- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT00186875
Therapy for Pediatric Relapsed or Refractory Acute Lymphoblastic Leukemia
A Study of Therapy for Pediatric Relapsed or Refractory Acute Lymphoblastic Leukemia
The main purpose of this study is to find out how well participants with relapsed or refractory ALL respond to treatment with an etoposide- and teniposide-based induction chemotherapy regimen and what the side effects are.
Primary Objectives:
- To estimate the response rate for patients with refractory or relapsed ALL.
- To estimate the survival rate of patients with refractory or relapsed ALL treated with risk-directed therapy.
Study Overview
Status
Intervention / Treatment
- Procedure: chemotherapy, intrathecal chemotherapy, steroid therapy
- Drug: Etoposide, cytarabine, vincristine, dexamethasone
- Drug: methotrexate, teniposide, PEG-asparaginase
- Drug: mitoxantrone, cyclophosphamide, mercaptopurine, vinblastine
- Drug: L-asparaginase, erwinia asparaginase
- Procedure: Hematopoietic Stem Cell Transplant
- Procedure: Natural Killer (NK) Cell Transplant
Detailed Description
In this study, subjects will be divided into high-risk and standard-risk subgroups according to the length of their first remission, the type of early cancer cell (T or B-cell) and the site or sites of disease relapse. The remission induction phase (the beginning phase of therapy) will consist of three blocks of therapy. Block A features daily IV low-dose etoposide in combination with cytarabine given by continuous IV, weekly vincristine, and daily dexamethasone. In block B, a combination of weekly PEG-asparaginase, vincristine, and daily dexamethasone will be given. Block C will be a combination of high-dose methotrexate, high-dose cytarabine, and teniposide.
There will be two phases of consolidation (treatment phase after induction therapy). Additional therapy will be given between the two consolidation phases. Continuation will consist of eight weekly cycles of chemotherapy. Periodic intrathecal therapy (medicine given into the spinal fluid) will be given throughout the treatment. Participants who do not achieve remission (absence of leukemia) after consolidation will be offered enrollment on St. Jude NKEHM protocol (NK cell transplant). Hematopoietic stem cell transplant (HSCT) is planned for participants with high risk disease. HSCT will be done according to current institutional practice. The duration of chemotherapy will be one year for patients with extramedullary (outside the bone marrow) relapse and two years for all others.
Exploratory objectives include:
- To determine the prevalence of MRD in children undergoing treatment for relapsed ALL and to compare the results to those obtained in children with newly diagnosed ALL.
- To compare the level of MRD in bone marrow and peripheral blood concomitantly in children undergoing treatment for relapsed ALL.
- To characterize the gene expression profile of leukemia cells at the time of diagnosis and relapse to improve our understanding of mechanisms of relapse and of the development of drug resistance.
- To study whether pre-existing or emerging development of serum antibodies to asparaginase is related to hypersensitivity reaction to asparaginase in patient with relapsed ALL.
Detailed Description of Treatment Plan:
All patients will receive the same remission induction. All high-risk patients will be offered HSCT which will be performed after a suitable donor is identified and preferably after MRD becomes negative. If they do not have a donor or they refuse HSCT, they will continue to receive chemotherapy. Standard-risk patients continue chemotherapy if MRD is negative after induction, but will be offered HSCT if MRD is >0.01% after Block C of Induction. Those who do not achieve morphological CR after induction will be treated according to the contingency plan.
Block A (14 days)
Dexamethasone 5 mg/m2/day, days 1-14
Vincristine 1.5 mg/m2 (max 2 mg), days 1 and 8
Etoposide 25 mg/m2, days 1-14
Cytarabine 25 mg/m2, days 1-14
All patients will proceed to Block B if the clinical condition permits.
CNS prophylaxis (IT MHA)
CNS-1: At the time of relapse and day 14.
CNS-2 and 3: At the time of relapse, day 8 and 14.
Leucovorin: 5 mg/m2 (5 mg max dose) PO, 24 and 30 hours after each IT MHA.
Block B (15 days)
All patients will proceed to Block B immediately after Block A if they are clinically well.
Dexamethasone 6 mg/m2, Days 1-14
Vincristine 1.5 mg/m2, days 1 and 8
PEG-Asparaginase 2500 units/m2, days 1, 8 and 15
CNS prophylaxis (IT MHA): CNS-2 or 3 only, if necessary.
- CNS-1: no IT MHA
- CNS-2 and 3: day 8 (minimum 4 doses and maximum 8 doses during induction)
Leucovorin: 5 mg/m2 (5 mg max) PO 24 and 30 hours after each IT MHA
Block C (1 day)
All patients who received Block B will proceed to Block C when WBC >1,000/microL, ANC >300/microL and platelets >50,000 microL after recovery from Block B.
Methotrexate 8 gm/m2, day 1
Cytarabine 1 g/m2 at least 24 h after ITHMA, day 1
Teniposide 165 mg/m2, day 1
CNS prophylaxis (IT MHA):
- CNS-1: at the time of BMA after Block C
- CNS-2 and 3: day 1 and 8 (These two doses of IT MHA may be omitted if the patient had negative CSF for blasts in the 3 preceding CSF exam) and at the time of BMA after Block C (regardless of the previous CSF status).
Leucovorin: 5 mg/m2 (5 mg maximum dose) PO 24 and 30 hours after each IT MHA
Consolidation I
This is a 4-week phase. It will be started if WBC >1000/microL, ANC >500/microL and platelets >50,000 /microL
Week 1: Dex day 1, 2, 3, PEG, VCR, Mito day 4
Week 2: Dex day 1, 2, 3, PEG, VCR, day 4
Week 3: Dex day 1, 2, 3, PEG, VCR, Mito day 4
Week 4: Dex day 1, 2, 3, PEG, VCR, day 4
Dexamethasone 8 mg/m2/day, day 1-3
PEG-Asparaginase 2500 units/m2 IM, day 4 each week
Vincristine 2 mg/m2 (max 2 mg), day 4 each week
Mitoxantrone 12 mg/m2, day 4 week 1 and 3
Interim Continuation
Week 1*†:
etoposide 300 mg/m2 IV, 1 dose on day 1
Cyclophosphamide 300 mg/m2 IV, 1 dose on day 1
Week 2*:
Methotrexate 40 mg/m2 IV, 1 dose on day 1
6-mercaptopurine# 75 mg/m2 PO, Days 1 to 7
Week 3*:
teniposide 150 mg/m2 IV, 1 dose on day 1
Cytarabine 300 mg/m2 IV, 1 dose on day 1
Week 4*:
Dexamethasone§ 12 mg/m2/day PO, TID Days 1 to 5
Vinblastine 6 mg/m2 IV (max 10 mg), 1 dose on day 1
Consolidation II
Week 1*†:
etoposide 300 mg/m2 IV, 1 dose on day 1
Cyclophosphamide 300 mg/m2 IV, 1 dose on day 1
Week 2*:
Methotrexate 40 mg/m2 IV, 1 dose on day 1
6-mercaptopurine# 75 mg/m2 PO, Days 1 to 7
Week 3*:
teniposide 150 mg/m2 IV, 1 dose on day 1
Cytarabine 300 mg/m2 IV, 1 dose on day 1
Week 4*:
Dexamethasone§ 12 mg/m2/day PO, TID, Days 1 to 5
Vinblastine 6 mg/m2 IV (max 10 mg), 1 dose on day 1
Continuation
Week 1*†¶:
etoposide 300 mg/m2 IV, 1 dose on day 1
Cyclophosphamide 300 mg/m2 IV, 1 dose on day 1
Week 2*:
Methotrexate 40 mg/m2 IV, 1 dose on day 1
6-mercaptopurine# 75 mg/m2 PO, QHS, Days 1 to 7
Week 3*:
teniposide 150 mg/m2 IV, 1 dose on day 1
Cytarabine 300 mg/m2 IV, 1 dose on day 1
Week 4:
Dexamethasone§ 12 mg/m2/day PO, TID, Days 1 to 5
Vincristine§ 2 mg/m2 IV(maximum 2mg), 1 dose on day 1
Week 5*‡:
etoposide 300 mg/m2 IV, 1 dose on day 1
Cyclophosphamide 300 mg/m2 IV, 1 dose on day 1
Week 6*:
Methotrexate 40 mg/m2 IV, 1 dose on day 1
6-mercaptopurine# 75 mg/m2 PO, QHS, Days 1 to 7
Week 7*:
teniposide 150 mg/m2 IV, 1 dose on day 1
Cytarabine 300 mg/m2 IV, 1 dose on day 1
Week 8*:
Dexamethasone§ 12 mg/m2/day PO, TID, Days 1 to 5
Vinblastine 6 mg/m2 IV(max 10 mg), 1 dose on day 1
Plan for Stem Cell Transplant
Patients who have positive MRD (high-risk or standard-risk) at the end of induction or all high-risk patients regardless of MRD are eligible for HSCT
- All high-risk patients are eligible for HSCT. HSCT will be performed as soon as MRD becomes negative after induction. If MRD becomes negative (<0.01%) and a donor has not been found, the patient will continue chemotherapy phases (Consolidation I, Interim Continuation, etc) until a suitable donor is found.
- Those who have persistent positive MRD (>0.01%) after Block C are also eligible for HSCT
All standard-risk patients will continue chemotherapy if MRD is negative (<0.01%) after induction.
- If MRD is positive (>0.01%) after Block C of induction, they become eligible for HSCT.
- Standard-risk patients who have no response or progressive disease after Block A and who have positive MRD (>0.01%) after Block B will be candidates for HSCT. They will be re-evaluated after Block C. If MRD after Block C is positive, follow the plan above. If MRD is negative after Block C, the management will be discussed with Transplant Service
Contingency Plan
Patients who do not achieve morphological CR (M1 marrow) after Induction
If CR (M1 marrow) is not achieved after Induction, patients will proceed to Consolidation I. If they do not achieve CR after Consolidation I, they will be offered enrollment on the St. Jude NKHEM protocol or offered alternative therapy. If they do not achieve CR after NKHEM, they will come off treatment.
Patients who achieve CR but have positive MRD (>0.01%) after Block C of induction: Become eligible for HSCT. Up to two more courses of chemotherapy (course 1 and 2) will be given to attempt reducing MRD. They will receive HSCT as soon as MRD becomes negative (MRD may be repeated every 2-4 weeks as indicated).
Standard-risk patients who have positive MRD (>0.01%) after Block B will proceed to Block C. Patients in this category will become candidates for HSCT, but if MRD becomes negative after Block C, the management will be discussed with Transplant Service. Chemotherapy may be administered to reduce MRD prior to HSCT. Patients will be transplanted as soon as the MRD becomes negative.
Patients (high-risk or standard-risk) who achieved CR, but have positive MRD (>0.01%) after Block C of Induction will become eligible for HSCT. Up to two more courses of chemotherapy (course 1 and 2) will be given to attempt reducing MRD. They will receive HSCT as soon as MRD becomes negative. If MRD remains positive after course 2, then, they will proceed to HSCT after discussion with Transplant Service.
Course 1
Give chemotherapy according to the plan for Consolidation I. Start it immediately regardless of CBC. BMA will be performed when WBC >1000/microL, ANC >300/microL and platelets >50,000/microL. If MRD is negative, they will receive HSCT.
Course 2
This course will be given if MRD is positive after Course 1. Patients will be offered enrollment on St. Jude NKHEM protocol.
If they are still MRD positive after Course 2, patients may receive Interim Continuation, Consolidation II, and then Continuation until MRD becomes negative or while awaiting HSCT.
Study Type
Enrollment (Actual)
Phase
- Phase 2
Contacts and Locations
Study Locations
-
-
California
-
San Diego, California, United States, 92123
- Rady Children's Hospital and Health Center
-
-
Tennessee
-
Memphis, Tennessee, United States, 38105
- St. Jude Children's Research Hospital
-
-
Participation Criteria
Eligibility Criteria
Ages Eligible for Study
Accepts Healthy Volunteers
Genders Eligible for Study
Description
Inclusion Criteria
- Childhood ALL in first relapse OR in first hematological relapse after an extramedullary relapse, OR not attaining a complete remission with frontline therapies, OR lymphoblastic leukemia in first relapse.
- Patients must be 21 years of age or younger
- Informed consent explained to and signed by parent/legal guardian.
Exclusion Criteria
- Life expectancy less than 8 weeks
- Patients with mature B cell ALL
Study Plan
How is the study designed?
Design Details
- Primary Purpose: TREATMENT
- Allocation: NA
- Interventional Model: SINGLE_GROUP
- Masking: NONE
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
---|---|
OTHER: Treatment
Participants receive chemotherapy, intrathecal chemotherapy, steroid therapy, hematopoietic stem cell transplant, and natural killer cell transplant as outlined in the Interventions section, including etoposide, cytarabine, vincristine, dexamethasone, methotrexate, teniposide, PEG-asparaginase, mitoxantrone, cyclophosphamide, mercaptopurine, vinblastine, L-asparaginase, erwinia asparaginase.
|
See Detailed Description section for details of treatment interventions.
See Detailed Description section for details of treatment interventions.
Other Names:
See Detailed Description section for details of treatment interventions.
Other Names:
See Detailed Description section for details of treatment interventions.
Other Names:
See Detailed Description section for details of treatment interventions.
Other Names:
See Detailed Description section for details of treatment interventions.
See Detailed Description section for details of treatment interventions.
|
What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Response Rate
Time Frame: End of re-induction Block C (approximately 1 month after the start of therapy)
|
The "response rate" is defined as the proportion of participants who attain morphological complete remission after the re-induction Block C, inclusive of all patients who begin re-induction.
Morphological complete remission was defined as <5% blasts in bone marrow by morphology.
|
End of re-induction Block C (approximately 1 month after the start of therapy)
|
Overall Survival (OS)
Time Frame: 2 years after last patient completes therapy (approximately 4 years after enrollment)
|
OS is measured from the start of on-study to the date of death or to the last date of follow-up.
Measurement is determined by Kaplan-Meyer estimate.
The probability of survival at 5 years after diagnosis is given.
|
2 years after last patient completes therapy (approximately 4 years after enrollment)
|
Other Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Minimal Residual Disease (MRD) Compared With Historical Data From TOTXV Protocol (NCT00137111)
Time Frame: End of Block Block C therapy (Day 46)
|
The prevalence of MRD in children undergoing treatment for relapsed ALL and to compare the results to those obtained in children with newly diagnosed ALL.
MRD is considered as positive (i.e., prevalent) if its level is >=0.01%.
The prevalence of MRD after Block C is defined as the proportion of MRD positives.
|
End of Block Block C therapy (Day 46)
|
Minimal Residual Disease (MRD) Compared With Historical Data From TOTXV Protocol (NCT00137111)
Time Frame: End of Block B therapy (Day 19)
|
The prevalence of MRD in children undergoing treatment for relapsed ALL and to compare the results to those obtained in children with newly diagnosed ALL.
MRD is considered as positive (i.e., prevalent) if its level is >=0.01%.
The prevalence of MRD after Block B is defined as the proportion of MRD positives.
|
End of Block B therapy (Day 19)
|
Collaborators and Investigators
Publications and helpful links
Study record dates
Study Major Dates
Study Start
Primary Completion (ACTUAL)
Study Completion (ACTUAL)
Study Registration Dates
First Submitted
First Submitted That Met QC Criteria
First Posted (ESTIMATE)
Study Record Updates
Last Update Posted (ACTUAL)
Last Update Submitted That Met QC Criteria
Last Verified
More Information
Terms related to this study
Keywords
Additional Relevant MeSH Terms
- Immune System Diseases
- Neoplasms by Histologic Type
- Neoplasms
- Lymphoproliferative Disorders
- Lymphatic Diseases
- Immunoproliferative Disorders
- Leukemia
- Precursor Cell Lymphoblastic Leukemia-Lymphoma
- Leukemia, Lymphoid
- Physiological Effects of Drugs
- Molecular Mechanisms of Pharmacological Action
- Anti-Infective Agents
- Autonomic Agents
- Peripheral Nervous System Agents
- Antiviral Agents
- Nucleic Acid Synthesis Inhibitors
- Enzyme Inhibitors
- Analgesics
- Sensory System Agents
- Anti-Inflammatory Agents
- Antirheumatic Agents
- Antimetabolites, Antineoplastic
- Antimetabolites
- Antineoplastic Agents
- Immunosuppressive Agents
- Immunologic Factors
- Tubulin Modulators
- Antimitotic Agents
- Mitosis Modulators
- Antiemetics
- Gastrointestinal Agents
- Glucocorticoids
- Hormones
- Hormones, Hormone Substitutes, and Hormone Antagonists
- Antineoplastic Agents, Hormonal
- Protease Inhibitors
- Antineoplastic Agents, Alkylating
- Alkylating Agents
- Myeloablative Agonists
- Antineoplastic Agents, Phytogenic
- Topoisomerase II Inhibitors
- Topoisomerase Inhibitors
- Dermatologic Agents
- Reproductive Control Agents
- Abortifacient Agents, Nonsteroidal
- Abortifacient Agents
- Folic Acid Antagonists
- Dexamethasone
- Dexamethasone acetate
- BB 1101
- Cyclophosphamide
- Etoposide
- Etoposide phosphate
- Cytarabine
- Methotrexate
- Vincristine
- Asparaginase
- Mitoxantrone
- Mercaptopurine
- Pegaspargase
- Vinblastine
- Teniposide
Other Study ID Numbers
- ALLR17
- NCI-2011-01256 (REGISTRY: NCI Clinical Trial Registration Program)
Drug and device information, study documents
Studies a U.S. FDA-regulated drug product
Studies a U.S. FDA-regulated device product
This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.
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