Total Therapy Study XVI for Newly Diagnosed Patients With Acute Lymphoblastic Leukemia

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Brief Title

Total Therapy Study XVI for Newly Diagnosed Patients With Acute Lymphoblastic Leukemia

Official Title

Total Therapy Study XVI for Newly Diagnosed Patients With Acute Lymphoblastic Leukemia

Brief Summary

      The primary objective of this study (TOTXVI) is to compare the clinical benefit, the
      pharmacokinetics, and the pharmacodynamics of polyethylene glycol-conjugated (PEG)
      asparaginase given in higher dose (HD PEG) versus those of PEG-asparaginase given in
      conventional dose (CD PEG) during the continuation phase.

      This study has several secondary objectives:

      Therapeutic Objectives:

      To estimate the event-free survival and overall survival of children with ALL who are treated
      with risk-directed therapy.

      To study whether intensifying induction, including fractionated cyclophosphamide and
      thioguanine, in patients with day 15 MRD > 5%, will result in improved leukemia cytoreduction
      in this subgroup compared to TOTXV.

      To assess whether intensification of central nervous system (CNS)-directed intrathecal and
      systemic chemotherapy will improve outcome in patients at high risk of CNS relapse.

      Exploratory Pharmacologic Objectives:

      To identify pharmacogenetic, pharmacokinetic and pharmacodynamic predictors for
      treatment-related outcomes in the context of the systemic therapy used in the protocol.

      To compare the pharmacokinetics and pharmacodynamics of PEG-asparaginase given in higher dose
      (3,500 or 3,000 units/m2) versus those of PEG-asparaginase given in conventional dose (2,500
      units/m2) in the continuation phase.

      Exploratory Biologic Objectives:

      To determine the prognostic value of levels of minimal residual disease in peripheral blood
      at day 8 of remission induction.

      To validate new markers and methods for MRD detection. To genotype natural killer (NK) cell
      receptors and measure their expressions at diagnosis and before reinduction, and to associate
      these features with treatment outcome.

      To identify new prognostic factors by applying new technologies to study patient material
      (e.g., stored plasma, serum, cerebrospinal fluid, and normal and leukemic cells).

      Exploratory Neuroimaging Objectives:

      To use quantitative MR measures (Diffusion Tensor Imaging and high resolution volumetric
      imaging) to assess differences in myelin and cortical thickness development in patients
      treated for ALL relative to healthy controls matched for age and gender.

      To assess the impact of folate pathway genetic polymorphisms on myelin and cortical thickness
      development and neurocognitive performance.

      To assess the impact of frontal-parietal lobe myelin and cortical thickness development on
      neurocognitive performance in attention, working memory, fluency, visual-spatial reasoning
      and processing speed.
    

Detailed Description

      Details of the Treatment Plan:

      Treatment will consist of three main phases: Remission Induction, Consolidation, and
      Continuation.

        1. Remission Induction

             -  Intrathecal Treatment during Induction

           Frequency and total number of triple intrathecal treatments for Remission Induction is
           based on the patient's risk of CNS relapse.All patients will receive triple intrathecal
           treatment on days 1 and 15. Patients with high risk features may receive additional
           triple intrathecal treatment on days 4, 8, 11, and 22.[t(1;19)/E2A-PBX1.

           Induction treatment will begin with prednisone, vincristine, daunorubicin,
           PEG-asparaginase and triple intrathecal treatment, followed by cyclophosphamide plus
           cytarabine plus thioguanine.

           Remission Induction Chemotherapy (6-7 weeks) Prednisone 40 mg/m2/day PO (divided t.i.d.)
           Days 1 - 28 Dexamethasone will be substituted for prednisone in patients with early
           T-cell precursor (ETP) immunophenotype.

           Mercaptopurine will be substituted for thiopurine in TPMT HET/deficient patients
           Dexamethasone (for ETP immunophenotype only) 10 mg/m2/day PO (divided t.i.d.)Days 1-21;
           4 mg/m2/day PO (divided t.i.d) Days 22-24; 2 mg/m2/day PO(divided t.i.d) Days 25-28
           Vincristine 1.5 mg/m2 IV (max 2 mg) Days 1, 8, 15, 22 Daunorubicin 25 mg/m2 IV Days 1
           and 8 PEG-asparaginase 3,000 Units/m2 IV Day 3

           - Participants with Day 15 MRD greater than or equal to 1%: PEG-asparaginase 3,000
           Units/m2 IV Day 15

           - Participants with Day 15 MRD less than 5% (excluding MLL positive infants):
           Cyclophosphamide 1000 mg/m2 IV Day 22 Cytarabine 75 mg/m2/dose IV Days 23-26, 30-33
           Thioguanine [Mercaptopurine (TPMT HET/deficient patients only)]60 mg/m2/dose PO Days
           22-35 Dasatinib (Ph+ participants only) 40 mg/m2 b.i.d starting Day 22 of induction to
           continue until end of treatment

           Day 15 MRD > or equal to 5% (excluding MLL+ infants) Cyclophosphamide† 300 mg/m2 IV/ q12
           hrs on Days 22-23 Cytarabine 75 mg/m2/dose IV Days 23-26, 30-33 Thioguanine
           [Mercaptopurine (TPMT HET/deficient patients only) 60 mg/m2/dose PO Days 22-35
           Dasatinib‡ (Ph+ participants only) 40 mg/m2 b.i.d Daily Starting Day 22 of induction to
           continue until end of treatment

           - Infants with MLL positive rearrangement: Clofarabine 40 mg/m2/dose IV Days 22-26
           Etoposide 100 mg/m2/dose IV Days 22-26 Cyclophosphamide 300 mg/m2/dose IV Days 22-26

        2. Consolidation Treatment (8 weeks) High Dose Methotrexate (HDMTX) 2.5 gm/ (low risk), or
           targeted 65 μM (std/high-risk) days 1, 15, 29 and 43. Mercaptopurine 50 mg/m2/day Days 1
           to 56. All patients will receive triple intrathecal therapy every other week for four
           doses on Days 1, 15, 29, and 43. Dose is age dependent.

           - Reintensification

           Patients with high-risk leukemia may receive reintensification therapy and then will be
           offered the option of transplant. This treatment will attempt to maximize leukemic cell
           kill before allogeneic hematopoietic stem cell transplantation.

           Dexamethasone 20 mg/m2/day PO or IV Days 1-6.Cytarabine 2 grams/m2, 3-hour IV infusion
           every 12 hours Days 1-2. Etoposide 100 mg/m2, 1-hour IV infusion every 12 hours Days
           3-5. Intrathecal methotrexate+hydrocortisone+cytarabine (ITMHA) Day 5; PEG-asparaginase
           3,000 units/m2 IV Day 6

           Patients with suboptimal response to reintensification may receive one to two cycles of
           clofarabine/cyclophosphamide/etoposide/dexamethasone:

           Clofarabine 40 mg/m2/day, 2-hour IV infusion Days 1-5 Etoposide 100 mg/m2/day, 2-hour IV
           infusion Days 1-5 Cyclophosphamide 300 mg/m2/day, 30-60 minute IV infusion Days 1-5
           Dexamethasone 8 mg/m2/day (divided t.i.d) Days 1-5

        3. Continuation Treatment (120 weeks)

      Abbreviations used below: DEX=dexamethasone; DOX=doxorubicin; VCR=vincristine;
      MP=mercaptopurine; PEG-ASP=polyethylene glycol-conjugated asparaginase; MTX=methotrexate;
      6MP=mercaptopurine

      Weeks 1 through 20 - treatment depends on risk assignment standard-high versus low-risk

      Week Standard-/High-Risk Low-Risk

        1. DEX+DOX+VCR+MP + PEG-ASP/MP + DEX + VCR

        2. MP MP + MTX

        3. MP + PEG-ASP/MP + MTX

        4. DEX + DOX + VCR + MP/MP + DEX + VCR

        5. MP + PEG-ASP MP + MTX

        6. MP MP + MTX

        7. Reinduction I

        8. Reinduction I

        9. Reinduction I

       10. MP/MP + MTX

       11. DOX + VCR +MP + PEG-ASP/MP + MTX

       12. MP/MP + MTX

       13. MP + PEG-ASP/MP + MTX

       14. DEX + DOX + VCR +6MP/MP + DEX + VCR

       15. MP + PEG-ASP/MP + MTX

       16. MP/MP + MTX

       17. Reinduction II

       18. Reinduction II

       19. Reinduction II

       20. No chemotherapy/MP + MTX

           Drug Dosages, Schedules and Routes for Continuation Therapy Weeks 1 to 6 and 10 to 16:

           Dexamethasone 12 mg/m2 (std/high risk) or 8 mg/m2 (low risk) PO daily (divided t.i.d.)
           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 < 10kg in weight). MP
           (mercaptopurine) 50 mg/m2 PO daily for 7 days (std/high risk), Days 1-7, 75 mg/m2 PO
           daily for 7 days (low risk), Days 1-7. PEG-ASP (PEG-asparaginase) 2,500 vs. 3,500
           units/m2 IV randomization, Day 1. Methotrexate 40 mg/m2 IV Day 1.

           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 white blood count (WBC) <1000/mm3 or absolute neutrophil
           count (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.

           Reinduction Treatment - This phase of treatment is part of continuation and will be
           started at weeks 7 and 17 after bone marrow examination confirms complete remission.
           Doxorubicin and HD-cytarabine will be held if ANC < or equal to 300/mm3 or WBC <
           1000/mm3.It is preferable to start HD-cytarabine when WBC > or equal to 1800/mm3 and ANC
           > 300/mm3 Reinduction treatment will be given twice: weeks 7 to 9 and weeks 17 to 19 for
           all patients. Intrathecal treatment will be followed by leucovorin rescue (5 mg/m2/dose
           PO, max 5 mg) at 24 and 30 hours only in patients with prior CNS toxicities or in
           patients with WBC < 1500/mm3, or ANC < 500/mm3.

           - Reinduction I for Standard/High Risk ALL excluding MLL infants: Dexamethasone 8
           mg/m2/day PO (divided t.i.d.) Days 1-8, 15-21. Vincristine 1.5 mg/m2/week IV Days 1, 8,
           15 Doxorubicin 30 mg/m2 IV Days 1, 8. PEG-asparaginase 2,500 or 3,500 units/m2 IV Days
           1, 15.

           Intrathecal chemotherapy, Methotrexate + hydrocortisone + Ara-C dose age dependent, Day
           1.

           - Reinduction II for Standard/High Risk ALL including MLL infants: Dexamethasone 8
           mg/m2/day PO (t.i.d.) Days 1-8, 15-21. Vincristine 1.5 mg/m2/week IV Days 1, 8, 15.
           PEG-asparaginase 2,500 or 3,500 units/m2 IV Days 1, 15. High-dose cytarabine 2 gm/m2 IV
           q 12 hr Days 15, 16. Intrathecal chemotherapy, dose age dependent, Day 1.

           - Reinduction I for Low-Risk ALL: Dexamethasone 8 mg/m2/day PO (divided t.i.d.) Days
           1-8, 15-21. Vincristine 1.5 mg/m2/week IV Days 1, 8, 15. PEG-asparaginase 2,500 or 3,500
           units/m2 IV Days 1, 15. Doxorubicin 30 mg/m2/IV Day 1. Intrathecal chemotherapy, dose
           age dependent, Day 1.

           - Reinduction II for Low-Risk ALL: Dexamethasone 8 mg/m2/day PO (divided t.i.d.) Days
           1-8, 15-21. Vincristine 1.5 mg/m2/week IV Days 1, 8, 15. PEG-asparaginase 2,500 or 3,500
           units/m2 IV Days 1, 15. Intrathecal chemotherapy, dose age dependent, Day 1.

           - Reinduction I for MLL Infants: Dexamethasone 8 mg/m2/day PO (divided t.i.d.) Days 1-8
           and 15-21. Clofarabine 40 mg/m2/day, -hour IV Days 1-5. Etoposide 100 mg/m2/day, 2-hour
           IV Days 1-5. cyclophosphamide 300 mg/m2/day, 1-hour IV Days 1-5. PEG-asparaginase 2,500
           or 3,500 units/m2 IV Days 1, 15. Intrathecal chemotherapy, dose age dependent, on Day 1.

           - Intrathecal Chemotherapy:

             -  Triple intrathecal treatment will be given to low-risk cases with CNS-1 status (no
                identifiable blasts in CSF) on weeks 7, 12, 17, 25, 33, 41, and 49.

             -  Triple intrathecal treatment will be given to low-risk cases with CNS-2, traumatic
                CSF with blasts status, or WBC > 100 x 109/L on weeks 3, 7, 12, 17, 25, 29, 33, 37,
                41, 45 and 49.

             -  Triple intrathecal treatment will be given to standard/high-risk cases on weeks 7,
                12, 17, 25, 29, 33, 37, 41, 45 and 49.

             -  Triple intrathecal treatment will be given to other standard/high-risk cases with
                WBC > or equal to 100 x 109/L, T-cell ALL, t (1;19)/E2A-PBX1, presence of
                Philadelphia chromosome, MLL rearrangement, hypodiploidy <44, CNS-2 or CNS-3
                status, or traumatic lumbar puncture with blasts on weeks 3, 7, 12, 17, 25, 29, 33,
                37, 41, 45, 49, 57, 65, 73, 81, 89 and 97

           Treatment (weeks 21 to 29)

           Week Standard/High Risk Low Risk

       21. MP + PEG-ASP+Dasatinib MP + MTX

       22. MP +Dasatinib MP + MTX

       23. MP + PEG-ASP + Dasatinib MP + MTX

       24. Cyclo + Ara-C + Dasatinib MP + MTX

       25. DEX + VCR + PEG-ASP + Dasatinib MP + DEX + VCR

       26. MP + Dasatinib MP + MTX

       27. MP + PEG-ASP+Dasatinib MP + MTX

       28. Cyclo + Ara-C + Dasatinib MP + MTX

       29. DEX + VCR +PEG-ASP + Dasatinib MP + DEX + VCR Dasatinib in Ph+ only

           Treatment (weeks 30 to end of therapy)

           Week Standard/High Risk Low Risk

       30. MP + MTX + Dasatinib MP + MTX

       31. MP + MTX + Dasatinib MP + MTX

       32. Cyclo + Ara-C+Dasatinib MP + MTX

       33. DEX + VCR + Dasatinib MP + DEX + VCR

       34. MP + MTX + Dasatinib MP + MTX

       35. MP + MTX + Dasatinib MP + MTX

       36. Cyclo + Ara-C + Dasatinib/MP + MTX

       37. DEX + VCR + Dasatinib /MP + DEX + VCR Dasatinib in Ph positive patients only

      Drug Dosages, Schedules and Routes for Continuation Therapy from Week 21 to End of Therapy:

      Mercaptopurine 75 mg/m2 PO daily for 7 days, Days 1-7. Methotrexate 40 mg/m2 IV or
      intramuscularly (IM) Day 1. Cyclophosphamide 300 mg/m2 IV, Day 1. Cytarabine 300 mg/m2 IV,
      Day 1. Dexamethasone 12 mg/m2 (std/high risk) or 8 mg/m2 (low risk) PO daily (divided t.i.d.)
      for 5 days, Day 1-5 (between week 21 and week 68).Decrease dexamethasone to 6 mg/m2 PO daily
      (divided t.i.d.) x 5 days,Day 1-5 between week 69 and week 101 for all risk groups.

      Vincristine2 mg/m2 IV push (max 2 mg), Day 1 (0.05mg/kg for patients < 1 year or < 10 kg).

      PEG-ASP 2,500 vs 3,500 units/m2 IV randomization (until week 30)

      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 5 times, until week 69 (see
      Section 5.5.3 for intrathecal therapy). After week 69, all patients will receive daily
      mercaptopurine and weekly methotrexate interrupted with pulses of dexamethasone, vincristine,
      and mercaptopurine every 4 weeks. The dose of dexamethasone will be decreased to 6 mg/m2
      between week 69 and week 101, after which only mercaptopurine and methotrexate will be given.
      Intrathecal treatment will be given every 8 weeks only to patients at risk of CNS relapse
      after week 49 and will be discontinued after week 97. Continuation therapy will be
      discontinued after 120 weeks.

      Hematopoietic Stem Cell Transplantation (for patients who meet the criteria of high-risk ALL
      are candidates for allogeneic hematopoietic stem cell transplantation). However, if the
      option is declined by the patients or guardians, or the procedure is deemed unsuitable by the
      attending physician and the principal investigator, the patient will remain on study and
      continue to receive chemotherapy.
    

Study Phase

Phase 3

Study Type

Interventional


Primary Outcome

Continuous complete remission of patients receiving high-dose and conventional dose PEG-asparaginase.

Secondary Outcome

 Event-free survival

Condition

Acute Lymphoblastic Leukemia

Intervention

Prednisone, Vincristine, Daunorubicin, PEG-L-asparaginase, Erwinia L-asparaginase, Doxorubicin, Cyclophosphamide, Cytarabine, Thioguanine

Study Arms / Comparison Groups

 HD PEG
Description:  Participants randomized to receive higher dose PEG-asparaginase during the continuation phase.
Interventions:
Prednisone, Vincristine, Daunorubicin, PEG-L-asparaginase, Erwinia L-asparaginase, Doxorubicin, Cyclophosphamide, Cytarabine, Thioguanine
Clofarabine, Methotrexate, Mercaptopurine, Dexamethasone, Etoposide, Dasatinib

Publications

* Includes publications given by the data provider as well as publications identified by National Clinical Trials Identifier (NCT ID) in Medline.

Recruitment Information


Recruitment Status

Drug

Estimated Enrollment

600

Start Date

October 29, 2007

Completion Date

November 30, 2020

Primary Completion Date

November 30, 2020

Eligibility Criteria

        Inclusion Criteria:

          -  Participant has a confirmed diagnosis of precursor B-cell or precursor T-cell acute
             lymphocytic leukemia (ALL) by immunophenotyping

          -  Participant is less than or equal to 18 years of age

          -  Limited prior therapy, including systemic glucocorticoids for one week or less, one
             dose of vincristine, emergency radiation therapy to the mediastinum and one dose of
             intrathecal chemotherapy. Other circumstances must be cleared by principal
             investigator (PI) or co-PI.

          -  Written, informed consent and assent following Institutional Review Board, NCI, FDA,
             and Office for Human Research Protections (OHRP) Guidelines.

        Exclusion Criteria:

          -  Participants with prior therapy, other than that listed above

          -  Pregnant or lactating

          -  Inability or unwillingness of research participant or legal guardian/representative to
             give written informed consent.
      

Gender

All

Ages

N/A - 18 Years

Accepts Healthy Volunteers

No

Contacts

Sima Jeha, MD, , 

Location Countries

United States

Location Countries

United States

Administrative Informations


NCT ID

NCT00549848

Organization ID

TOTXVI

Secondary IDs

R01CA140729

Responsible Party

Sponsor

Study Sponsor

St. Jude Children's Research Hospital

Collaborators

 National Cancer Institute (NCI)

Study Sponsor

Sima Jeha, MD, Principal Investigator, St. Jude Children's Research Hospital


Verification Date

November 2019