension, optic atrophy, 
transient cortical blindness, and auditory damage.  Acute shortness of breath and severe 
bronchospasm have been reported after administration of vinca alkaloids.  Myelosuppression is 
rare at usual doses.  Vincristine is a vesicant and may cause severe tissue damage if extravasation 
occurs. Note that dose reduction may be necessary in patients <1 year of age or <10 kg in 
weight; dosing on a per kg (rather than per m2) basis has been advocated for infants in order to 
decrease toxicity.
Guidelines for Administration: See Treatment and Dose Modification sections of the protocol.
3. DAUNORUBICIN (Daunomycin, Cerubidine)
Source and Pharmacology:  Daunorubicin is an anthracycline antibiotic derived from 
Streptomyces coeruleorubidus.  Daunorubicin intercalates between base pairs of DNA, causing 
steric obstruction, disruption of DNA function and inhibition of RNA synthesis.  In addition, 
daunorubicin inhibits topoisomerase II, an enzyme responsible for allowing strands of DNA to 
pass through one another as they unwind.  Even though daunorubicin exerts its major effects in 
the S phase, it is considered to be cell cycle phase non-specific.  Daunorubicin is widely 
distributed in tissues but does not cross the blood brain barrier.  It is metabolized to 
daunorubicinol (the major active metabolite) and aglycones (inactive metabolite).  The major 
route of elimination is through the bile (40%), with additional elimination through the urine.  
Dosages should be reduced in patients with liver dysfunction (see section 7.3) or renal 
dysfunction (creatinine >3 mg/dL) (see section 7.2).  
Formulation and Stability:  Daunorubicin is supplied in vials containing 20 mg of a reddish 
colored lyophilized powder and 100 mg of mannitol.  The intact vials should be stored at room 
temperature.  Each vial can be reconstituted with 4 mL of sterile water for injection to give a 
final concentration of 5 mg/mL.  Reconstituted solutions are stable for 24 h at room temperature 
and 48 h if refrigerated.      
Supplier: The drug is commercially available.
Toxicity:  Dose-limiting toxicities of daunorubicin include myelosuppression and cardiotoxicity. 
Two forms of cardiac toxicity can occur.  Acute toxicity may take the form of arrhythmias, heart 
block, or pericarditis and may be fatal.  Chronic cardiotoxicity is related to total cumulative dose 
and is characterized by heart failure. Mediastinal radiotherapy and/or other cardiotoxic drugs 
may increase the risk of cardiotoxicity.  In general, total lifetime dosages of 450–550 mg/m2 
should not be exceeded.  Other toxicities include nausea and vomiting, mucositis, alopecia, 
diarrhea, and red discoloration of the urine and other body fluids. Severe tissue damage and 
necrosis can occur upon extravasation.  Radiation recall reactions can occur and can be severe.  
Rarely, allergic reactions have occurred.  Typhlitis can occur when daunorubicin is combined 
with cytarabine.
Guidelines for Administration: See Treatment and Dose Modification sections of the protocol.


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Revision 3.1, dated 03-03-2015
IRB approval date: 03-27-2015
Protocol version, dated 03-03-2015
4. PEG-L-ASPARAGINASE (Pegaspargase, Oncaspar)
Source and Pharmacology:  PEG-asparaginase is a modified version of the enzyme, L-
asparaginase.  L-asparaginase is modified by covalently conjugating units of polyethylene glycol 
(PEG) to the enzyme.   The asparaginase used in the manufacturing of PEG-asparaginase is 
derived from Escherichia coli.  Asparaginase hydrolyzes serum asparagine (an amino acid 
required to synthesize proteins and DNA) to aspartic acid and ammonia, and is therefore lethal to 
cells that cannot synthesize asparagine.  Asparaginase is active during all phases of the cell 
cycle.  Asparaginase is not absorbed from the GI tract and must be given parenterally.  PEG-
asparaginase has a plasma half-life of approximately 6 days, but is measurable for at least 15 
days following the initial treatment.  It cannot be detected in the urine.     
Formulation and Stability:  PEG-asparaginase is available in single-use vials containing 5 mL 
of PEG-asparaginase as a clear solution.  Each vial contains 3750 units of drug at a concentration 
of 750 units/mL.  The intact vials should be stored under refrigeration. Freezing destroys its 
activity, which cannot be detected visually.  It should not be used if it is cloudy or a precipitate is 
present.  
Supplier: The drug is commercially available.
Toxicity:  Acute toxicity includes anaphylactic reactions which occur most commonly when the 
drug is given IV. These can be characterized by laryngeal constriction, hypotension, diaphoresis, 
fever, chills, edema and loss of consciousness.  Allergic reactions at the site of IM injection 
include pain, swelling and erythema. The incidence of hypersensitivity reactions to PEG-
asparaginase may be less than with conventional E. coli derived asparaginase although cross-
sensitivity can occur.  Other adverse effects include neutropenia and associated 
immunosuppression, mild nausea and vomiting, malaise, anorexia, elevated LFT’s, pancreatitis 
and hyperglycemia.  A decrease in protein synthesis including albumin, fibrinogen and other 
coagulation factors may occur which can result in thrombosis or pulmonary embolism.  Less 
common side effects include renal dysfunction and CNS complications including somnolence, 
weakness, lethargy, coma and seizures. 
Guidelines for Administration: See Treatment and Dose Modification sections of the protocol.
5. ERWINIA L-ASPARAGINASE (Erwinase)
Source and Pharmacology: Erwinia asparaginase is an enzyme derived from Erwinia 
chrysanthemi and may be useful in patients who are allergic to the E. coli derived product.  
Asparaginase hydrolyzes serum asparagine (an amino acid required to synthesize proteins) to 
aspartic acid and ammonia, and is therefore lethal to cells that cannot synthesize asparagine.  
Asparaginase is active during all phases of the cell cycle. Asparaginase is not absorbed from the 
GI tract and must be given parenterally.  Asparaginase does not cross into the CSF. The plasma 
half-life of erwinia asparaginase when given IM is approximately 16 h.  Only minimal urinary 
and biliary excretion occurs.  Clearance is not affected by age, renal function, or hepatic 
function.


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Revision 3.1, dated 03-03-2015
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Protocol version, dated 03-03-2015
Formulation and Stability: Erwinia asparaginase is available in vials containing 10,000 units of 
the lyophilized drug.   Unused vials should be refrigerated.  The contents of each vial should be 
diluted with 1 mL of preservative-free normal saline, giving a resultant solution of 10,000 
units/mL.  Once in solution, it is recommended that it be used within 8 h, as no preservative is 
added.  Occasionally, a small number of gelatinous-like fibers may develop upon standing, in 
which case the solution can be filtered through a 5 micron filter to remove the particles, with no 
change in potency.
Supplier:   The drug is commercially available.
Toxicity: Acute toxicity includes anaphylactic reactions that occur most commonly with IV 
administration of the drug. These can be characterized by laryngeal constriction, hypotension, 
diaphoresis, fever, chills, edema, and loss of consciousness.  Allergic reactions at the site of IM 
injection include pain, swelling, and erythema.   Other adverse effects include neutropenia and 
associated immunosuppression, mild nausea and vomiting, malaise, anorexia, elevated liver 
function tests (LFTs), pancreatitis, and hyperglycemia.  A decrease in synthesis or proteins such 
as albumin, fibrinogen, and other coagulation factors may occur, which can result in hemorrhage. 
Thrombosis and pulmonary embolism can also occur.   Less common side effects include renal 
dysfunction and CNS complications such as somnolence, weakness, lethargy, coma, and 
seizures.
Guidelines for Administration: See Treatment and Dose Modification sections of the protocol. 
For additional information about this drug, see package insert.
6. DOXORUBICIN (Adriamycin)
Source and Pharmacology:  Doxorubicin is an anthracycline antibiotic produced by 
Streptomyces peucetius.  Doxorubicin intercalates between base pairs of DNA, causing steric 
obstruction, disruption of DNA function, and inhibition of RNA synthesis.  In addition, 
doxorubicin inhibits topoisomerase II, an enzyme responsible for allowing strands of DNA to 
pass through one another as they unwind.  Lastly, doxorubicin undergoes enzymatic electron 
reduction to generate highly reactive species, including the hydroxyl free radical, which may be 
responsible for the drug’s cardiac toxicity but play a role in its antitumor activity as well.   
Doxorubicin is cell-cycle, phase non-specific.  It is widely distributed in the tissues and plasma, 
but does not cross the blood brain barrier to an appreciable extent. It is metabolized to 
doxorubicinol (which may be the major active metabolite) and aglycones. Doxorubicin and its 
metabolites are excreted mainly in the bile and feces (~80%), and the remainder in the urine.  
Dosage should be reduced in patients with liver dysfunction (section 7.3) or renal dysfunction 
(creatinine >3 mg/dL).
Formulation and Stability:  Doxorubicin is available in vials containing 10 mg, 20 mg, 50 mg 
or 200 mg as a 2 mg/mL red-orange solution.  Vials containing 10 mg, 20 mg, 50 mg, 100 mg, or 
150 mg of the drug as a red-orange lyophilized powder are also available.  Intact vials of 
doxorubicin solution should be stored under refrigeration, whereas the lyophilized product 
should be stored at room temperature.  Both products should be protected from light. Lyophilized 
doxorubicin can be reconstituted by adding 5, 10, 25, 50, or 75 mL of 0.9% NaCl, respectively, 


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to the 10, 20, 50, 100, and 150 mg vials to produce a final concentration of 2 mg/mL.  
Bacteriostatic diluents are not recommended.  After reconstitution, the resultant solution should 
be protected from light and is stable for 7 days at room temperature and 15 days if refrigerated.
 
Supplier:  The drug is commercially available.
Toxicity: Dose-limiting toxicities include myelosuppression and cardiotoxicity. Two forms of 
cardiac toxicity can occur.  Acute toxicity may take the form of arrhythmias, heart block, or 
pericarditis and may be fatal.  Chronic cardiotoxicity is related to the total cumulative dose and is 
characterized by heart failure. Mediastinal radiotherapy and/or other cardiotoxic drugs may 
increase the risk of cardiotoxicity.  In general, total lifetime dosages of 450–550 mg/m2 should 
not be exceeded.  Other toxicities include nausea and vomiting, mucositis, alopecia, diarrhea, and 
red discoloration of the urine and other body fluids. Severe tissue damage and necrosis can occur 
upon extravasation.  Radiation recall reactions can occur and can be severe.  Rarely, allergic 
reactions have occurred.  Typhilitis can occur when combined with cytarabine.
7. CYCLOPHOSPHAMIDE (Cytoxan)
Source and Pharmacology:  Cyclophosphamide is a nitrogen mustard derivative.  It acts as an 
alkylating agent that causes cross-linking of DNA strands by binding with nucleic acids and other 
intracellular structures, thus interfering with the normal function of DNA.  Cyclophosphamide is 
cell-cycle, phase non-specific.  It is well absorbed from the GI tract and has a bioavailability of 
>75%.  Cyclophosphamide is a prodrug that requires activation.  It is metabolized by mixed-
function oxidases in the liver to 4-hydroxycyclophosphamide, which is in equilibrium with 
aldofosfamide.  Aldofosfamide spontaneously splits into cyclophosphamide mustard (considered 
the major active metabolite) and acrolein.  In addition, 4-hydroxycyclophosphamide may be 
enzymatically metabolized to 4-ketocyclophosphamide, and aldofosfamide may be enzymatically 
metabolized to carboxyphosphamide, which are generally considered to be inactive.  
Cyclophosphamide and its metabolites are excreted mainly in the urine.  Dosage adjustments 
should be made in patients with a creatinine clearance of <50 mL/min.
Formulation and Stability:  Cyclophosphamide is available as 25 and 50 mg tablets.  
Cyclophosphamide is also available in vials containing 100, 200, 500, 1000, or 2000 mg of the 
lyophilized drug and 75 mg mannitol per 100 mg of cyclophosphamide.  Both forms of the drug 
can be stored at room temperature.  The vials are reconstituted with 5, 10, 25, 50 or 100 mL of 
sterile water for injection, respectively, to the 100, 200, 500, 1000, or 2000 mg vials to yield a 
final concentration of 20 mg/mL.  Reconstituted solutions may be further diluted in either 5% 
dextrose or 0.9% NaCl-containing solutions.  Diluted solutions are physically stable for 24 h at 
room temperature and 6 days if refrigerated, but as they contain no preservative, it is 
recommended that they be used within 24 h of preparation.
Supplier:  The drug is commercially available.
Toxicity:  Dose-limiting toxicities of cyclophosphamide are bone marrow suppression and 
cardiac toxicity.  Cardiac toxicity is typically manifested as congestive heart failure, cardiac 
necrosis, or hemorrhagic myocarditis and can be fatal.  Hemorrhagic cystitis may occur and 


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necessitates withholding therapy.  The incidence of hemorrhagic cystitis is related to 
cyclophosphamide dose and duration of therapy.  Forced fluid intake and/or the administration of 
mesna decrease the incidence and severity of hemorrhagic cystitis.  Other toxicities reported 
commonly include nausea and vomiting (may be mild to severe depending on dosage), diarrhea, 
anorexia, alopecia, immunosuppression, and sterility.  Pulmonary fibrosis, SIADH, anaphylaxis, 
and secondary neoplasms have been reported rarely.
Guidelines for Administration: See Treatment and Dose Modification sections of the protocol.
8. CYTARABINE (Ara-C) (Cytosar-U)
Source and Pharmacology:  Cytarabine is a deoxycytidine analog.  It must be triphosphorylated 
to its active form, ARA-CTP, by deoxycytidine kinase and other nucleotide kinases.  Ara-CTP 
inhibits DNA polymerase. In addition, ara-CTP is incorporated into DNA as a false base, causing 
inhibition of DNA synthesis.  It is cell cycle, S phase specific.  Cytarabine does penetrate the 
blood brain barrier.  It is converted to its inactive form, uracil arabinoside, by pyrimidine 
nucleoside deaminase.  Approximately 80% of the dose is recovered in the urine, mostly as 
uracil arabinoside (ara-U).
Formulation and Stability: Cytarabine is available in multi-dose vials containing 100, 500, 
1000, or 2000 mg of the lyophilized drug.  Intact vials can be stored at room temperature.  For IV 
use, either sterile water for injection or bacteriostatic water for injection can be used to 
reconstitute the lyophilized drug.  For intrathecal use, only sterile water for injection should be 
used for reconstitution.  The 100 and 500 mg vials are reconstituted with 2 and 10 mL, 
respectively, resulting in a final concentration of 50 mg/mL.  The 1000 and 2000 mg vials are 
reconstituted with 20 mL and 40 mL, respectively, resulting in a final concentration of 50 
mg/mL.  After reconstitution, the drug is stable for 8 days at room temperature.
Supplier: The product is commercially available.
Toxicity:  The dose-limiting adverse effect is myelosuppression, with leukopenia and 
thrombocytopenia being predominant.  Other adverse effects reported commonly include nausea 
and vomiting (may be severe at high doses), diarrhea, mucositis, anorexia, alopecia, skin rash, 
and liver dysfunction.  A flu-like syndrome characterized by fever and muscle and bone aches is 
common. Less common side effects include allergic reactions and cellulitis at the injection site.   
High doses of cytarabine can cause conjunctivitis, hepatitis, and a spectrum of CNS symptoms, 
such as somnolence, peripheral neuropathy, ataxia, and personality changes.  CNS symptoms are 
usually reversible and are more common in patients who have received previous cranial 
irradiation.  In addition, the syndrome of sudden respiratory distress progressing to pulmonary 
edema can occur.
Guidelines for Administration: See Treatment and Dose Modification sections of the protocol.


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9. CYTARABINE (High-Dose Ara-C)
Source and Pharmacology:  Cytarabine is a deoxycytidine analog.  It must be triphosphorylated 
to its active form, ARA-CTP, by deoxycytidine kinase and other nucleotide kinases.  Ara-CTP 
inhibits DNA polymerase. In addition, ara-CTP is incorporated into DNA as a false base, causing 
inhibition of DNA synthesis.  It is cell cycle, S phase specific.  Cytarabine does penetrate the 
blood brain barrier.  It is converted to its inactive form, uracil arabinoside, by pyrimidine 
nucleoside deaminase.  Approximately 80% of the dose is recovered in the urine, mostly as 
uracil arabinoside (ara-U).
Formulation and Stability: Cytarabine is available in multidose vials containing 100, 500, 1000 
or 2000 mg of the lyophilized drug.  Intact vials can be stored at room temperature.  For IV use, 
either sterile water for injection or bacteriostatic water for injection can be used to reconstitute 
the lyophilized drug.  For intrathecal use, only sterile water for injection should be used for 
reconstitution.  The 100 and 500 mg vials are reconstituted with 2 and 10 mL, respectively, 
resulting in a final concentration of 50 mg/mL.  The 1000 and 2000 mg vials are reconstituted 
with 20 mL and 40 mL, respectively, resulting in a final concentration of 50 mg/mL.  After 
reconstitution, the drug is stable for 8 days at room temperature.
Supplier:  The drug is commercially available.
Toxicity:  The dose-limiting adverse effect is myelosuppression, with leukopenia and 
thrombocytopenia being predominant.  Other adverse effects reported commonly include nausea 
and vomiting (may be severe at high doses), diarrhea, mucositis, anorexia, alopecia, skin rash, 
and liver dysfunction.  A flu-like syndrome characterized by fever and muscle and bone aches is 
common. Less common side effects include allergic reactions and cellulitis at the injection site.   
High doses of cytarabine can cause conjunctivitis, hepatitis, and a spectrum of CNS symptoms, 
including somnolence, peripheral neuropathy, ataxia, and personality changes.  CNS symptoms 
are usually reversible and are more common in patients who have received previous cranial 
irradiation.  In addition, the syndrome of sudden respiratory distress progressing to pulmonary 
edema can occur.
Guidelines for Administration: See Treatment and Dose Modification sections of the protocol.
10. THIOGUANINE
Source and Pharmacology:  Thioguanine is a purine antimetabolite.  It is intracellularly 
converted to ribonucleotides, which are incorporated into the DNA and RNA.  Absorption of 
thioguanine is variable and poor and is decreased by food.  Thioguanine undergoes extensive 
metabolism in the liver and other tissues to get converted to the inactive, methylated derivative 
and to 6-thiouracil by xanthine oxidase.  Thioguanine is excreted in the urine almost completely 
as metabolites. 
Formulation and Stability:  Thioguanine is available as a 40 mg scored tablet.  It may be stored 
at room temperature.  


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Supplier:  Tablets are commercially available. 
Toxicity:  The major dose-limiting toxicity is myelosuppression.  Nausea and vomiting are 
usually mild.  Other toxicities reported include diarrhea, rash, anorexia, stomatitis, and 
hyperuricemia.  Jaundice and elevated liver function tests have been reported rarely.
Guidelines for Administration: See Treatment and Dose Modification sections of the protocol.
11. CLOFARABINE (Cl-F-Ara-A, CAFdA, 2-Chloro-9-(2-deoxy-2-fluoro-beta-D-
arabinofuranosyl)-9H-purin-6-amine, Clofarex, Clolar™)
Source and Pharmacology: Clofarabine is sequentially metabolized intracellularly to the 5’-
monophosphate metabolite by deoxycytidine kinase and mono- and diphosphokinases to the 
active 5’-triphosphate metabolite. Clofarabine has high affinity for the activating 
phosphorylating enzyme deoxycytidine kinase, equal to or greater than that of the natural 
substrate deoxycytidine. Clofarabine inhibits DNA synthesis by decreasing cellular 
deoxynucleotide triphosphate pools by inhibiting ribonucleotide reductase and by terminating 
DNA chain elongation and inhibiting repair through incorporation into the DNA chain by 
competitive inhibition of DNA polymerases. The affinity of clofarabine triphosphate for these 
enzymes is similar to or greater than that of deoxyadenosine triphosphate. In preclinical models, 
clofarabine has been shown to inhibit DNA repair by incorporation into the DNA chain during 
the repair process. Clofarabine 5’- triphosphate also disrupts the integrity of mitochondrial 
membrane, leading to release of the proapoptotic mitochondrial proteins cytochrome C and 
apoptosis-inducing factor, leading to programmed cell death. Clofarabine is cytotoxic to rapidly 
proliferating and quiescent cancer cell types in vitro.
The population pharmacokinetics of clofarabine was studied in 40 pediatric patients (21 males, 
19 females) aged 2 to 19 years  with relapsed or refractory ALL or AML. At the given 52 mg/m2 
dose, similar concentrations were obtained over a wide range of body surface areas. Clofarabine 
was 47% bound to plasma proteins, predominantly to albumin. Noncompartmental analysis 
showed that systemic clearance and volume of half-life was estimated to be 5.2 h. There was no 
apparent difference in pharmacokinetics between patients with ALL and AML or between males 
and females. In children, 24-hour urine collections show that 49%–60% of the dose is excreted in 
the urine unchanged. In vitro studies using isolated human hepatocytes indicate very limited 
metabolism (0.2%); therefore, the pathways of nonrenal elimination remain unknown. Although 
no clinical drug–drug interaction studies have been conducted to date, it can be inferred from in 
vitro studies that cytochrome P450 inhibitors and inducers are unlikely to affect the metabolism 
of clofarabine. The effect of clofarabine on the metabolism of cytochrome P450 substrates has 
not been studied. The pharmacokinetics of clofarabine has not been evaluated in patients with 
renal or hepatic dysfunction.
Formulation and Stability: Clofarabine (1 mg/mL) is supplied in a 20 mL single-use vial. The 
20 mL vial contains 20 mg clofarabine formulated in 20 mL unbuffered normal saline 
(comprising water for injection, USP, and sodium chloride USP). The pH range of the solution is 
4.5 to 7.5. The solution should be stored at 25°C; excursions are permitted to 15°C–30°C.


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Toxicity:  The most common toxicities of clofarabine are vomiting, nausea, diarrhea, anemia, 
leukopenia, thrombocytopenia, neutropenia, febrile neutropenia, and infection.  More than 10% 
of patients receiving clofarabine have the following adverse events:  tachycardia, abdominal pain, 
constipation, gingival bleeding, sore throat, edema, fatigue, injection site pain, lethargy, mucosal 
inflammation, pain, pyrexia, rigors, hepatomegaly, jaundice, weight loss, anorexia, arthralgia, 
myalgia, back pain, limb pain, dizziness, headache, somnolence, tremor, anxiety, depression, 
irritability, hematuria, cough, dyspnea, epistaxis, and pleural effusion. Respiratory distress, 
confusion, dermatitis, dry skin, erythema, palmar-plantar erythrodysesthesia syndrome, petechiae, 
pruritus, flushing, hypertension, hypotension, increases in ALT, AST, and bilirubin, transient left 
ventricular systolic dysfunction, and increased serum creatinine have also been reported. In a 
study, 4 of 113 pediatric patients experienced capillary leak syndrome or SIRS, leading to 
multiorgan failure.  Fetal and teratogenic effects have been noted in animals.  It is not known 
whether clofarabine or its metabolites are excreted in human milk.
Guidelines for Administration: See Treatment and Dose Modification sections of the protocol.  
Clofarabine should be filtered through a sterile 0.2 μm syringe filter and then further diluted with 
5% dextrose injection USP or 0.9% sodium chloride injection USP to a convenient volume and 
infused over 2 h. The resulting admixture may be stored at room temperature, but must be used 
within 24 h of preparation.
To reduce the effects of tumor lysis and other adverse events, it is recommended that continuous 
IV fluids be given throughout the 5 days of clofarabine administration. 
Because clofarabine is primarily excreted through the kidneys, drugs with known renal toxicity 
should be avoided during the 5 days of clofarabine administration. In addition, since the liver is a 
known target organ for clofarabine toxicity, concomitant use of medications known to induce 
hepatic toxicity should be avoided.
Supplier: The drug is commercially available.
12. METHOTREXATE
Source and Pharmacology:  Methotrexate is a folate analog that acts by inhibiting 
dihydrofolate reductase.  Dihydrofolate reductase is an enzyme important in the conversion of 
folic acid to tetrahydrofolic acid, which is necessary in the synthesis of purine nucleotides and 
thymidylate.  By inhibiting the production of tetrahydrofolic acid, methotrexate interferes with 
DNA, RNA, and protein synthesis.  Methotrexate is poorly and variably absorbed orally, at an 
average of approximately 40% for doses of <30 mg/m2.  At higher dosages, the extent of 
absorption decreases.  Methotrexate is approximately 50% protein bound.  It distributes widely 
into body tissues and fluids with sustained concentrations in the kidney and the liver. 
Methotrexate undergoes metabolism by cytosolic aldehyde oxidase to give hydroxymethotrexate.  
It is excreted unchanged mainly in the urine, with small amounts being excreted in the bile and 
feces. The percent recovered as unchanged drug in the urine is higher with short infusions than 
with prolonged infusions.  Methotrexate has a biphasic elimination, with an initial half-life of 2–
3 h and a terminal half-life of 10–12 h. Methotrexate may be “sequestered” in body fluid 
collections and eliminated slowly from these areas. Patients with effusions or GI obstruction 


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should have plasma levels monitored closely for delayed excretion after being administered high-
dose methotrexate.
Formulation and Stability:  Methotrexate is supplied in single-dose vials containing 50 mg, 
100 mg, 200 mg, or 250 mg of methotrexate as a 25 mg/mL preservative-free solution and in 
vials containing 20 mg, 50 mg, 100 mg, 250 mg, and 1000 mg of lyophilized drug.  It is also 
available in 2.5 mg tablets. Methotrexate preservative–free solution and lyophilized drug should 
be stored at room temperature and protected from light.  Methotrexate tablets can also be stored 
at room temperature. The vials containing 20, 50, 100, and 250 mg of lyophilized product can be 
reconstituted by adding sterile water, 0.9% NaCl, or D5W to a final concentration not exceeding 
25 mg/mL.  The 1000 mg vials containing lyophilized product are reconstituted to a final 
concentration of 50 mg/mL.
Supplier: The drug is commercially available.
Toxicity:    The dose-limiting toxicities of methotrexate are generally bone marrow suppression, 
ulcerative stomatitis, severe diarrhea, and acute nephrotoxicity.  Toxicities reported frequently 
include nausea and vomiting, diarrhea, anorexia, alopecia, hepatic toxicity, and alopecia.  Less 
common side effects include blurred vision, photosensitivity, anaphylaxis, headache, 
pneumonitis, skin depigmentation or hyperpigmentation, rash, vasculitis, and encephalopathy.   
During high-dose methotrexate therapy, most patients experience a transient decrease in GFR, 
but renal failure can occur, particularly if the patient does not receive urinary alkalinization and 
aggressive hydration before, during and after receiving HD-MTX.  Leucovorin rescue should be 
initiated within 48 h of starting HD-MTX and adjusted on the basis of MTX levels in order to 
prevent bone marrow toxicity and mucositis.  Leucovorin may also be necessary after IT 
administration, especially if IT methotrexate therapy is given to patients with renal dysfunction.  
Patients with Down syndrome have a tendency to have delayed methotrexate clearance and a 
greater risk of toxicity, despite increased leucovorin rescue.
Guidelines for Administration: See Treatment and Dose Modification sections of the protocol.
13. LEUCOVORIN (Folinic Acid)
Source and Pharmacology:  Leucovorin is a racemic mixture of tetrahydrofolic acid, which is 
involved as a cofactor for 1-carbon transfer reactions in the synthesis of purine and pyrimidines.  
Leucovorin acts as a potent antidote for both the hematopoietic and reticuloendothelial toxic 
effects of folic acid antagonists by replenishing reduced folate pools.  It is postulated that in 
some cancers, leucovorin enters and “rescues” normal cells from the toxic effects of folic acid 
antagonists rather than tumor cells, because of differences in membrane transport and affinity for 
polyglutamylation. Leucovorin is converted in the intestinal mucosa and the liver to 5-methyl-
tetrahydrofolate, which is also active as a reduced folate.  It is excreted primarily in the urine, 
with some excretion occurring in the feces.
Formulation and Stability:  Leucovorin is supplied as 5, 15, or 25 mg tablets and vials 
containing 50, 100, or 350 mg of leucovorin, respectively, as a lyophilized powder.   The tablets 
and the lyophilized powder can be stored at room temperature.  The 50 mg and 100 vials can be 


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reconstituted by adding 5 or 10 mL of sterile water or bacteriostatic water for injection, 
respectively, to yield a final concentration of 10 mg/mL.  The 350 mg vials can be reconstituted 
with 17 mL of sterile water or bacteriostatic water for injection to yield a final concentration of 
20 mg/mL.   The reconstituted solution is stable for at least 7 days at room temperature.  
Leucovorin may be further diluted in 5% dextrose or 0.9% NaCl-containing solutions.  
Leucovorin is also available as a 1 mg/mL oral solution. 
Supplier:  The drug is commercially available.
Toxicity:  Leucovorin is generally well tolerated.  Toxicities that have been reported 
uncommonly include rash, mild nausea, headache, and wheezing (possible allergic reaction).   
Intrathecal leucovorin is contraindicated and has caused neurotoxic deaths.  There have been rare 
reports of leucovorin promoting seizures.
Guidelines for Administration: See Treatment and Dose Modification sections of the protocol.
14. MERCAPTOPURINE (6-MP) (Purinethol)
Source and Pharmacology:  Mercaptopurine is a purine antimetabolite.  It must be converted 
intracellularly to 6-thioguanine nucleotides (6-TGNs), the active forms of the drug, which are 
then incorporated into the DNA and RNA and inhibit DNA and RNA synthesis.  Mercaptopurine 
is cell cycle, S phase specific.  Absorption is variable and incomplete (5%–37%) and is 
decreased by the presence of food in the gut.  Mercaptopurine does distribute into the CSF, with 
CSF concentrations of approximately 27% of plasma concentrations when given by continuous 
infusion.  Mercaptopurine undergoes first-pass metabolism in the GI mucosa and the liver.   It is 
metabolized in hematopoietic tissues by HPRT to the active nucleotide forms.  It is inactivated to 
methylated metabolites by TPMT and to 6-thiouric acid by xanthine oxidase.  TPMT is a 
genetically regulated, polymorphically distributed enzyme and is deficient in approximately 1 in 
300 individuals who cannot tolerate usual doses of 6-MP.  Mercaptopurine is eliminated through 
the urine as both unchanged drug and metabolites.       
Formulation and Stability: Mercaptopurine is commercially available as a 50 mg tablet and a 
20 mg/mL oral suspension.  The tablets should be stored at room temperature and protected from 
light.  
Supplier:  Tablets are commercially available.  
Toxicity:  The dose-limiting toxicity of mercaptopurine is myelosuppression.  Mercaptopurine 
can cause intrahepatic cholestasis and focal centralobular necrosis and is usually manifested by 
hyperbilirubinemia and increased liver function tests.  Other toxicities include mild nausea and 
vomiting, skin rash, hyperuricemia, and mild diarrhea.
Guidelines for Administration: See Treatment and Dose Modification sections of the protocol.


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15.
DEXAMETHASONE (Decadron)
Source and Pharmacology: Dexamethasone is a synthetic congener of the natural adrenal 
hormone hydrocortisone.  Dexamethasone is a white or yellowish crystalline powder.  It binds 
with steroid receptors on nuclear membranes to impair cellular mitosis and inhibit protein 
synthesis.  Dexamethasone also has potent antiinflammatory effects and suppresses the immune 
system. Dexamethasone is absorbed well orally.  It is metabolized in the liver, and the 
metabolites are excreted mainly in the urine.  
Formulation and Stability:  Dexamethasone is available as tablets of various strengths and as 
an elixir. It is also available as a solution for parenteral use.   All formulations of the drug can be 
stored at room temperature.  The injectable form may be further diluted in 5% dextrose or 0.9% 
NaCl-containing solutions and is stable for at least 24 h at room temperature.
Supplier: The drug is commercially available.
Toxicity: The side effects of dexamethasone vary depending on the duration of its use.  Side 
effects that can occur with short-term use include peptic ulcers with possible perforation and 
hemorrhage, increased susceptibility to infections, emotional instability, insomnia, increased 
appetite, weight gain, acne, and hyperglycemia. Side effects more commonly associated with 
prolonged use include cataracts, increased intraocular pressure and associated glaucoma, 
development of a “cushingoid” state, compression fractures, menstrual irregularities, suppression 
of growth in children, secondary adrenocortical and pituitary unresponsiveness particularly in 
times of stress as in trauma, surgery or illness, osteoporosis and muscle wasting.
Guidelines for Administration: See Treatment and Dose Modification sections of the protocol.
16. HYDROCORTISONE, Systemic (Cortef®, Solu-Cortef®)
Source and Pharmacology: Hydrocortisone is a synthetic steroid akin to the natural adrenal 
hormone cortisol.  Hydrocortisone decreases inflammation by suppressing the migration of 
polymorphonuclear leukocytes and reversing the increased capillary permeability.  It is excreted 
in the urine and catabolized in the liver.  
Formulation and Stability:  Solu-Cortef sterile powder is supplied in the following packages:  
100 mg plain, and 100 mg, 250 mg, 500 mg, and 1000 mg ACT-O-VIAL (MIX-O-VIAL).  The 
lyophilized product should be stored at controlled room temperature (15C–30C). The 
reconstituted solution should be stored in the refrigerator and protected from light.  Unused 
solution should be discarded after 3 days.  
Supplier: The drug is commercially available.
Toxicity:  The dose-limiting toxicities of hydrocortisone are hyperphagia, obesity, striae, acne, 
cataracts, immunosuppression, electrolyte disturbances, edema, hypertension, osteoporosis, 
personality changes, insomnia, headaches, diabetes and Cushingoid syndrome.  Pancreatitis, 
peptic ulcer and/or GI bleeding have also been noted. 
Guidelines for Administration: See Treatment and Dose Modification sections of the protocol.


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17. ETOPOSIDE (VP-16) (Vepesid)
Source and Pharmacology:  Etoposide is an epipodophyllotoxin derived from Podophyllum 
pelatatum. It is thought to act mainly by inhibiting topoisomerase II, causing double- and single-
strand DNA breaks.  Etoposide is cell cycle, phase-specific, with activity in the G2 and S phases.  
Absorption of etoposide is approximately 30%–40% and is highly variable and somewhat dose-
dependent.  It is extensively bound to serum proteins and is metabolized in the liver, including 
cytochrome P450 3A metabolism, to several moieties that include a reactive oxidized species.  
Etoposide and its metabolites are excreted mainly in the urine, with a smaller amount excreted in 
the feces.  Dosage adjustments should be considered in patients with liver dysfunction, kidney 
dysfunction, or hypoalbuminemia.
Formulation and Stability:  Etoposide is available in multidose vials containing 100 mg, 150 
mg, 500 mg, or 1000 mg of etoposide as a 20 mg/mL solution and 30% alcohol.   Etoposide is 
also available as a 50 mg capsule.  Intact vials of etoposide solution should be stored at room 
temperature. The capsules should be stored under refrigeration.  Etoposide solution should be 
diluted in D5W or 0.9% NaCl before administration.  Solutions with a final concentration of 0.2 
and 0.4 mg/mL are stable at room temperature for 96 hours and 24 h, respectively.
Supplier:  The drug is commercially available.
Toxicity:  The dose-limiting toxicity of etoposide is myelosuppression.  Nausea and vomiting 
(usually of low to moderate severity), diarrhea, mucositis (particularly with high doses), 
alopecia, and anorexia are fairly common.  Hypotension can occur with rapid infusions.  Other 
side effects reported less commonly include hepatitis, fever and chills, anaphylaxis and 
peripheral neuropathy. Secondary leukemia has been reported.
Guidelines for Administration: See Treatment and Dose Modification sections of the protocol.


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APPENDIX III:  DEFINITIONS RELATED TO INFECTIOUS DISEASES
I.
ASSESSMENTS
A.
Fever:  A single temperature of >38.3oC (101oF) or >38.0oC (100.4oF) on 2 
occasions within 1 h.  The measurement must be oral with glass or IVAC7 
thermometers or at the tympanic membrane by infrared instruments 
(Thermoscan7).  The same method should be used throughout the febrile episode 
for each patient.
B.
Neutropenia:  Neutrophil count of <500/mm3 or <1000/mm3, with predicted 
decline to <500/mm3.
C.
Duration of Fever (for episodes of fever with neutropenia):  The initial 
temperature is the one immediately before the first dose of antibiotics and GCSF.  
This is designated as zero hour.  The end of a febrile period is at the time of the 
first temperature of 38.0oC or less, which is sustained at this level over a period of 
24 h or longer without antipyretic intervention.  The duration of fever is the 
number of hours from zero hour to the end of the febrile period.
D.
Antibiotic Therapy:  Any systemic antibacterial drug will be considered as 
antibiotic therapy whether given orally or parenterally.  Topical antibiotics will 
not be included.
E.
Antifungal Therapy:  Any antifungal drug administered orally or parenterally will 
be considered antifungal therapy.  Antifungal therapy will be categorized for 
analysis as:
1.
Treatment for oral candidiasis
Nystatin
Clotrimazole troches
Micafungin
Fluconazole
Voriconazole
2.
Treatment for systemic mycoses (includes empirical use)
Systemic amphotericin B (standard and liposomal)
Fluconazole
Voriconazole
Posaconazole
Itraconazole
Micafungin
II.
BACTERIAL INFECTIONS
1.
Bacteremia only: Defined as a growth of an organism that is judged not to be a 
contaminant in a blood culture drawn during a febrile episode. Organisms are 
considered contaminants if they are part of skin flora (e.g., diphtheroids other than 
Corynebacterium jeikeium, Bacillus spp. not B. cereus, Propionibacterium spp., 
coagulase-negative staphylococcus (CNS) or Micrococcus spp.) and if they are 
isolated from only one culture receptacle. All other organisms are regarded as 
pathogens (specify whether or not catheter related). 


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Appendix III
Revision 3.1, dated 03-03-2015
IRB approval date: 03-27-2015
Protocol version, dated 03-03-2015
2.
Bacterial sepsis:  Blood culture positive for any bacterium, plus clinical evidence 
of infection (fever, chills, hypotension, etc.)  (specify whether or not catheter 
related).
3.
Urinary tract infection: A urine colony count of 100,000 or greater of a single 
organism plus symptoms such as dysuria and flank pain.  Asymptomatic 
bacteriuria is the same colony count without symptoms.
4.
Pneumonia (bacterial):  A radiographically discernible infiltrate plus isolation of 
potentially causative bacteria from bronchoalveolar lavage, blood, or biopsy 
specimen.  If blood culture is positive, should be coded as bacterial sepsis with 
pneumonia.
5.
Meningitis:  A positive culture of causative bacteria from the CSF plus symptoms 
consistent with meningitis.
6.
Osteomyelitis:  Radiographic lesions plus positive blood or bone aspirate/biopsy 
cultures.
7.
Acute Otitis Media:  Physician diagnosis plus antibiotic treatment.
8.
Pharyngitis:  Only if group A beta hemolytic streptococcus is isolated from throat 
culture in patients with symptoms.  A positive rapid streptococcal test is 
acceptable in place of culture.  Other types of pharyngitis will not be considered.
9.
Cellulitis:  Erythema and induration plus isolation of bacteria from aspirate or 
drainage.
III.
FUNGAL INFECTIONS
A.
Candidiasis
1.
Systemic:  Isolation of Candida species from an otherwise sterile body 
fluid or tissue (e.g., blood, CSF, aspirate or biopsy of tissue, bone marrow, 
joint fluid) along with clinically compatible illness, or histologic evidence 
of typical budding yeast and pseudohyphae in tissue biopsy plus isolation 
of Candida species in culture from the same tissue or otherwise sterile 
body fluid or tissue.  Typical histopathology with pseudohyphae in 
pulmonary, hepatic, splenic, brain, or renal lesions is adequate since the 
organism often fails to grow from cultures of organs.
2.
Oral:  Presence of typical whitish lesions on the mucosal surface with 
yeast or pseudomycelia on gram stain or KOH preparation or isolation of 
Candida species in culture from the mouth.
3. 
Esophageal or urinary bladder:  Evidence of tissue involvement proven by 
endoscopy and biopsy plus isolation of fungus in culture.
B.
Aspergillosis
1.  
Systemic:  Isolation of Aspergillus species from an otherwise sterile body 
fluid or tissue plus clinically compatible illness (e.g., pulmonary infiltrate, 
sinusitis, CNS lesion, hepatic or splenic lesion).  Demonstration of typical 
branching septate hyphae in biopsies or aspirated tissue specimens plus 
isolation of the organism in culture also allows systemic diagnosis.
2. 
Pulmonary:  Typical cystic lesion with fungus ball ("half-moon sign") in 
chest radiograph and/or CT scan, and Aspergillus species isolated from 
sputum, tracheal aspirate, or bronchoalveolar lavage fluid.


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Revision 3.1, dated 03-03-2015
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Protocol version, dated 03-03-2015
C.
Histoplasmosis:  Isolation of Histoplasma capsulatum in culture from patient with 
compatible illness.
D.
Presumptive Systemic Fungal Infection:  Typical lesions in the liver, spleen, 
kidney, or brain on CT or MRI scans plus compatible clinical features and treated 
with systemic antifungal drugs.
E.
Others:  The investigator may include certain other infectious diseases of unique 
nature.  Acceptance requires a decision to be made before decoding occurs and 
with the agreement of the PI and an attending physician from the Department of 
Infectious Diseases.
IV.
PROTOZOAN INFECTIONS
A.
Pneumocystis carinii Pneumonia:  Discernible radiographic lesion plus 
identification of P. carinii in bronchoalveolar lavage fluid, biopsy, or induced 
sputum.
B.
Cryptosporidiosis:  C. parum identified in stools plus diarrhea.
C.
Toxoplasmosis:  See ACTG protocol 254.
V.
TOPOGRAPHIC DIAGNOSIS
The following diagnoses are acceptable for objectively identified infections without 
confirmation of etiology.
1.
Pneumonia:  Lesion on radiograph
2.
Osteomyelitis:  Radiologic diagnosis
3.
Sinusitis:  Radiologic diagnosis (X-ray, CT, MRI)
4.
Cellulitis:  Physician diagnosis
VI.
FEVER OF UNDETERMINED ETIOLOGY
A febrile episode with no etiologic or topographic evidence of disease can be identified 
as being.
1.
neutropenic if ANC is <500/mm3
2.
nonneutropenic if  ANC is ≥500/mm3
VII. 
CULTURE NEGATIVE SEPSIS
In the absence of a positive culture, a systemic response to a possible infection by 
hemodynamic instability, focal or multiple organ involvement such as poor skin 
perfusion, oliguria, hypoxemia, and/or altered mental status or lethargy


NHL16
Appendix IV
Revision 3.1, dated 03-03-2015
IRB approval date: 03-27-2015
Protocol version, dated 03-03-2015
APPENDIX IV:  TESTS/EVALUATIONS/PROCEDURES PERFORMED FOR 
STANDARD OF CARE AND FOR RESEARCH
Standard of care

Complete history and physical exam, with careful notation and assessment of clinical 
signs relevant to lymphoma

Coagulation profile

Complete blood count with differential

Chemistry profile: glucose, electrolytes, blood urea nitrogen (BUN), creatinine, lactate 
dehydrogenase (LDH), uric acid, bilirubin, SGOT, SGPT, calcium, phosphorous, 
magnesium, total protein and albumin.

Lipid screen: Total cholesterol, triglycerides, free fatty acids, and high-density 
lipoprotein cholesterol

Plasma 25-hydroxyvitamin D, osteocalcin N-MID, urine N-Telopeptide with creatinine, 
bone specific alkaline phosphatase, parathyroid hormone

Spot urine for magnesium, creatinine, calcium, and calcium/creatinine ratio

Thyroid function test (free T4, TSH)

Chest X-ray

Echo (echocardiogram)/EKG (electrocardiogram) and/or multiple gate acquisition scan 
(MUGA), Troponin T, natriuretic hormone levels

Neck/chest/abdomen/pelvis CT

Positron emission tomography (PET)/CT scan

Biopsy/cytology

Bone marrow evaluation: morphology, cytochemistry, immunophenotyping, 
cytogenetics, DNA index, molecular diagnosis, MRD studies

Peripheral blood MRD study

Lumbar puncture with CSF examination (cell count with differential of cytospin 
preparation) 

Other studies as clinically indicated, e.g. sickle cell prep, hemoglobin electrophoresis, 
and G6PD screen for Black children; varicella titer; Hepatitis B antigen; HIV, Epstein-
Barr virus (EBV), toxoplasma (TOXO), cytomegalovirus (CMV), histoplasma, and 
Bartonella titers.

PT/OT evaluation; patients > 9 year old

Total joint MRI (shoulders, elbows, hips, knees and pelvis): patients > 9 year old

QCT for bone density

TPMT genotype

TPMT and TGN

CYP2D6 genotyping

Methotrexate pharmacokinetics

Pregnancy testing


NHL16
Appendix IV
Revision 3.1, dated 03-03-2015
IRB approval date: 03-27-2015
Protocol version, dated 03-03-2015
Research

Semen analysis (through Fertility of Memphis)

Inhibin B level

Anti-müllerian hormone

Biology and molecular genetic research, and storage for future research (pre-trial material 
obtained at diagnosis)