Escalating Dose Intravenous Methotrexate Without Leucovorin Rescue Versus Oral Methotrexate and Single Versus Double Delayed Intensification for Children With Standard Risk Acute Lymphoblastic Leukemia
OBJECTIVES:
- Compare the event-free survival and overall survival of children with standard-risk
acute lymphoblastic leukemia treated with escalating-dose IV methotrexate without
leucovorin calcium versus oral methotrexate during the interim maintenance phase of
therapy.
- Compare the event-free survival and overall survival of these patients after receiving
treatment in two delayed intensification phases versus one delayed intensification
phase.
- Compare the toxic effects of oral versus escalating-dose intravenous methotrexate in
these patients.
- Determine the prognostic significance of the rate of disappearance of peripheral
lymphoblasts and lymphocytes during the first week of treatment in these patients.
- Determine the prognostic significance of trisomies of chromosomes 4, 5, 10, and 17 and
early treatment response in patients treated with these regimens.
- Determine the prognostic significance of the TEL-AML1 fusion transcript and early
treatment response in patients treated with these regimens.
- Determine the minimal residual disease (MRD) by polymerase chain reaction in bone
marrow and cerebrospinal fluid at various stages of therapy in these patients.
- Determine the prognostic significance of MRD during various stages of therapy in these
patients.
- Determine whether a second delayed intensification therapy improves the prognosis of
patients who have MRD at the end of induction therapy.
OUTLINE: This is a randomized, multicenter study. Patients without CNS disease at diagnosis,
achieving a specified early marrow response profile and M1 marrow status of less than 5%
blasts in the bone marrow (regardless of the proportion of mature lymphocytes) by day 28 of
induction therapy, and remaining event free with favorable bone marrow status and
cytogenetics between day 21 and 28 of consolidation therapy are randomized to one of four
treatment arms. Patients with CNS disease at diagnosis are assigned to treatment arm II and
undergo cranial irradiation. Patients with any of the following unfavorable bone marrow
features and/or unfavorable cytogenetic features are assigned to the augmented treatment
regimen by day 21 of induction chemotherapy or at the beginning of consolidation
chemotherapy:
NOTE: All T-cell precursor patients that are not more than 4 months past completion of the
delayed intensification phase of therapy should be switched to the augmented regimen as of
3/8/2004. These patients may be switched to the augmented regimen. The protocol gives
specific instructions according to the phase of therapy the patients are actually in.
- Unfavorable marrow status:
- M2: 5-25% blasts in bone marrow at day 28 of induction chemotherapy (or at day 14
of induction chemotherapy if day 7 status is M3) OR
- M3: More than 25% blast cell in bone marrow, regardless of the proportion of
mature lymphocytes at day 14 of induction chemotherapy
- Unfavorable cytogenetics: Must have 1 of the following:
- t(9;22)(q34;q11)
- t(4;11)(q21;q23)
- Balanced t(1;19)(q23;p13)
- Hypodiploidy with less than 45 chromosomes
- Other 11q23 translocations involving MLL Patients receive standard induction
chemotherapy comprising cytarabine (ARA-C) intrathecally (IT) on day 0 or up to 72
hours before day 0; oral dexamethasone (DM) twice daily on days 0-27; vincristine
(VCR) IV on days 0, 7, 14, and 21; and pegaspargase (PEG-ASP) intramuscularly (IM)
once between days 3-5. Patients without CNS disease at diagnosis receive
methotrexate (MTX) IT on days 7 and 28. Patients with CNS disease at diagnosis
receive MTX IT on days 7, 14, 21, and 28.
Patients who have achieved M1 marrow status by day 28 of induction therapy and have
favorable early bone marrow response and cytogenetics proceed to standard consolidation
therapy once blood counts have recovered. Patients with M3 bone marrow status at day 28 of
induction therapy are taken off the protocol. All other patients are assigned to the
augmented treatment regimen.
Beginning on day 28 of induction chemotherapy, patients receive standard consolidation
chemotherapy comprising VCR IV on day 0 and oral mercaptopurine (MP) on days 0-27. Patients
without CNS disease at diagnosis receive MTX IT on days 7, 14, 21, and 28. Patients with CNS
disease at diagnosis receive MTX IT on day 7 and cranial irradiation 5 days a week for 2
weeks. Patients with testicular disease receive bilateral testicular radiotherapy 5 days a
week for 1 week and then for 3 consecutive days during the next week.
NOTE: As of 3/8/2004, patients with T-cell disease who did not achieve M1 marrow status by
day 14 of induction OR who did not receive augmented induction and/or consolidation
(regardless of early marrow status) receive cranial irradiation.
- Arm I: Beginning on day 28 of consolidation chemotherapy, patients receive interim
maintenance I chemotherapy comprising oral DM twice daily on days 0-4 and 28-32; VCR IV
on days 0 and 28; oral MTX on days 0, 7, 14, 21, 28, 35, 42, and 49; oral MP on days
0-49; and MTX IT on day 28.
Beginning on day 56 of interim maintenance I chemotherapy, patients receive delayed
intensification chemotherapy comprising oral DM twice daily on days 0-6 and 14-20; VCR IV
and doxorubicin (DOX) IV over 15 minutes to 2 hours on days 0, 7, and 14; PEG-ASP IM on day
3; cyclophosphamide (CTX) IV over 20-30 minutes on day 28; oral thioguanine (TG) on days
28-41; ARA-C IV or subcutaneously (SC) daily on days 28-31 and 35-38; and MTX IT on days 0
and 28.
Beginning on day 56 of delayed intensification chemotherapy, patients receive interim
maintenance II chemotherapy identical to interim maintenance I chemotherapy except patients
receive MTX IT on days 0 and 28.
Beginning on day 56 of interim maintenance II chemotherapy, patients receive maintenance
chemotherapy comprising oral DM twice daily on days 0-4, 28-32, and 56-60; VCR IV on days 0,
28, and 56; oral MP on days 0-83; oral MTX on days 7, 14, 21, 28, 35, 42, 49, 56, 63, 70,
and 77; and MTX IT on day 0.
- Arm II: Patients receive interim maintenance I chemotherapy, delayed intensification
chemotherapy, and interim maintenance II chemotherapy as in arm I. Beginning on day 56
of interim maintenance II chemotherapy, patients then receive a second course of
delayed intensification chemotherapy followed by maintenance chemotherapy as in arm I.
- Arm III: Beginning on day 28 of consolidation chemotherapy, patients receive interim
maintenance I chemotherapy comprising VCR IV; escalating doses of MTX IV on days 0, 10,
20, 30, and 40; and MTX IT on day 30. Patients then receive delayed intensification
chemotherapy as in arm I. Patients receive interim maintenance II chemotherapy as in
interim maintenance I chemotherapy, but with IV MTX starting at 2/3 of the maximum
tolerated dose (MTD) attained in interim maintenance I chemotherapy. Patients then
receive maintenance chemotherapy as in arm I.
- Arm IV: Patients receive interim maintenance I chemotherapy as in arm III, delayed
intensification chemotherapy as in arm I, interim maintenance II chemotherapy as in arm
III, delayed intensification II chemotherapy as in arm II, and maintenance chemotherapy
as in arm I.
- Augmented Treatment: Patients receive induction chemotherapy comprising daunorubicin IV
continuously for 48 hours beginning no later than day 21; oral DM twice daily on days
14-27; and VCR IV on days 14 and 21. Patients without CNS disease at diagnosis receive
MTX IT on days 21 and 35. Patients with CNS disease at diagnosis receive MTX IT on days
21 and 28.
NOTE: Patients with T-cell disease should re-start with augmented consolidation and proceed
as per the augmented regimen.
Beginning on day 35 of induction chemotherapy, patients receive consolidation therapy
comprising CTX IV over 20-30 minutes on days 0 and 28; oral MP on days 0-13 and 28-41; ARA-C
IV or SC daily on days 0-3, 7-10, 28-31, and 35-38; VCR IV on days 14, 21, 42, and 49; and
PEG-ASP IM on days 14 and 42. Patients without CNS disease at diagnosis receive MTX IT on
days 7, 14, and 21. Patients with CNS disease at diagnosis receive MTX IT on day 7 and
cranial irradiation as in the randomized treatment section. Patients with testicular
leukemia receive radiotherapy as in the randomized treatment section.
Beginning on day 63 of consolidation chemotherapy, patients receive interim maintenance I
chemotherapy comprising VCR IV on days 0, 10, 20, 30, and 40; escalating doses of MTX IV on
days 10, 20, 30, and 40; PEG-ASP IM on days 1 and 21; and MTX IT on days 0 and 30.
Beginning on day 56 of interim maintenance I chemotherapy, patients receive delayed
intensification I chemotherapy comprising oral DM twice daily on days 0-6 and 14-20; VCR IV
on days 0, 7, 14, 42, and 49; DOX IV over 15 minutes to 2 hours on days 0, 7, and 14;
PEG-ASP IM on days 3 and 42; CTX IV over 20-30 minutes on day 28; oral TG on days 28-41;
ARA-C IV or SC daily on days 28-31 and 35-38; and MTX IT on days 0 and 28.
NOTE: Patients with T-cell disease who are in interim maintenance I chemotherapy with
escalating IV methotrexate should continue this phase and then proceed as per the augmented
regimen. If these patients are receiving conventional interim maintenance chemotherapy with
oral methotrexate, they should stop and restart the interim maintenance as per the augmented
regimen. These patients receive cranial irradiation starting on day 28 of delayed
intensification II chemotherapy.
Beginning on day 56 of delayed intensification I chemotherapy, patients receive interim
maintenance II chemotherapy as in interim maintenance I chemotherapy, but with IV MTX
starting at 2/3 of the MTD attained in interim maintenance I chemotherapy.
NOTE: Patients with T-cell disease who are in delayed intensification I chemotherapy proceed
with this phase, with the addition of 2 vincristine doses on days 42 and 49 and PEG-ASP on
day 42. These patients then proceed as per the augmented regimen with the addition of
cranial irradiation starting on day 28 of delayed intensification II chemotherapy.
NOTE: Patients with T-cell disease who are within 4 months of completing delayed
intensification I chemotherapy and have not received interim maintenance II chemotherapy
with escalating IV methotrexate or delayed intensification II chemotherapy receive a course
of interim maintenance chemotherapy and delayed intensification II chemotherapy according to
the augmented regimen. If these patients have received interim maintenance II chemotherapy
with escalating IV methotrexate, they receive delayed intensification II chemotherapy
according to the augmented regimen. These patients also receive cranial irradiation starting
on day 28 of delayed intensification II chemotherapy and then proceed to maintenance
therapy.
Beginning on day 56 of interim maintenance II chemotherapy, patients receive delayed
intensification II chemotherapy as in delayed intensification I chemotherapy.
Beginning on day 56 of delayed intensification II chemotherapy, patients receive maintenance
chemotherapy comprising oral DM twice daily on days 0-4, 28-32, and 56-60; VCR IV on days 0,
28, and 56; oral MP on days 0-83; oral MTX on days 7, 14, 21, 28, 35, 42, 49, 56, 63, 70,
and 77; and MTX IT on day 0.
Patients are followed every 4-8 weeks for one year, every 3 months for one year, every 6
months for one year, and then annually thereafter.
PROJECTED ACCRUAL: A total of 2,037 randomized patients will be accrued for this study
within 3.75 years.
Interventional
Allocation: Randomized, Endpoint Classification: Safety/Efficacy Study, Intervention Model: Parallel Assignment, Masking: Open Label, Primary Purpose: Treatment
Event Free Survival
The primary outcome index used in examining the randomized treatment groups will be event free survival (EFS) from the time of randomization (i.e., end of Consolidation), where the life table events will consist of the first occurrence of leukemic relapse at any site, death, or occurrence of a second malignancy.
Time of randomization
No
Yousif H. Matloub, MD
Study Chair
University of Wisconsin, Madison
United States: Federal Government
1991
NCT00005945
June 2000
Name | Location |
---|---|
Memorial Sloan-Kettering Cancer Center | New York, New York 10021 |
University of Michigan Comprehensive Cancer Center | Ann Arbor, Michigan 48109-0752 |
Children's Hospital of Philadelphia | Philadelphia, Pennsylvania 19104 |
Mayo Clinic Cancer Center | Rochester, Minnesota 55905 |
Jonsson Comprehensive Cancer Center, UCLA | Los Angeles, California 90095-1781 |
University of Chicago Cancer Research Center | Chicago, Illinois 60637 |
University of Minnesota Cancer Center | Minneapolis, Minnesota 55455 |
Cancer Center of Albany Medical Center | Albany, New York 12208 |
Rhode Island Hospital | Providence, Rhode Island 02903 |
Medical City Dallas Hospital | Dallas, Texas 75230 |
Yale Comprehensive Cancer Center | New Haven, Connecticut 06520-8028 |
Presbyterian - St. Luke's Medical Center | Denver, Colorado 80218 |
Carole and Ray Neag Comprehensive Cancer Center at the University of Connecticut Health Center | Farmington, Connecticut 06360-2875 |
Baystate Regional Cancer Program at D'Amour Center for Cancer Care | Springfield, Massachusetts 01199 |
Bronson Methodist Hospital | Kalamazoo, Michigan 49007 |
Geisinger Medical Center | Danville, Pennsylvania 17822-0001 |
Gundersen Lutheran Cancer Center at Gundersen Lutheran Medical Center | La Crosse, Wisconsin 54601 |
Marshfield Clinic - Marshfield Center | Marshfield, Wisconsin 54449 |
Lutheran General Cancer Care Center | Park Ridge, Illinois 60068 |
Newark Beth Israel Medical Center | Newark, New Jersey 07112 |
New York Medical College | Valhalla, New York 10595 |
Meritcare Roger Maris Cancer Center | Fargo, North Dakota 58122 |
Deaconess Medical Center | Spokane, Washington 99210-0248 |
University of Wisconsin Comprehensive Cancer Center | Madison, Wisconsin 53792 |
Holden Comprehensive Cancer Center at University of Iowa | Iowa City, Iowa 52242-1002 |
Long Island Cancer Center at Stony Brook University Hospital | Stony Brook, New York 11790-7775 |
Lineberger Comprehensive Cancer Center at University of North Carolina - Chapel Hill | Chapel Hill, North Carolina 27599-7570 |
CCOP - Columbia River Oncology Program | Portland, Oregon 97225 |
CCOP - Scott and White Hospital | Temple, Texas 76508 |
St. Barnabas Medical Center | Livingston, New Jersey 07039 |
MBCCOP - LSU Health Sciences Center | New Orleans, Louisiana 70112 |
Children's Hospital Los Angeles | Los Angeles, California 90027-0700 |
Children's Hospital of Orange County | Orange, California 92668 |
Children's National Medical Center | Washington, District of Columbia 20010-2970 |
Children's Mercy Hospital | Kansas City, Missouri 64108 |
St. Joseph's Hospital and Medical Center | Paterson, New Jersey 07503 |
Children's Hospital of Pittsburgh | Pittsburgh, Pennsylvania 15213 |
Children's Hospital and Regional Medical Center - Seattle | Seattle, Washington 98105 |
Kaiser Permanente Medical Center/Kaiser Foundation Hospital - San Diego | San Diego, California 92120 |
Kaiser Permanente Medical Center - Santa Clara | Santa Clara, California 95051-5386 |
Schneider Children's Hospital | New Hyde Park, New York 11042 |
City of Hope Comprehensive Cancer Center | Duarte, California 91010 |
UCSF Comprehensive Cancer Center | San Francisco, California 94115 |
Phoenix Children's Hospital | Phoenix, Arizona 85016-7710 |
Southern California Permanente Medical Group | Downey, California 90242 |
Children's Hospital Central California | Madera, California 93638-8762 |
Santa Barbara Cottage Hospital | Santa Barbara, California 93102 |
Medical Center of Central Georgia | Macon, Georgia 31201 |
Southern Illinois University School of Medicine | Springfield, Illinois 62794-9658 |
Kosair Children's Hospital | Louisville, Kentucky 40202-3830 |
CCOP - Beaumont | Royal Oak, Michigan 48073-6769 |
Children's Hospital of Omaha | Omaha, Nebraska 68114 |
Sunrise Hospital and Medical Center | Las Vegas, Nevada 89109-2306 |
Brookdale University Hospital and Medical Center | Brooklyn, New York 11212 |
Brooklyn Hospital Center | Brooklyn, New York 11201 |
Children's Hospital Medical Center of Akron | Akron, Ohio 44308 |
Children's Medical Center - Dayton | Dayton, Ohio 45404 |
St. Vincent Mercy Medical Center | Toledo, Ohio 43608 |
Toledo Children's Hospital | Toledo, Ohio 43601 |
East Tennessee Children's Hospital | Knoxville, Tennessee 37901 |
Texas Tech University Health Sciences Center School of Medicine | Amarillo, Texas 79106 |
Children's Hospital of Austin | Austin, Texas 78701 |
Covenant Children's Hospital | Lubbock, Texas 79410 |
Children's Hospital of the King's Daughters | Norfolk, Virginia 23507 |
Bellin Memorial Hospital | Green Bay, Wisconsin 54301 |
Markey Cancer Center at University of Kentucky Chandler Medical Center | Lexington, Kentucky 40536-0084 |
Herbert Irving Comprehensive Cancer Center at Columbia University | New York, New York 10032 |
Blumenthal Cancer Center at Carolinas Medical Center | Charlotte, North Carolina 28232-2861 |
SUNY Downstate Medical Center | Brooklyn, New York 11203 |
Ireland Cancer Center at University Hospitals of Cleveland and Case Western Reserve University | Cleveland, Ohio 44106 |
Sioux Valley Hospital and University of South Dakota Medical Center | Sioux Falls, South Dakota 57117-5134 |
Loma Linda University Cancer Institute at Loma Linda University Medical Center | Loma Linda, California 92354 |
Curtis & Elizabeth Anderson Cancer Institute at Memorial Health University Medical Center | Savannah, Georgia 31403-3089 |
Blank Children's Hospital | Des Moines, Iowa 50309 |
Alvin and Lois Lapidus Cancer Institute at Sinai Hospital | Baltimore, Maryland 21215 |
Breslin Cancer Center at Ingham Regional Medical Center | Lansing, Michigan 48910 |
Albert Einstein Cancer Center at Albert Einstein College of Medicine | Bronx, New York 10461 |
SUNY Upstate Medical University Hospital | Syracuse, New York 13210 |
Presbyterian Cancer Center at Presbyterian Hospital | Charlotte, North Carolina 28233-3549 |
Cincinnati Children's Hospital Medical Center | Cincinnati, Ohio 45229-3039 |
West Virginia University - Robert C. Byrd Health Sciences Center - Charleston Division | Charleston, West Virginia 25302 |
CCOP - Marshfield Clinic Research Foundation | Marshfield, Wisconsin 54449 |
St. Mary's - Duluth Clinic Cancer Center | Duluth, Minnesota 55805 |
Group Health Central Hospital | Seattle, Washington 98104 |
Lombardi Cancer Center at Georgetown University Medical Center | Washington, District of Columbia 20007 |
Josephine Ford Cancer Center at Henry Ford Health System | Detroit, Michigan 48202 |
UNMC Eppley Cancer Center at the University of Nebraska Medical Center | Omaha, Nebraska 68198-7680 |
New York Weill Cornell Cancer Center at Cornell University | New York, New York 10021 |
Samuel Oschin Comprehensive Cancer Institute at Cedars-Sinai Medical Center | Los Angeles, California 90048-1865 |
Alfred I. duPont Hospital for Children | Wilmington, Delaware 19803 |
AFLAC Cancer Center and Blood Disorders Service of Children's Healthcare of Atlanta - Scottish Rite Campus | Atlanta, Georgia 30342 |
Cancer Institute of New Jersey at UMDNJ - Robert Wood Johnson Medical School | New Brunswick, New Jersey 08903 |
Children's Hospital and Research Center at Oakland | Oakland, California 94609-1809 |
Kaiser Permanente Medical Center - Sacramento | Sacramento, California 95825 |
Mountain States Tumor Institute - Boise | Boise, Idaho 83712 |
University of Illinois Medical Center | Chicago, Illinois 60612 |
Riley Children Cancer Center at Riley Hospital for Children | Indianapolis, Indiana 46202-5225 |
William Beaumont Hospital - Royal Oak | Royal Oak, Michigan 48073-6769 |
Valerie Fund Children's Center at Atlantic Health | Summit, New Jersey 07901 |
Comprehensive Cancer Center at Maimonides Medical Center | Brooklyn, New York 11219 |
Dakota Cancer Institute at Innovis Health - Dakota Clinic | Fargo, North Dakota 58103-4940 |
Doernbecher Children's Hospital at Oregon Health & Science University | Portland, Oregon 97239-3098 |
East Tennessee State University Cancer Center at Johnson City Medical Center | Johnson City, Tennessee 37604 |
Vanderbilt Children's Hospital | Nashville, Tennessee 37232-6310 |
Methodist Cancer Center at Methodist Specialty and Transplant Hospital | San Antonio, Texas 78229-3902 |
MBCCOP - South Texas Pediatrics | San Antonio, Texas 78229-3900 |
Mary Bridge Children's Hospital and Health Center | Tacoma, Washington 98415-0299 |
Cabell Huntington Hospital | Huntington, West Virginia 25701 |
Chao Family Comprehensive Cancer Center at University of California Irvine Medical Center | Orange, California 92868 |
General Robert Huyser Cancer Center at David Grant Medical Center | Travis Air Force Base, California 94535 |
Children's Hospital Cancer Center | Denver, Colorado 80218 |
DeVos Children's Hospital | Grand Rapids, Michigan 49503 |
Children's Hospitals and Clinics - Minneapolis/St. Paul | Minneapolis, Minnesota 55404 |
Columbus Children's Hospital | Columbus, Ohio 43205-2696 |
Children's Hospital at Milton S. Hershey Medical Center | Hershey, Pennsylvania 17033 |
MD Anderson Cancer Center at University of Texas | Houston, Texas 77030-4009 |