Clinical Trials /

Different Therapies in Treating Infants With Newly Diagnosed Acute Leukemia

NCT00550992

Description:

RATIONALE: Giving chemotherapy before a donor stem cell transplant helps stop the growth of cancer cells. It also helps stop the patient's immune system from rejecting the donor's stem cells. When the healthy stem cells from a donor are infused into the patient they may help the patient's bone marrow make stem cells, red blood cells, white blood cells, and platelets. Sometimes the transplanted cells from a donor can make an immune response against the body's normal cells. Giving cyclosporine, methotrexate, leucovorin, and antithymocyte globulin before and after transplant may stop this from happening. It is not yet known which treatment regimen is most effective in treating acute leukemia. PURPOSE: This randomized clinical trial is studying how well different therapies work in treating infants with newly diagnosed acute leukemia.

Related Conditions:
  • Acute Lymphoblastic Leukemia
Recruiting Status:

Recruiting

Phase:

N/A

Trial Eligibility

Document

Title

  • Brief Title: Different Therapies in Treating Infants With Newly Diagnosed Acute Leukemia
  • Official Title: International Collaborative Treatment Protocol for Infants Under One Year With Acute Lymphoblastic or Biphenotypic Leukemia

Clinical Trial IDs

  • ORG STUDY ID: CDR0000570260
  • SECONDARY ID: DCOG-INTERFANT-06
  • SECONDARY ID: EUDRACT-2005-004599-19
  • SECONDARY ID: CCLG-LK-2006-10
  • NCT ID: NCT00550992

Conditions

  • Leukemia

Interventions

DrugSynonymsArms
anti-thymocyte globulin
asparaginase
busulfan
cyclophosphamide
cyclosporine
cytarabine
daunorubicin hydrochloride
etoposide
leucovorin calcium
melphalan
mercaptopurine
methotrexate
mitoxantrone hydrochloride
pegaspargase
prednisolone
prednisone
therapeutic hydrocortisone
thioguanine
vincristine sulfate

Purpose

RATIONALE: Giving chemotherapy before a donor stem cell transplant helps stop the growth of cancer cells. It also helps stop the patient's immune system from rejecting the donor's stem cells. When the healthy stem cells from a donor are infused into the patient they may help the patient's bone marrow make stem cells, red blood cells, white blood cells, and platelets. Sometimes the transplanted cells from a donor can make an immune response against the body's normal cells. Giving cyclosporine, methotrexate, leucovorin, and antithymocyte globulin before and after transplant may stop this from happening. It is not yet known which treatment regimen is most effective in treating acute leukemia. PURPOSE: This randomized clinical trial is studying how well different therapies work in treating infants with newly diagnosed acute leukemia.

Detailed Description

      OBJECTIVES:

      Primary

        -  To compare an early intensification regimen comprising two "acute myeloid leukemia"
           induction therapy blocks with a standard protocol IB regimen administered directly after
           induction therapy in medium-risk (MR) and high-risk (HR) patients with newly diagnosed
           acute lymphoblastic or biphenotypic leukemia.

      Secondary

        -  To compare through a randomized study the role of these regimens in treating these
           patients.

        -  To compare the overall outcome of the Interfant-06 study with outcomes in the historical
           control series, especially in the Interfant-99 study.

        -  To compare the outcomes of low-risk, MR, or HR patients in this study with those of
           patients in the historical control series Interfant-99 study.

        -  To study which factors have independent prognostic value in patients treated with these
           regimens.

        -  To assess the role of stem cell transplantation in HR patients.

      OUTLINE: This is a multicenter study.

        -  Induction therapy:

             -  Prednisone phase: Patients receive prednisone orally or IV three times daily on
                days 1-7 and methotrexate (MTX) and prednisolone (PRDL) intrathecally (IT) on day
                1. Patients then proceed to remission induction therapy.

             -  Remission induction phase: Patients receive dexamethasone (DEXA) IV or orally three
                times daily on days 8-28 followed by a taper to 0 over 1 week; vincristine (VCR) IV
                on days 8, 15, 22, and 29; cytarabine (ARA-C) IV over 30 minutes on days 8-21;
                daunorubicin hydrochloride (DNR) IV over 1 hour on days 8 and 9; asparaginase (ASP)
                IV over 1 hour or intramuscularly (IM) on days 15, 18, 22, 25, 29, and 33; MTX IT
                on days 1 and 29*; and ARA-C IT on day 15. Patients also receive PRDL or
                therapeutic hydrocortisone (HC) IT on days 1, 15, and 29.

      NOTE: *Patients with CNS involvement at initial diagnosis also receive MTX IT on days 8 and
      22. If CNS leukemia is still present at day 29, then patients receive weekly MTX IT until the
      CNS is free of leukemia.

      After completion of induction therapy, patients are stratified according to risk group
      (low-risk [LR] vs medium-risk [MR] vs high-risk [HR]). Patients with low-risk disease are
      assigned to treatment arm I. Patients with MR or HR disease that is in complete remission
      (CR) on day 33 are randomized to 1 of 2 treatment arms. These patients are stratified
      according to status (MR with rearranged MLL vs MR with unknown MLL vs HR).

        -  Arm I (standard therapy):

             -  Protocol IB therapy (beginning on day 36 of induction therapy): Patients receive
                cyclophosphamide (CPM) IV over 1 hour on days 1 and 29 and oral mercaptopurine (MP)
                on days 1-28; ARA-C IV on days 3-6, 10-13, 17-20, and 24-27; ARA-C IT on day 10;
                and MTX IT on day 24. Patients also receive PRDL or therapeutic HC IT on days 10
                and 24.

             -  MARMA therapy:

                  -  Part I: Patients receive oral MP once daily on days 1-14; high-dose (HD) MTX
                     IV over 24 hours on days 1 and 8; leucovorin calcium orally or IV at 42, 48,
                     and 54 hours after each dose of MTX until MTX plasma levels are safe; and MTX
                     IT on days 2 and 9. Patients also receive PRDL or therapeutic HC IT on days 2
                     and 9.

                  -  Part II: Patients receive HD ARA-C IV over 3 hours twice daily with 12-hour
                     intervals on days 15, 16, 22, and 23; and pegaspargase (PEG-ASP) IV over 1
                     hour or IM on day 23.

             -  OCTADA(D) reinduction therapy:

                  -  Part I: At least 2 weeks after the completion of MARMA chemotherapy, patients
                     receive oral dexamethasone (DEXA) three times daily on days 1-14, followed by
                     a taper to 0 at day 21; oral thioguanine (TG) once daily on days 1-28; VCR IV
                     on days 1, 8, 15, and 22; DNR IV over 1 hour on days 1, 8, 15, and 22; PEG-ASP
                     IV over 1 hour or IM on day 1; ARA-C IV on days 2-5, 9-12, 16-19, and 23-26;
                     and ARA-C IT on days 1 and 15. Patients also receive PRDL or therapeutic HC IT
                     on days 1 and 15.

                  -  Part II: Patients receive oral TG once daily on days 36-49; ARA-C IV once
                     daily on days 37-40 and 45-48; and CPM IV over 1 hour on days 36 and 49.

             -  Maintenance therapy: At least 2 weeks after completion of the last course of
                OCTADA(D) chemotherapy, patients receive oral MP once daily; oral MTX once weekly;
                MTX IT in weeks 1 and 15; and ARA-C IT in week 8. Patients also receive PRDL or
                therapeutic HC IT in weeks 1, 8, and 15. Treatment continues for up to 104 weeks
                after initial diagnosis in the absence of disease progression or unacceptable
                toxicity.

        -  Arm II (experimental therapy):

             -  ADE therapy (beginning on day 36 of induction therapy: Patients receive ARA-C IV
                every 12 hours on days 1-10; DNR IV over 1 hour on days 1, 3, and 5; etoposide
                (VP-16) IV over 4 hours on days 1-5; and ARA-C IT on day 1. Patients also receive
                PRDL or therapeutic HC IT on day 1.

             -  MAE therapy: Patients receive ARA-C IV every 12 hours on days 1-10; mitoxantrone
                hydrochloride IV over 1 hour on days 1, 3, and 5; VP-16 IV over 4 hours on days
                1-5; and MTX IT on day 1. Patients also receive PRDL or therapeutic HC IT on day 1.

             -  MARMA therapy:

                  -  Part I: Patients receive oral MP once daily on days 1-14; high-dose (HD) MTX
                     IV over 24 hours on days 1 and 8; leucovorin calcium orally or IV at 42, 48,
                     and 54 hours after each dose of MTX until MTX plasma levels are safe; and MTX
                     IT on days 2 and 9. Patients also receive PRDL or therapeutic HC IT on days 2
                     and 9.

                  -  Part II: Patients receive HD ARA-C IV over 3 hours twice daily with 12-hour
                     intervals on days 15, 16, 22, and 23; and pegaspargase (PEG-ASP) IV over 1
                     hour or IM on day 23.

             -  OCTADA reinduction therapy:

                  -  Part I: At least 2 weeks after the completion of MARMA chemotherapy, patients
                     receive oral DEXA three times daily on days 1-14, followed by a taper to 0 at
                     day 21; oral TG once daily on days 1-28; VCR IV on days 1, 8, 15, and 22;
                     PEG-ASP IV over 1 hour or IM on day 1; ARA-C IV on days 2-5, 9-12, 16-19, and
                     23-26; and ARA-C IT on days 1 and 15. Patients also receive PRDL or
                     therapeutic HC IT on days 1 and 15.

                  -  Part II: Beginning 1 week after completion of part I, patients receive oral TG
                     once daily on days 36-49; ARA-C IV once daily on days 37-40 and 45-48; and CPM
                     IV over 1 hour on days 36 and 49.

             -  Maintenance therapy: At least 2 weeks after completion of the last course of OCTADA
                chemotherapy, patients receive oral MP once daily; oral MTX once weekly; MTX IT in
                weeks 1 and 15; and ARA-C IT in week 8. Patients also receive PRDL or therapeutic
                HC IT in weeks 1, 8, and 15. Treatment continues for up to 104 weeks after initial
                diagnosis in the absence of disease progression or unacceptable toxicity.

      All HR patients with a suitably matched donor are scheduled for allogeneic stem cell
      transplantation (SCT) after MARMA or before or during OCTADA(D) chemotherapy, provided they
      are in CR1 and no more than 8 months have elapsed since initial diagnosis.

        -  Conditioning regimens for allogeneic SCT:

             -  Matched sibling donor (MSD): Patients receive oral busulfan (BU) every 6 hours on
                days -7 to -4; CPM IV over 1 hour on days -3 to -2; and melphalan (MEL) IV over 1
                hour on day -1.

             -  Matched donors (MD): Patients receive oral BU every 6 hours on days -7 to -4; CPM
                IV over 1 hour on days -3 to -2; MEL IV over 1 hour on day -1; and anti-thymocyte
                globulin (ATG) IV over 4 hours on days -3 to -1.

        -  Graft-Versus-Host Disease (GVHD) prophylaxis and therapy:

             -  MSD: Patients receive cyclosporine (CsA) IV or orally twice daily beginning on day
                -1 and continuing to day 60 after SCT, followed by a taper in the absence of GVHD
                symptoms.

             -  MD: Patients receive CsA as in group MSD; MTX IV on days 1, 3, and 6; leucovorin
                calcium IV on days 2, 4, and 7; and ATG IV on days -3 to -1.

        -  Allogeneic SCT: Patients undergo infusion of bone marrow, peripheral blood, or cord
           blood hematopoietic stem cells on day 0.

      After completion of study therapy, patients are followed periodically for up to 2 years.
    

Trial Arms

NameTypeDescriptionInterventions

Eligibility Criteria

        DISEASE CHARACTERISTICS:

        Inclusion criteria:

          -  Diagnosis of acute lymphoblastic leukemia (ALL) or biphenotypic leukemia meeting the
             following criteria:

               -  Based on European Group for the Classification of Acute Leukemia (EGIL)
                  diagnostic criteria

               -  Newly diagnosed disease

               -  Verified by morphology and confirmed by cytochemistry and immunophenotyping

                    -  Trephine biopsy is recommended (unless diagnosis can be confirmed by
                       peripheral blood examination) in the event that bone marrow aspiration
                       results in a "dry tap"

          -  Must have MLL gene rearrangements documented by split-signal fluorescence in situ
             hybridization and meets 1 of the following risk criteria:

               -  Low-risk disease, defined as all MLL germline cases

               -  Medium-risk disease, defined by 1 of the following criteria:

                    -  MLL status unknown

                    -  MLL rearranged AND age > 6 months

                    -  MLL rearranged AND age < 6 months AND WBC < 300 x 10^9/L AND prednisone good
                       response

               -  High-risk disease, defined by MLL rearrangement AND meets the following criteria:

                    -  Age at diagnosis < 6 months (i.e., < 183 days)

                    -  WBC ≥ 300 x 10^9/L AND/OR prednisone poor response

          -  Minimum donor and stem cell requirements for high-risk patients undergoing stem cell
             transplantation:

               -  Donor meeting 1 of the following criteria:

                    -  HLA-identical sibling

                    -  Very well-matched related or unrelated donor

                    -  Must be HLA compatible in 10/10 or 9/10 alleles by 4 digit/allele
                       high-resolution molecular genotyping

               -  Stem cell source

                    -  Bone marrow (preferred source) OR peripheral blood stem cells of filgrastim
                       [G-CSF]-stimulated donors OR cord blood

                         -  Highly-matched unrelated umbilical cord blood (UCB) (> 7/8 matches
                            identified by high-resolution typing) accepted if a sibling donor is
                            not able to donate bone marrow AND UCB with a sufficient number of
                            nucleated cells (NCs) (i.e., > 1.5 x 10^7/kg recipient body weight
                            [BW]) is cryopreserved

               -  Must have ≥ 3 x 10^8 NCs/kg BW OR 3 x 10^6/kg BW CD34-positive cells available
                  for transplantation

          -  CNS or testicular leukemia at diagnosis allowed

        Exclusion criteria:

          -  Mature B-ALL, defined by the immunophenotypical presence of surface immunoglobulins or
             t(8;14) and breakpoint as in B-ALL

          -  Presence of the t(9;22) (q34;q11) or bcr-abl fusion in the leukemic cells (if data are
             not known, patient still may be eligible)

          -  Relapsed ALL

        PATIENT CHARACTERISTICS:

          -  See Disease Characteristics

        PRIOR CONCURRENT THERAPY:

          -  More than 4 weeks since prior systemic corticosteroids

               -  Corticosteroids by aerosol are allowed
      
Maximum Eligible Age:1 Year
Minimum Eligible Age:N/A
Eligible Gender:All
Healthy Volunteers:No

Primary Outcome Measures

Measure:Disease-free survival
Time Frame:
Safety Issue:
Description:

Secondary Outcome Measures

Measure:Survival
Time Frame:
Safety Issue:
Description:
Measure:Event-free survival
Time Frame:
Safety Issue:
Description:
Measure:Event-free survival within each risk group (i.e., low-risk, medium-risk, or high-risk)
Time Frame:
Safety Issue:
Description:

Details

Phase:N/A
Primary Purpose:Interventional
Overall Status:Recruiting
Lead Sponsor:Dutch Childhood Oncology Group

Trial Keywords

  • untreated childhood acute lymphoblastic leukemia
  • T-cell childhood acute lymphoblastic leukemia
  • acute undifferentiated leukemia

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