Adult Acute Lymphoblastic Leukemia Treated With Pediatric Regimen in Brazil

Study Overview
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Brief Summary
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In this project, the investigators intend to start a prospective registry for patients with newly diagnosed Philadelphia-negative ALL from 16 years old and above in participating centers, provided that all patients will be treated with the same regimen (a pediatric regimen BFM-based incorporating peg-asparaginase). All diagnostic/follow-up (after induction and consolidation blocks) samples will be centrally biobanked at Instituto do Cancer do Estado de Sao Paulo. The main goal of this study is to examine whether the implementation of a pediatric protocol under a prospective registry can increase event-free survival (EFS) and overall survival (OS) of newly diagnosed patients in the participating centers.

Detailed Description
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Notably, pediatric regimens for adult acute lymphoblastic leukemia (ALL) have resulted in better long-term outcomes, especially in the Philadelphia-negative counterpart. These regimens are essentially based on higher cumulative doses of asparaginase and the use of less myelotoxic agents, applying allogeneic transplantation only for high-risk ALL subsets. Recent metanalysis encompassing 27 clinical trials demonstrated an improved prognosis when these regimens are adopted. In adults, incorporation of these regimens has been hampered by a perception of higher toxicity and a more complex design, especially with asparaginase. Remarkably, this drug might bring side effects not usually seen with other cancer drugs, such as thrombosis, liver, and pancreatic toxicities. In addition, the incorporation of minimal residual disease (MRD) monitoring throughout the treatment protocol in a scheduled and standardized manner is considered paramount in the contemporary ALL treatment. Treating adult patients with acute leukemia under prospective studies allows accurate data collection and positively impacts the disease prognosis, creating a cooperative scientific environment. In Brazil, few data are available on the clinical- laboratory characteristics of ALL in adults and their outcomes under a standardized treatment protocol. Few single-center reports point to a worse overall survival rate when compared to developed countries. There is great heterogeneity across the centers regarding the treatment regimens and genetic/MRD assessment. In this project, the investigators intend to start a prospective registry for patients with newly diagnosed Philadelphia-negative ALL from 16 years old and above in participating centers, provided that all patients will be treated with the same regimen (a pediatric regimen BFM-based incorporating peg-asparaginase). All diagnostic/follow-up (after induction and consolidation blocks) samples will be centrally biobanked at Instituto do Cancer do Estado de Sao Paulo. At the diagnosis, a genetic characterization encompassing conventional karyotype, fluorescent in-situ hybridization (FISH), and molecular biology in our central laboratory will be performed to classify the cases. Genomic classification will include identifying Philadelphia- like B-cell ALL cases, a recent group of cases with worse prognosis, whose incidence seems higher in Hispanics. In Brazil, there is no study addressing this incidence and, more importantly, evaluating its impact on outcomes under a standardized treatment protocol. MRD analysis will also be centralized to standardize and validate our flow cytometry panel in a homogeneous cohort. Additionally, the investigators plan to assess baseline factors predictive of survival and relapse and those related to major toxicities such as infections, liver toxicity, and thrombosis.

Official Title
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Adult Acute Lymphoblastic Leukemia Treated With Pediatric Regimen in Brazil - a Prospective Collaborative Study

Conditions
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Acute Lymphoid Leukemia, Minimal Residual Disease, Gene Abnormality, Chemotherapeutic Toxicity

Intervention / Treatment
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* Drug: Prednisone
* Drug: Vincristin
* Drug: Daunorubicin
* Drug: Peg-asparaginase
* Drug: Intrathecal Suspension
* Drug: Cyclophosphamide
* Drug: Cytarabine
* Drug: Mercaptopurine
* Drug: Methotrexate
* Drug: Doxorubicin


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Patients between 16 and 50 years-old with newly diagnosed ALL, negative for Philadelphia chromosome not previously treated (except for hydroxyurea, corticosteroids, or intrathecal chemotherapy) with 20% or more lymphoblasts in bone marrow or peripheral blood. Exclusion Criteria: Burkitt leukemia Prior myeloproliferative disease Philadelphia chromosome positivity through whichever methodology (RT-PCR, FISH, or conventional karyotype) ECOG>2 (appendix 3) Total bilirubin>2x upper limit of normal (ULN) Transaminases>5x ULN Creatinine>2,5 mg/dl Positive serology for HIV or HTLV Heart failure NYHA Class III or IV (appendix 4) Severe psychiatric disorder which prevents adequate compliance Prior treatment with intravenous chemotherapy Refusal to participate in the study Down syndrome

Ages Eligible for Study
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Minimum Age: 16 Years
Maximum Age: 50 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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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Eligible patients<br>All patients deemed eligible to intensive protocol of treatment are going to be included as sole group. There is no intervention or control group in this trial. | Drug: Prednisone<br>* 60 mg/m2 D1 to D21<br>Drug: Vincristin<br>* 1.5 mg/m2 D1, D8, D15 and D22<br>Drug: Daunorubicin<br>* 40 mg/m2 D1, D8, D15 and D22<br>Drug: Peg-asparaginase<br>* 2000 UI/m2 D12 and D26<br>Drug: Intrathecal Suspension<br>* MTX 12 mg, Dexamethasone 2 mg, Cytarabine 60 mg D1, D8, D15, D22, D29<br>Drug: Cyclophosphamide<br>* 1000 mg/m2 D36 and D64<br>Drug: Cytarabine<br>* 75 mg/m2 D36 to D39, D43 to D46, D50 to D53 and D57 to D60<br>Drug: Mercaptopurine<br>* 30 mg/m2 D36 to D63 and D1 to D56 of consolidation<br>Drug: Methotrexate<br>* 3.000 mg/m2 D8, D22, D36 and D50<br>Drug: Doxorubicin<br>* 30 mg/m2 D1 and D22<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Overall survival (OS) | cumulative proportion of patients alive (considering the time between the date of diagnosis and death or last follow-up) | 4 years | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Event-free survival (EFS) | time between enrollment in the study and the occurrence of any event: refractoriness after the first two cycles of induction, death or relapse. | 4 years | 
| Early death rate | proportion of patients who died before the first bone marrow evaluation of response (after induction I) | 60 days | 
| Complete response rate | proportion of patients with bone marrow aspirate with less than 5% blasts and evidence of normal hematopoiesis; CSF without blasts and recovery of peripheral blood (neutrophils≥ 1,000/μL and platelets≥100,000/μL), without the need for transfusion | 60 days | 
| Cumulative incidence of relapse | rate of disease relapse after CR calculated considering death as a competing event. | 4 years | 
| HSCT rate | proportion of patients eligible for the protocol who were able to perform the procedure in their first CR | 2 years |