Combination Chemotherapy in Treating Patients With Acute Lymphoblastic Leukemia or Advanced Lymphoblastic Non-Hodgkin's Lymphoma

Study Overview
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Brief Summary
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RATIONALE: Drugs used in chemotherapy use different ways to stop tumor cells from dividing so they stop growing or die. Combining more than one drug may kill more tumor cells. Dexrazoxane may lessen the side effects of chemotherapy. PURPOSE: Randomized phase III trial to compare combination chemotherapy with or without dexrazoxane and with or without high-dose methotrexate in patients with acute lymphoblastic leukemia or advanced lymphoblastic non-Hodgkin's lymphoma.

Detailed Description
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OBJECTIVES: I. Determine, in a randomized trial, the effectiveness of high-dose methotrexate when added to a multiagent chemotherapy backbone (the Dana Farber Cancer Institute regimen, protocol DFCI-87001) proven effective in T-cell acute lymphoblastic leukemia (T-ALL) and advanced lymphoblastic non-Hodgkin's lymphoma (NHL). II. Determine the role of dexrazoxane in preventing cardiotoxicity in children with T-ALL and advanced lymphoblastic NHL treated with an anthracycline-based regimen. III. Study the biology of T-cell lymphoid malignancies by accumulating data on the concurrent ALL classification study (POG-9400) and analyzing the data relative to outcome. IV. Evaluate the correlation of minimal residual disease (using the TAL 1 proto-oncogene) with event-free survival. V. Determine the role of p53 and p16 tumor suppressor genes in T-ALL. VI. Determine whether drug sensitivity profiles of blast cells to doxorubicin, methotrexate, and cytarabine correlate with initial response and subsequent relapse. OUTLINE: This is a randomized, multicenter study. Patients are stratified according to disease category (acute lymphoblastic leukemia (ALL) with no CNS disease vs. ALL with CNS disease vs. non-Hodgkin's lymphoma (NHL) with no CNS disease vs. NHL with CNS disease), gender, race (Caucasian vs. African American vs. Hispanic). Patients are randomized to one of four treatment arms. ARM I: During induction therapy, patients receive vincristine IV once daily on days 1, 8, 15, and 22, oral prednisone three times a day on days 1-21, doxorubicin IV daily on days 1, 2, and 22, methotrexate IV once, at least 8 hours after doxorubicin on day 2, and oral mercaptopurine daily on days 22-35. Patients receive triple intrathecal therapy (TIT) consisting of methotrexate, cytarabine, and hydrocortisone on weeks 1, 3, 4, 5, and 6. Patients with CNS 2 or 3 disease receive TIT on week 2. During weeks 7-33, patients receive consolidation therapy consisting of vincristine IV once every 3 weeks, oral prednisone three times a day over 5 days, every 3 weeks, doxorubicin IV once every 3 weeks, oral mercaptopurine daily for 14 days, every 3 weeks, and asparaginase intramuscularly (IM) weekly on weeks 7-26. Patients receive TIT on week 10 and 22 (on week 16 for patients with CNS 2 or 3 disease). Patients receive radiotherapy beginning on week 22. During weeks 34-108, patients receive continuation therapy consisting of vincristine IV once every 3 weeks, oral prednisone three times a day over 5 days, every 3 weeks, methotrexate IV or IM weekly (omitted during TIT) and oral mercaptopurine daily for 14 days, every 3 weeks. Patients receive TIT on weeks 40, 58, 76, and 94. Arm II: Patients receive induction therapy as in Arm I with an addition of dexrazoxane IV given prior to doxorubicin on days 1, 2, and 22. Patients receive consolidation therapy as in Arm I with an addition of dexrazoxane IV given prior to doxorubicin once every 3 weeks. Patients receive continuation therapy as in Arm I. Arm III: Patients receive induction therapy as in Arm I in addition to high dose methotrexate IV on week 4 and leucovorin calcium IV or orally every 6 hours for 7 doses beginning 36 hours after high dose methotrexate. Patients receive consolidation therapy as in Arm I in addition to high dose methotrexate IV on weeks 7, 10, and 13 followed by leucovorin calcium as in induction therapy. Patients receive continuation therapy as in Arm I. Arm IV: Patients receive induction therapy and consolidation therapy as in Arms I, II, and III. Patients receive continuation therapy as in Arm I. Treatment continues for up to 108 weeks in the absence of disease progression or unacceptable toxicity. Patients are followed every 2 months for 1 year, every 4 months for 3 years, then every 6 months for 2 years. PROJECTED ACCRUAL: A total of 494 patients will be accrued for this study.

Official Title
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Intensive Treatment For T-CELL Acute Lymphoblastic Leukemia and Advanced Stage Lymphoblastic Non-Hodgkin's Lymphoma: A Pediatric Oncology Group Phase III Study

Conditions
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Cardiac Toxicity, Leukemia, Lymphoma

Intervention / Treatment
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* Drug: asparaginase
* Drug: cytarabine
* Drug: dexrazoxane hydrochloride
* Drug: doxorubicin hydrochloride
* Drug: leucovorin calcium
* Drug: mercaptopurine
* Drug: methotrexate
* Drug: prednisone
* Drug: therapeutic hydrocortisone
* Drug: vincristine sulfate
* Radiation: radiation therapy


Participation Criteria
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Eligibility Criteria
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DISEASE CHARACTERISTICS: T-cell acute lymphoblastic leukemia (ALL) Registration on current ALL classification study (POG-9400) required within 6 working days prior to entry DR-, T+ DR-, T- or DR+, T+ eligible if T-cell ALL confirmed at the Johns Hopkins Reference Laboratory Biopsy-proven diffuse lymphoblastic lymphoma Murphy stage III/IV disease Registered on ALL classification study (POG-9400) PATIENT CHARACTERISTICS: Age: Over 12 months to under 22 years for T-ALL Under 22 years for lymphoma PRIOR CONCURRENT THERAPY: No prior therapy other than steroids or emergency mediastinal irradiation in patients with severe respiratory distress from mediastinal disease Steroid treatment allowed provided that physical examination and complete blood count with differential were performed immediately prior to beginning steroids and results of both are known

Ages Eligible for Study
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Maximum Age: 21 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Supportive Care
Allocation: Non-Randomized
Intervention Model: Single Group Assignment
Masking: Double


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Treatment 1: (No HD MTX / No Zinecard)<br>Closed 09/2000 Induction (Vincristine sulfate, Prednisone, doxorubicin hydrochloride, Methotrexate (MTX), mercaptopurine (6-MP), methotrexate/cytarabine), Consolidation (Vincristine sulfate), Prednisone, doxorubicin hydrochloride, mercaptopurine (6-MP), asparaginase, IT methotrexate /cytarabine radiation therapy (XRT)). Continuation (Vincristine sulfate, Prednisone, IT methotrexate/Ara-C,mercaptopurine (6-MP), IT methotrexate/cytarabine) | Drug: asparaginase<br>* Given IV<br>* Other names: NSC #10922;Drug: cytarabine<br>* Given IV<br>* Other names: NSC #06387;Drug: doxorubicin hydrochloride<br>* Given IV<br>* Other names: NSC #123127;Drug: mercaptopurine<br>* Given orally<br>* Other names: NSC #000755;Drug: methotrexate<br>* Given IV<br>* Other names: NSC #000740;Drug: prednisone<br>* Given orally<br>* Other names: NSC #010023;Drug: therapeutic hydrocortisone<br>* Given IT<br>* Other names: NSC #010483;Drug: vincristine sulfate<br>* Given IV<br>* Other names: NSC #067574;Radiation: radiation therapy<br>* Radiation to cranium<br>* Other names: XRT;|
| Active Comparator: Treatment 2: (No HD MTX / Zinecard)<br>Closed 09/2000 Induction (Vincristine sulfate, Prednisone, doxorubicin hydrochloride, Methotrexate (MTX), mercaptopurine (6-MP), methotrexate/cytarabine, dexrazoxane hydrochloride (Zinecard or DZR)), Consolidation (Vincristine sulfate), Prednisone, doxorubicin hydrochloride, mercaptopurine (6-MP), asparaginase, dexrazoxane hydrochloride (Zinecard or DZR), IT methotrexate /cytarabine, radiation therapy (XRT)). Continuation (Vincristine sulfate, Prednisone, IT methotrexate/Ara-C,mercaptopurine (6-MP), IT methotrexate/cytarabine) | Drug: asparaginase<br>* Given IV<br>* Other names: NSC #10922;Drug: cytarabine<br>* Given IV<br>* Other names: NSC #06387;Drug: dexrazoxane hydrochloride<br>* Given IV<br>* Other names: NSC #169780;Drug: doxorubicin hydrochloride<br>* Given IV<br>* Other names: NSC #123127;Drug: mercaptopurine<br>* Given orally<br>* Other names: NSC #000755;Drug: methotrexate<br>* Given IV<br>* Other names: NSC #000740;Drug: prednisone<br>* Given orally<br>* Other names: NSC #010023;Drug: therapeutic hydrocortisone<br>* Given IT<br>* Other names: NSC #010483;Drug: vincristine sulfate<br>* Given IV<br>* Other names: NSC #067574;Radiation: radiation therapy<br>* Radiation to cranium<br>* Other names: XRT;|
| Active Comparator: Treatment 3: (HD MTX / No Zinecard)<br>Closed 09/2001 Induction (Vincristine sulfate, Prednisone, doxorubicin hydrochloride, Methotrexate (MTX), mercaptopurine (6-MP), leucovorin calcium (LCV), HD methotrexate/cytarabine), Consolidation (Vincristine sulfate), Prednisone, doxorubicin hydrochloride, mercaptopurine (6-MP), asparaginase, leucovorin calcium (LCV), HD methotrexate /cytarabine radiation therapy (XRT)). Continuation (Vincristine sulfate, Prednisone, IT methotrexate/Ara-C,mercaptopurine (6-MP), HD methotrexate/cytarabine) | Drug: asparaginase<br>* Given IV<br>* Other names: NSC #10922;Drug: cytarabine<br>* Given IV<br>* Other names: NSC #06387;Drug: doxorubicin hydrochloride<br>* Given IV<br>* Other names: NSC #123127;Drug: leucovorin calcium<br>* Given IV<br>* Other names: NSC #003590;Drug: mercaptopurine<br>* Given orally<br>* Other names: NSC #000755;Drug: methotrexate<br>* Given IV<br>* Other names: NSC #000740;Drug: prednisone<br>* Given orally<br>* Other names: NSC #010023;Drug: therapeutic hydrocortisone<br>* Given IT<br>* Other names: NSC #010483;Drug: vincristine sulfate<br>* Given IV<br>* Other names: NSC #067574;Radiation: radiation therapy<br>* Radiation to cranium<br>* Other names: XRT;|
| Active Comparator: Treatment 4: (HD MTX / Zinecard)<br>Closed 09/2001 Induction (Vincristine sulfate, Prednisone, doxorubicin hydrochloride, Methotrexate (MTX), mercaptopurine (6-MP), leucovorin calcium (LCV), HD methotrexate/cytarabine, dexrazoxane hydrochloride (Zinecard or DZR)), Consolidation (Vincristine sulfate), Prednisone, doxorubicin hydrochloride, mercaptopurine (6-MP), asparaginase, HD methotrexate /cytarabine, dexrazoxane hydrochloride (Zinecard or DZR), radiation therapy (XRT)). Continuation (Vincristine sulfate, Prednisone, IT methotrexate/Ara-C,mercaptopurine (6-MP), HD methotrexate/cytarabine) | Drug: asparaginase<br>* Given IV<br>* Other names: NSC #10922;Drug: cytarabine<br>* Given IV<br>* Other names: NSC #06387;Drug: dexrazoxane hydrochloride<br>* Given IV<br>* Other names: NSC #169780;Drug: doxorubicin hydrochloride<br>* Given IV<br>* Other names: NSC #123127;Drug: leucovorin calcium<br>* Given IV<br>* Other names: NSC #003590;Drug: mercaptopurine<br>* Given orally<br>* Other names: NSC #000755;Drug: methotrexate<br>* Given IV<br>* Other names: NSC #000740;Drug: prednisone<br>* Given orally<br>* Other names: NSC #010023;Drug: therapeutic hydrocortisone<br>* Given IT<br>* Other names: NSC #010483;Drug: vincristine sulfate<br>* Given IV<br>* Other names: NSC #067574;Radiation: radiation therapy<br>* Radiation to cranium<br>* Other names: XRT;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Complete Continuous Remission | Since all patients receive the same induction, the endpoint will be CCR , i.e. complete continuous remission (the time to failure for any cause among patients achieving a complete response) | Time to failure for any cause among patients achieving a complete response | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Abnormalities in the 31 week and the year 3 echocardiograms | Endpoint will be abnormalities in the 31 week and the year 3 echocardiograms (i.e. year 1 off therapy). Secondarily, we shall compare the CCR rates for the two treatment regimens, in a two sided fashion. | 1 year off therapy | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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stage III childhood lymphoblastic lymphoma, stage IV childhood lymphoblastic lymphoma, untreated childhood acute lymphoblastic leukemia, T-cell childhood acute lymphoblastic leukemia, cardiac toxicity