CLG Treatment guidelines for Acute Lymphoblastic Leukemia Therapeutic regimens, dose modifications and toxicities (to be used in parallel with the EORTC 58081 study)  First Version – agreed after Ghent – 24/08/2010 – named : CLG_ALLFrontline_Treatmentguidelines_vs02  Second Version – agreed after Toulouse – 23/11/2010 – named : CLG_ALLFrontline_Treatmentguidelines_vs03.1 (white)  Third Version – agreed after Leuven–26/04/2013 and Porto–10/10/2014 – named: CLG_ALLFrontline_Treatmentguidelines_vs04.02 (amendment PEG asparaginase – IKAROS - CNS) 1

RISK GROUP DEFINITIONS ..................................................................................................................................... 5

2

GENERAL SCHEME OF THE TREATMENT GUIDELINES ..................................................................................... 8

3 IMPORTANT “MINOR” ADAPTATIONS AND CHANGES IN COMPARISON WITH THE STUDY 58951 AND THE CLG ALL FRONTLINE TREATMENT GUIDELINES VS04.2 .................................................................................. 9 4

VERY LOW RISK (VLR) ..........................................................................................................................................11

4.1.

Prephase VLR ........................................................................................................................................................................... 11

4.2.

Protocol I A Reduced (Induction) - VLR ................................................................................................................................ 11

4.3.

Protocol I B Reduced (Consolidation) - VLR ......................................................................................................................... 12

4.4.

Interval therapy - VLR ............................................................................................................................................................. 13

4.5.

Protocol II Reduced – VLR (Reinduction or Late intensification) ....................................................................................... 14

4.6.

Maintenance therapy - VLR .................................................................................................................................................... 14

5

AVERAGE RISK 1 (AR1) .........................................................................................................................................15

5.1.

Prephase – AR1 ......................................................................................................................................................................... 15

5.2.

Protocol I A (Induction) – AR1 ................................................................................................................................................ 16

5.3.

Protocol I B (Consolidation) – AR1 ......................................................................................................................................... 17

5.4.

Interval therapy – AR1 ............................................................................................................................................................. 17

5.5.

Protocol II – AR1 (Reinduction or Late Intensification) ..................................................................................................... 18

5.6.

Maintenance therapy – AR1 .................................................................................................................................................... 19

6

AVERAGE RISK 2 (AR2) - B-CELL ALL ................................................................................................................20

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6.1. Prephase – AR2-B .......................................................................................................................................................................... 20 6.2. Protocol I A Augmented – AR2-B (Induction) ............................................................................................................................ 21 6.3. Protocol I B – AR2-B (Consolidation) ........................................................................................................................................ 22 6.4. Interval therapy – AR2-B .............................................................................................................................................................. 22 6.5. Protocol II - – AR2-B (Reinduction or Late intensification) ...................................................................................................... 23 6.6. Maintenance therapy – AR2-B ..................................................................................................................................................... 24 7

AVERAGE RISK 2 (AR2) - T-CELL ALL .................................................................................................................26

7.1.

Prephase – AR2-T ..................................................................................................................................................................... 26

7.2.

Procotol I A - AR2-T (Induction) ............................................................................................................................................ 27

7.3.

Protocol I B - AR2-T (Consolidation) ...................................................................................................................................... 27

7.4.

Interval therapy - AR2-T.......................................................................................................................................................... 28

7.5.

Protocol II - AR2-T (Reinduction or Late intensification) .................................................................................................... 29

7.6.

Maintenance therapy - AR2-T ................................................................................................................................................. 30

8

VERY HIGH RISK (VHR) .........................................................................................................................................32

8.1.

Prephase – VHR ........................................................................................................................................................................ 32

8.2.

Protocol I A c – VHR (Induction) ............................................................................................................................................ 33

8.3.

Treatment of VHR patients beyond protocol IA .................................................................................................................... 34

8.4.

Protocol I B augmented – VHR (1° Consolidation).............................................................................................................. 34

8.5.

Protocol VANDA – VHR (2° Consolidation) ........................................................................................................................ 35

8.6.

1° Interval therapy– VHR: 3 cures of HDMTX .................................................................................................................... 36

8.7.

Protocol II modified – VHR (1° Reinduction or 1° Late Intensification) ........................................................................... 36

8.8.

2° Interval therapy – VHR: 3 cures of HDMTX .................................................................................................................. 37

8.9.

Protocol II modified – VHR (2° Reinduction or 2° Late Intensification) ............................................................................. 37

8.10. Maintenance therapy – VHR ................................................................................................................................................... 37 9

PRACTICAL GUIDELINES ......................................................................................................................................39

9.1.

Prephase ..................................................................................................................................................................................... 39

9.2.

Induction (IA reduced, IA, IA augmented) ............................................................................................................................. 39

9.3.

Consolidation (IB reduced and IB) .......................................................................................................................................... 41

9.4.

1° Consolidation for VHR (IB augmented) ............................................................................................................................. 41

9.5.

Interval therapy ........................................................................................................................................................................ 41

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9.6.

Reinduction or Late Intensification (II reduced, II normal, II modified) ............................................................................ 43

9.7.

2° Consolidation VHR (VANDA) ............................................................................................................................................ 44

9.8.

Maintenance .............................................................................................................................................................................. 44

10

GENERAL DRUG INFORMATION ......................................................................................................................46

10.1. Adriamycin (= Doxorubicin) (ADR) ........................................................................................................................................ 46 10.2. Asparaginase (PEG-asparaginase and Erwinase) .................................................................................................................. 46 10.3. Cyclophosphamide (CPM) ....................................................................................................................................................... 48 10.4. Cytosine-arabinoside (ARA-C) ................................................................................................................................................ 48 10.5. Daunorubicin (DNR)................................................................................................................................................................. 48 10.6. Etoposide (VP-16) ..................................................................................................................................................................... 48 10.7. Corticosteroids .......................................................................................................................................................................... 48 10.8. Methotrexate (MTX)................................................................................................................................................................. 48 10.9. 6-mercaptopurine (6-MP)......................................................................................................................................................... 48 10.10. 6-thioguanine (6-TG) ................................................................................................................................................................ 49 10.11. Vincristine (VCR) ..................................................................................................................................................................... 49 10.12. Vindesine (VDS) ........................................................................................................................................................................ 49 11

DEFINITIONS AND TREATMENT OF INITIAL EXTRA-MEDULLARY INVOLVEMENT ...................................50

11.1. Initial CNS status (CSF findings at Day 1) ............................................................................................................................. 50 11.2. Final CNS status (CSF findings after the first IT injection, see table below) ...................................................................... 51 11.3. CNS involvement at diagnosis: ................................................................................................................................................ 51 11.4. Treatment of CNS involvement (see table page 55) ............................................................................................................... 52 11.5. Cytocentrifugation technique (cytospin) and instructions for cerebro-spinal fluid (CSF) ................................................. 55 11.6. Gonadal involvement: ............................................................................................................................................................... 56 12

MRD GUIDELINES ...............................................................................................................................................57

12.1. How to measure MRD? ............................................................................................................................................................ 57 12.2. When MRD measurements? .................................................................................................................................................... 57 12.3. Decisions taken from MRD results: ......................................................................................................................................... 57 12.4. Schematic overview ................................................................................................................................................................... 59 13

SCT INDICATIONS...............................................................................................................................................60

13.1. Patient Selection for SCT ......................................................................................................................................................... 60 CLG_ALLFrontline_Treatmentguidelines_vs04.02 (amendment PEG aspa - IKAROS - CNS) Date: 01/08/2015

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13.2. Timing of SCT: .......................................................................................................................................................................... 60 13.3. Schematic Overview .................................................................................................................................................................. 61

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1 Risk Group Definitions These Risk Group definitions are a copy of the risk group definitions used in the EORTC study 58081. Note: for bilineage ALL, the risk group is determined by the most prominent immune-subtype. If B predominant: AR1, AR2 (B) or VHR following the other criteria. If T predominant: AR2 (T) or VHR.

1

Very low risk (VLR)

Acute lymphoblastic leukaemia with the following diagnostic criteria: B-cell lineage with a leukocyte count < 10x109/l     

and age > 1 year and < 10 years and absence of CNS involvement with a CNS 1 status of the CSF and absence of gonadal involvement and absence of t(9;22)/BCR-ABL, of t(4;11)/MLL-AF4, of 11q23/MLL rearrangement and DNA index (DI) ≥1.16 and < 1.50, and chromosome number 54-66 or DI ≥1.16 and < 1.50, and chromosome number is unknown or chromosome number 54-66, and D. I. is not assessed NB: all criteria are required. o In the absence of DI and of cytogenetics results, patients meeting all other VLR criteria will be treated according to AR 1 group (see below). o A normal karyotype (46 chromosomes without any structural abnormality) can only be ascertained when at least 20 mitoses have been analyzed. When the number of normal interpretable mitoses < 20, the result is to be labeled “technical failure” and should be ignored for patient stratification. For instance, a patient with a leukemic clone with a DI >or= 1.16 and a normal karyotype on less than 20 mitoses may be allocated to the VLR group (if all other VLR criteria are met). o If both DI and cytogenetics are available but are discordant, the data must be compared in order to rule out a non-informative result. If karyotype presents 51 to 66 chromosomes whereas the DNA index is close to 1 (0.97-1.03), take only into account the result of karyotype (because DNA index failed to detect aneuploidy, and only detected nonleukemic cells). If karyotype is normal whereas DNA index detects aneuploidy (DI) > or = 1.16 and < 1.50), take into account only the result of DNA index (because karyotype failed to detect aneuploidy and detected only non leukemic cells). In this case, it is recommended to confirm chromosome gains using interphasic FISH with at least 4 probes of the following chromosomes X,4,6,10,14,17,18,21. If both DI and cytogenetics are available but are discordant, the most biologic acceptable of the two factors must be taken into account if DI≥1.16 and or = 1.16 and < 1.50 whereas karyotype is abnormal with chromosome number ≤ 50 (which is very unlikely), the patient cannot be allocated to the VLR group either. o When two (or more) leukemic clones are present and different with respect to DI or cytogenetics (this type of bi- or multiclonality is mostly revealed by the presence of two or more peaks on DI evaluation), the most unfavorable should be taken into

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consideration for patient stratification, even when the clone with the lowest DI or the lowest chromosome number is quantitatively the smallest. Ex: 2 clones on DI: one hypo (DI ≥ 0.7 and ≤ 0.8) and one hyper (DI ≥ 1.4 and ≤ 1.8), and karyotype shows only a hyperdiploid clone, the patient cannot be allocated to the VLR group but must go to the VHR group. The profile of chromosome gains specific of neartriploidy/duplication hypo must be ascertained by the central reviewer of cytogenetic analyses. AND with the following response criterion: Good response to the prephase (GPhR)

2

Average risk (AR)

ALL with good response to the prephase who are neither VLR nor VHR. AR patients are sub-stratified in: Average Low Risk or AR 1   

B-cell lineage ALL with < 100x109/l patients with CNS1 or TLP – (see table p. 55) Very Low Risk patients (VLR in CLG) with “Late CNS1” or “Persistent CNS 2” or “Persistent TLP+” status (see table p.55)

Average High Risk or AR 2   

B-cell lineage ALL with ≥ 100x109/l T-cell lineage ALL whatever the leukocyte count and without CNS involvement Very Low Risk (VLR) B-cell lineage ALL patients or Average Low Risk (AR1) Group B-cell lineage ALL patients with CNS involvement (see table p.55) Gonadal involvement

 Notes  

Down’s syndrome patients with AR2 features will be allocated to the AR1 group. IKZF1 positive patients with Average Risk will only switch to VHR if the MRD at the end of induction is ≥10-3 (see VHR criteria).

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3

Very high risk (VHR)

Acute lymphoblastic leukaemia with one of the following diagnostic criteria:     

 

t(9;22) or bcr/abl * OR t(4;11) / MLL-AF4 OR 11q23 / MLL rearrangement including t(9;11) /MLL-AF9, t(10;11) /MLL-AF10 and t(6;11)/MLL-AF6 and t(11;19),/MLL-ENL. See remark below for the subgroup t(11:19) **, OR near-haploidy (≤ 34 chromosomes or DI < 0.67) OR hypodiploid (35-43 chromosomes or D. I. ≥ 0.67 and ≤ 0.94) (or near-triploidy resenting the specific profile of near-triploidy/duplication of hypodiploid 30-40 chromosomes. This diagnosis must be confirmed by the detection of both clones on DI - hypo DI ≥ 0.65 and ≤ 0.94 and near-triplo DI ≥ 1.3 and ≤ 1.8) OR iamp21 OR Average High Risk Group (AR2) patients with CNS involvement (see table p.55)

OR with one of the following response criteria:      

Poor response to the prephase OR failure to achieve CR/GPR after induction OR minimal residual disease (MRD) ≥10-2 at evaluation of the induction OR IKZF1 deletion AND MRD ≥10-3 at evaluation of the induction*** OR failure to achieve CR after consolidation OR minimal residual disease ≥10-3 at the end of IB

Notes: * Patients with t (9;22) or bcr/abl will be treated following specific therapeutic recommendations. ** Patients with T-ALL and t(11;19) may have a better prognosis. This is still debated. Please contact the clinical coordinators. *** Please note that the presence of IKZF1 deletion and MRD ≥ 10 -3 at evaluation of the induction is a VHR criterion but is not a criterion for SCT Down’s syndrome patients with VHR features will be allocated to the AR1 group.

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2

General Scheme of the treatment guidelines

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3 Important “Minor” adaptations and changes in comparison with the Study 58951 and the CLG ALL Frontline Treatment guidelines vs04.2 We describe here some “minor” but important changes that we introduced in the treatment in comparison with the previous study 58951 and the CLG ALL Frontline Treatment guidelines vs03.1. As you know we adapted our guidelines in the first place according to the IDMC recommendations after closure of the 58951 but we also deduced some adaptations from the BFM 2000 results, from the CCG and the experience from Lyon. Of course it is mandatory to read the full recommendations but this section is to remind you some important “minor” adaptations and changes.

Prephase: 

The corticosteroid in the prephase is prednisolone for all patients.

Inductions: 

o o    

Prednisolone is also the corticosteroid in the inductions except for : AR 2 – B ALL: Dexa at 6 mg/m² AR 2 – T ALL: Dexa at 10 mg/m². The maximum dose of Dexa in induction is 15 mg/day. In induction all patients will receive two administrations of PEG-aspa at a dose of 2500 IU/m² Leucovorin Rescue of HD MTX for AR 2 – B ALL starts at H42 and not at H36. The VHR risk patients will have Cyclofosfamide 1 gr IV at Day 8 of IA. For all CNS positive patients we have intensified the IT injections. They have more IT injections in induction and also in late intensification (protocol II) than in the 58951 study.

Consolidations, Interval and Reinductions (Late Intensifications) For all patients  We have intensified the IT injections for all patients in II B. All patients will receive a second IT during this phase.  Leucovorin Rescue of all HD MTX starts 6 hours later at H42 (and not at H36) and at a higher dose (15mg/m²).  In Re-induction all patients will receive one dose of PEG-aspa at 2500 IU/m²  The maximum daily dose of Dexa is 15 mg in all reinductions. For VHR Patients  VHR: The old I B’ is replaced by an I B augmented (I B augm.)  Also the blocks R1, R2 and R3 are no longer given.  All VHR patients receive one dose of PEG-aspa at 2500 IU/m² in I B augm. and VANDA.  VANDA, double shortened Interval and double delayed intensifications (II modified) are the treatment elements.  For short course of Dexa (like in VANDA) the dose is NOT limited to 15 mg/day.  In the II A modified the Doxo administrations are limited to 3 x. The dose of Doxo is also less: 25 mg/m² (instead of 4 x 30 mg in the normal II A).

Maintenance   

For all AR1 : pulses with dex/vincritine For AR2 – B ALL: HD MTX/PEG-aspa (1000 IU/m²) and also the pulses dex/vincristine but not synchrone For AR 2 – T ALL : HD MTX/PEG-aspa (1000 IU/m²) and no pulses

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CNS involvement and treatment 

 o o o

o

New definitions in line of international standards and also adapted treatment are proposed (see section 11) In version 4.2 : The CNS definitions are not changed (CNS1, 2, 3 and TLP+) But treatment proposals in our recommendations and the problems that are present in some centres make an adaption of the treatments very desirable. Some centers have high level of “late CNS2 patients” and the consequence is that many of these patients received a high treatment burden if they follow the recommendation of the previous version. That is the reason why we are obliged to change our strategy in treatment for initial CNS2 patients. All the details of these treatment adaptations are described in detail in chapter 11 and the recommendations are also incorporated in the treatment for the risk group.

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4 Very low risk (VLR) CNS treatment according to the CNS status The following patients will be treated as VLR (see tables pages 52 and 55): - Patients VLR with CNS 1 status See more details in section 2 "Definition and treatment of extra-medullary involvement”.

4.1.

Prephase VLR Design Drugs

Dose

PDN or methyl-PDN MTX

60 mg/m² (30 mg/m² bid) See below *

Number days

Route P.O. or I.V. (1 hour) I.T.

of

Days

7

1 to 7

1

1

* Note: a patient with any kind of CNS disease can never be a VLR patient, see table p. 55. Doses of MTX: Age 1y 0.5 x 109/L. Once a Ara-C block has been started, it should be pursued over four days whatever the further evolution of the blood cell counts.

Design 6 mg/m² 1.5 mg/m² VCR (Maximum: 2.0 mg per injection) ADR 30 mg/m² 2500 U/m² PEG-aspa** (Maximum: 3750 IU per infusion) OR Native E. 10,000 U/m² coli aspa **

P.O.

Number Days of days 21 1 to 21

I.V.

4

8, 15, 22, 29

I.V. (1 h)

2*

8, 15

Ara-C

Drugs

Dose/day

DXM

IIa

75 mg/m²

6-TG 60 mg/m² I.T. chemotherapy see below *** (MTX)

IIb

Route

I.V. (1 or 2h) 1

8

I.V. (1 h)

4

8, 11, 15, 18

I.V.

8

P.O.

14

38 to 41 45 to 48 36 to 49

I.T.

2

38, 45

NOTES: * VLR patients receive 2 injections only of adriamycin and no cyclophosphamide ** For adjustment of Asparaginase treatment: see 9. Practical guidelines *** Intrathecal chemotherapy (methotrexate): Age

MTX

 1 y < 2 y 8 mg  2 y < 3 y 10 mg 12 mg 3y

4.6.

Maintenance therapy - VLR Conditions for starting maintenance Starts 14 days after completion of protocol II and must be of 74 weeks duration.

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5 Average risk 1 (AR1) CNS treatment according to the CNS status The following patients will be treated as AR1 (see tables pages 52 and 55): -

Patients VLR or AR1 with “Late CNS 1 status” (= patients with initial CNS-2 or TLP + becoming CSF negative at D4 of prephase,

-

Patients VLR and AR1 with o “Persistent CNS 2” (= Patients with initial CNS-2 remaining CSF positive at D4 of prephase) o or “Persistent TLP+” (= Patients with initial TLP + remaining CSF positive at D4 of prephase) status

See more details in section 2 "Definition and treatment of extra-medullary involvement”.

5.1. Prephase – AR1 Design Drugs PDN or methyl-PDN MTX

Dose/day 60 mg/m² (30 mg/m² bid) See below *

Route P.O. or I.V. (1 hour) I.T.

Number days

of

Days

7

1 to 7

1

1

* Notes: doses of MTX: Age 1y 50x109/l, and if the cell counts are increasing. If these counts are lower, one has to wait until these values are reached. Starting conditions for II b are: o Leukocytes > 1 x 109/L o Platelets > 50 x 109/L o Increasing blood counts

Design Drugs

Dose

Route

DXM

IIA

IIB

6 mg/m² P.O. 1.5 mg/m² VCR (maximum dose per I.V. injection 2.0 mg) ADR 30 mg/m² I.V. (1 h) 2500 U/m² PEG-aspa* (maximum: 3750 IU I.V. (1 or2 h) per infusion) OR Native E. coli 10,000 U/m² I.V. (1 h) aspa* Cyclophosphamide 1 g/m² I.V. (1 h)

Number Days of days 21 1 to 21 4

8, 15, 22, 29

4

8, 15, 22, 29

1

8

4

8, 11, 15, 18

1

Ara-C

75 mg/m²

I.V.

8

6-TG Triple I.T chemotherapy

60 mg/m²

P.O.

14

36 38 to 41 45 to 48 36 to 49

see below**

I.T.

2

38, 45

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Age 1y 1 x 109/L o Platelets > 50 x 109/L o Increasing blood counts

Design Drugs DXM VCR IIA

ADR PEG-aspa*

IIB

Dose 10 mg/m² (max dose of 15mg/day) (5 mg/m² BID) 1.5 mg/m² (Max : 2.0 mg per injection) 30 mg/m² 2500 U/m² (Max: 3750IU per infusion) coli 10.000 U/m²

Route

Number of days

Days

P.O.

21

1 to 21

I.V.

4

8, 15, 22, 29

I.V. (1 h)

4

8, 15, 22, 29

I.V. (1 or 2 h) 1

8

I.V. (1 h)

4

8, 11, 15, 18

OR Native E. aspa* Cyclophosphamide**

1 g/m²

I.V. (1 h)

1

Ara-C

75 mg/m²

I.V.

8

6-TG Triple I.T chemotherapy

60 mg/m²

P.O.

14

36 38 to 41 45 to 48 36 to 49

see below***

I.T.

2

38, 45

NOTES: * For adjustment of Asparaginase treatment: see 9. Practical guidelines ** I.V. over 1 h. MESNA: I.V. bolus: 350 mg/m² at H0, H4 and H8

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*** Triple I.T. chemotherapy Age 1y 1 x 109/L o Platelets > 50 x 109/L o Increasing blood counts

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Drugs

Dose

6 mg/m² (3 mg/m² BID) 1.5 mg/m² VCR (Max : 2.0 mg per injection) ADR 25mg/m² 2500 U/m² PEG-aspa** (Max: 3750IU per infusion) OR Native E. coli 10,000 U/m² aspa** Only in case of CNS Triple I.T. involvement (initially AR2 or VHR) Cyclophosphamide 1 g/m² DXM

IIA mod

IIB

Route

Number of Days days

P.O.

21

1 to 21

I.V.

4

8, 15, 22, 29

I.V. (1 h)

3*

8, 15, 22

I.V. (1 or2 h) 1

8

I.V.

4**

8, 11, 15, 18

I.T.

2

1, 18

I.V. (1 h)

1

36 38 to 41 45 to 48 36 to 49 38, 45

Ara-C

75 mg/m²

I.V.

8

6-TG Triple I.T.

60 mg/m² see below ***

P.O. I.T.

14 2

Notes * Only 3 injections of adriamycine at 25 mg/m² ** For adjustment and monitoring of Asparaginase treatment: see 9. Practical guidelines

8.8. 2° Interval therapy – VHR: 3 cures of HDMTX See 8. 6. Interval therapy

8.9. Protocol II modified – VHR (2° Reinduction or 2° Late Intensification) See 8.7 Protocol II modified

8.10. Maintenance therapy – VHR Conditions for starting maintenance Starts 14 days after completion of protocol II modified and ends at 2 years after day 1 of the treatment.

Design Maintenance chemotherapy will consist of:  

6-MP: 50 mg/m²/day, P.O. in one administration, in the evening MTX: 20 mg/m², P.O. once a week

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Duration of Maintenance: In progenitor B ALL we presume that the total duration of the maintenance treatment must be given. Therefor we advise in progenitor B ALL to catch up the lost weeks of maintenance until the full 74 weeks are given. There is however less evidence that this in necessary for T ALL and for VHR patients. We advise here to stick to a total duration of treatment of exactly 2 year

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9 Practical guidelines 9.1. Prephase -

PDN or methyl-PDN are given in two doses a day. If administered I.V., corticosteroids (methylPDN) should be injected over 1 hour.

-

In case of important leukemic burden and blast counts remaining unchanged or increasing by Day 4 the administration of cyclophosphamide can be advanced to day 4 and day 5 in the dosage of 500 mg/m2 on each of the two days. The patient will of course follow the VHR protocol (PPR)

9.2. Induction (IA reduced, IA, IA augmented) -

PDN or DXM are given in two doses a day (Bis in Diem or BID). After day 28 they are tapered down over 9 days. The maximum dose of DXM per day is 15 mg.

-

Vincristine (VCR) is given as an intravenous bolus or in mini-bag, concomitantly with DNR. In case the DNR has to be postponed, VCR will also be given later. The dose of VCR is 1.5 mg/m², with a maximum dose of 2.0 mg.

-

Daunorubicin (DNR) is given over 1 hour, as an I.V. infusion.

-

HD-MTX 5 g/m² is administered as described for interval therapy.

-

Cyclophosphamide is given I.V. over 1 h and MESNA is given as an I.V. bolus 350 mg/m2 respectively at H0, H4 and H8.

-

PEG-asparaginase: is given intravenously as a 1 or 2-hour infusion (maximum dose per infusion: 3750 IU). In case of allergy grade 2 or more during the course, one should switch to Erwinase at the dose of 20,000 U/m² every other day. In order to maintain adequate asparaginase activity for erwinase a strict dose interval with administrations every 48h (even in the weekend) is mandatory (see Table 1). As a result of cross-reactivity switch to E. coli asparaginase is not allowed. Table 3 Protocol Aspa adaptations – all patients: Instructions for switch from PEG-asparaginase to Erwinase Treatment IA IIA Maint (AR2) IB augmented VANDA

PEG-asparaginase 2500 U/m² x 2 (D12 and 26) 2500 U/m² x 1 (D8) 1000 U/m² x 1 (D23) 2500 U/m² x 1 (D16) 2500 U/m² x 1 (D7)

ERWINASE 20.000 U/m² x 12 20.000 U/m² x 6 25.000 U/m² x 2 20.000 U/m² x 6 20.000 U/m² x 6

The total number of Erwinase administrations should be six times that of the PEG-asparaginase administrations. For instance, if one PEG-asparaginase administration has to be given and has to be replaced by Erwinase, 6 injections of the latter will be given within the same time period (2 weeks). CLG_ALLFrontline_Treatmentguidelines_vs04.02 (amendment PEG aspa - IKAROS - CNS) Date: 01/08/2015

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Except during maintenance where one PEG-asparaginase administration of 1000 IU/m² has to be replaced by 2 administrations of Erwinase at a dose of 25000 U/m². -

In centers where PEG-asparaginase is not available, the treatment guidelines with native E. coli asparaginase are continued as described in the CLG ALL Frontline Treatment guidelines vs03.1 (also table 2) Table 4. Instructions of PEG-asparaginase and equivalent Native E. coli asparaginase dosages Treatment IA

PEG- asparaginase 2500 U/m² x 2 (D12 and D26)

IIA Maint (AR2) IB augmented VANDA

2500 U/m² 1000 U/m² 2500 U/m² 2500 U/m²

x 1 (D8) x 1 (D23) x 1 (D16) x 1 ( D7)

Native E.Coli asparaginase 10.000 U/m² x 8 Except for AR-2 T : 5.000 U/m² x 8 10.000 U/m² x 4 25.000 U/m² x1 6.000 U/m² x 6 10.000 U/m² x 4

Monitoring guidelines (to be adapted to local practice): Cautious monitoring (preferably at least twice weekly) of body weight, glycaemia, glycosuria, clotting factors (fibrinogen), liver and pancreatic function and complete ionogram with plasma level of proteins are required before and until 14 days after PEG-asparaginase administration or longer until normalization of parameters. Treatment adjustment should be as follows: o fibrinogen  1.0 g/l: full dose of PEG-asparaginase o fibrinogen  0.5 – 1.0 g/l: full dose of PEG-asparaginase, eventually FFP o fibrinogen < 0.5 g/l: postponement of the next PEG-asparaginase administration and substitutive treatment with inactivated fresh frozen plasma (10 ml / kg) will be administered until fibrinogen level is restored (> 0.5 g/l). NB. Substitution should not be done with fibrinogen alone. Treatment adjustments according to other criteria (AT, total plasma protein level, transaminases) are optional in each center. Diabetes mellitus can occur during treatment with PEG-asparaginase and corticosteroids. Insulin therapy may be necessary. However PEG-asparaginase treatment should be continued. The study on monitoring of asparaginase therapy will be continued after the switch to PEGasparaginase. Samples for real-time PEG-asparaginase activity monitoring are taken: before, 1h after PEGasparaginase administration, at day 7 and day 14 (= through level for next PEG-asparaginase). Additional samples are taken in case of allergy or severe toxicity. NB: Centers who are willing to take samples twice a week are kindly encouraged to do so. Samples for asparaginase antibody titers and measurement of asparagine/glutamine are taken on the same moment and handled as described in the Investigator Brochure version …,

-

Cotrimoxazole (dose equivalent to 5 mg trimethoprim/kg/day, during 3 days a week) may be given as a prophylaxis of Pneumocystis carinii pneumonia as soon as the lymphocyte count falls below 0.5x109/l, and may be continued throughout the protocol according to the local risk for this infection as evaluated by each investigator. It should not be given simultaneously with high dose methotrexate.

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9.3. Consolidation (IB reduced and IB) -

For AR1, AR2 and VHR patients, the first 4-day sequence starts 2 days after the CPM injection. The following Ara-C blocks will be retarded if the leukocyte count is < 0.5 x 109/L or if the platelets are < 20x109/L. Retarding the Ara-c block means also that you stop the 6MP at the same time until the Ara-C is restarted. Each Ara-C injection is in bolus. Once it has been started, it should be pursued over four days whatever the further evolution of the blood cell counts. The same is true for the last block of Ara-C immediately followed by cyclophosphamide. Once started the last Ara C block the cyclophosphamide must be given without delay. In order to prevent severe aplasia at the time of cyclophosphamide administration on day 63, it is a possible option to delay the starting of the fourth Ara-C block until there are slightly higher counts than for an Ara-C block alone: leukocytes are > 1x109/L and the platelets > 50x109/L. Ara-C: injection in bolus. 6-mercaptopurine (6-MP) p.o., once a day, in the evening.

9.4. 1° Consolidation for VHR (IB augmented) -

MTX: MTX is administered as a 24-hour intravenous infusion, with the same recommendations as in interval therapy (see 5.4. Interval therapy).

-

Leucovorin rescue: leucovorin is administered with the same recommendations as in interval therapy (see 8.5. Interval therapy)

-

PEG-asparaginase: is given by I.V. route (maximum dose per infusion: 3750 IU). In case of allergy grade 2 or more, one should switch to Erwinase, with the same recommendations as in phase IA (see 9.2. Protocol IA).

9.5. Interval therapy -

6-MP: cumulative dose of 6-MP during this phase is 1.400 mg/m².

-

MTX: MTX is administered as a 24-hour intravenous infusion. One tenth of the dose (500 mg/m²) is given over the first hour. The remaining of the dose (4.500 mg/m²) is infused over the subsequent 23 hours at a constant rate. Prior to the MTX infusion is hyperhydration unnecessary. However, urinary pH must be > 7 before starting I.V.MTX. Alkalinisation is achieved through administration of bicarbonate, 1 mEq/kg, in 20 to 50 ml (according to age) of 5 % glucose solute over 15 minutes (1 ml of NaHCO3 4.2 % contains 1 mEq). Hyperhydration is started with the MTX infusion and is pursued during 72 h, at a rate of 3 L/m²/24h. On the first day, hyperhydration is implemented intravenously with the following solute mixture: o glucose 5 % : 2/3 of the total volume

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o NaHCO3 (14/∞): 1/3 of the total volume o KCL 30 mEq/L MTX can be mixed with this solution. On day 2 and day 3, in the absence of emesis, hyperhydration and alkalinisation can be continued orally. During 72 hours starting from the beginning of MTX infusion, hyperhydration and alkalinisation must be pursued in order for the diuresis to be maintained > 1.600 ml/m²/24 h and urinary pH > 7. Urinary pH must be measured on fresh urine immediately after each voiding. Whenever it becomes < 7, a booster alkalinisation is to be given through the administration of NaHCO3 1 mEq/kg in 50 ml of glucose 5 % over 15 minutes. Urinary pH tends to fall during the night and monitoring should be particularly stringent at that time. The triple intrathecal chemotherapy is given near the end of the MTX infusion. -

Leucovorin rescue: the first dose of Leucovorin at 15mg/m² is given 42 hours after the start of the MTX-infusion (in the 951 study we had our first rescue dose at 36h) Following doses of 15 mg/m² each are given at 6-hour interval until hour 72 or until MTX serum level has fallen to < 2 x 10-7 M. If MTX levels are closely monitored, Leucovorin can often be stopped after 4 administrations. Leucovorin should preferentially be given orally. If the per oral route cannot be used because of emesis, the drug is given through I.V. bolus every 6-hours in the same dose. In case Levofolinic acid is used, half dose is required (7,5 mg/m²). 



MTX levels are measured at 48 hrs and 72 hrs after the start of the MTX infusion. If the level dose at 48 hrs is too high and there is a need for a higher rescue dose it is recommended to measure also the MTX level at 60hrs (with also an ionogram and ureum/creatinine) The dose of Leucovorin may have to be adjusted in case of protracted high serum MTX levels according to the guidelines of table 3: Table 3. Adjustments of Leucovorin doses to MTX serum levels and timing. (half dose if levofolinic acid is used).

MTX/T > 1 x 10-5 > 5 x 10-6 > 1 x 10-6 > 5 x 10-7 > 2 x 10-7 < 2 x 10-7

48 H 4 x 50 mg/m² 4 x 15 mg/m² 4 x 15 mg/m² 4 x 15 mg/m² 4 x 15 mg/m² 0 mg

60 H 4 x 50 mg/m² 4 x 15 mg/m² 4 x 15 mg/m² 4 x 15 mg/m² 4 x 15 mg/m² 0 mg

72 H 4 x 200 mg/m² 4 x 100 mg/m² 4 x 50 mg/m² 4 x 15 mg/m² 4 x 15 mg/m² 0 mg

96 H 4 x 200 mg/m² 4 x 200 mg/m² 4 x 100 mg/m² 4 x 50 mg/m² 4 x 15 mg/m² 0 mg

> 96 H 4 x 200 mg/m² 4 x 200 mg/m² 4 x 200 mg/m² 4 x 100 mg/m² 4 x 50 mg/m² 0 mg

T = time since the start of MTX infusion MTX = MTX serum level in moles/l (M)

-

Management of severely delayed MTX clearance with acute kidney injury o Definition: increase in plasma creatinine by > 0.3 mg/dl or relative increase of 1.5 above baseline* together with severely high plasma MTX concentrations at one or more of the following time-points after initiation of the MTX infusion:  36h MTX > 20 μM

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 

42h MTX > 10 μM 48h MTX > 5 μM

* The baseline plasma creatinine should be measured within 4 days prior to start of the hydration preceding the HDMTX infusion and be monitored until MTX clearance is demonstrated. o Carboxypeptidase-G2 (glucarpidase - VORAXASE®)  Definition: Unlicensed medicine within the EU available as on a named patient basis for rescue therapy in patients with delayed elimination following high-dose (HD) methotrexate (MTX).  Mechanism of action: hydrolyzes MTX to inactive metabolites (DAMPA and glutamic acid) and causes an immediate and marked reduction in plasma MTX by more than 95 % within one hour of administration.  Administration:  Dose: 50 U/kg IV over 5 minutes (max 4 000 UI).  Start in the 96 hours after start of MTX infusion. Dialysis may be used in the meantime.  Folinic acid should be stopped for at least 2 hours before and after carboxypeptidase administration.  Hyperhydratation and and alkalinisation must be continued.  In case of failure of carboxypeptidase-G2, a second administration is useless and is therefore not indicated.  Presentation: 1000 units of lyophilized glucarpidase to be maintained between 2°C and 4°C.  Reconstitution: 1 ml of 0.9% NaCl to be introduced into the flasks brought to room temperature. Avoid foaming.  MTX concentration monitoring: the HPLC method should be used to monitor the MTX concentration as it does not overestimate the MTX concentration after carboxypeptidase administration (unlike TDx, which overestimates the MTX concentration because of cross reactivity of MTX with its metabolite DAMPA)

9.6. Reinduction or Late Intensification (II reduced, II normal, II modified) -

Dexamethasone (DXM) is given in two doses a day at the total daily dose of 6 mg/m² for B- ALL and in AR2 – T ALL at 10mg/m² (with a maximum of 15 mg per day). After day 21, it is tapered down over 9 days. In case of severe behavioral difficulties, the tapering down may be started earlier.

-

Vincristine (VCR) is given as an I.V. bolus, always on the same day as ADR. If ADR has to be postponed, VCR will also be given later. The dose of VCR is 1.5 mg/m², with a maximum dose of 2.0 mg.

-

Adriamycine (ADR) = doxorubicine is given over 1 hour, as an I.V. infusion.

-

PEG-asparaginase (PEG-Aspa): is given intravenously over one (or two) hour (maximum dose per infusion: 3750 IU). In case of allergy grade 2 or more to PEG-asparaginase, one has to switch to Erwinase at the dose of 20,000 U/m² per administration, the number of Erwinase administrations being increased to six times that of the PEG-aspa administrations. Practically, this means that one PEG-aspa administration will be replaced by 3 administrations of Erwinase a week during 2 weeks..

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-

Cytosine arabinoside = aracytine (Ara-C): the first 4-day sequence starts 2 days after the CPM injection. It is to be retarded if the leukocyte count is < 0.5 x 10 9/L. Retarding the Arac block means also that you stops the 6TG at the same time until the Ara-C is restarted Once it has been started, it should be pursued over four days whatever the further evolution of the blood cell counts. Each Ara-C injection is in bolus.

-

Cyclophosphamide (CPM) is given intravenously over 60 minutes, with MESNA (“Uromitexan”). The latter drug is given in the same total dose as cyclophosphamide, divided in 3 administrations: a third of the dose before the administration of CPM, a third at 4 hours and a third at eight hours. Requirements for administration of CPM (= for starting IIB) are : o Leukocytes > 1 x 109/L o Platelets > 50 x 109/L o Increasing blood counts

-

6-thioguanine (6-TG) is given every evening during 14 days. The same hematologic criteria as for CPM are required for starting. The drug is interrupted if the leukocytes fall below 0.5 x 109/L. In the latter case, the course will have to be prolonged until a cumulative dose of 840 mg/m² has been reached.

-

I.T. chemotherapy is given on the day of the first Ara-C injection.

9.7. 2° Consolidation VHR (VANDA) -

DXM: P.O., 2 times/d. The dose is NOT limited to 15 mg/day

-

MTZ (mitoxantrone): 1 h I.V. infusion

-

VP 16: 1 h I.V. infusion

-

PEG-asparaginase: is given by I.V. route over one (or two) hour (maximum dose per infusion: 3750 IU). In case of allergy grade 2 or more, one should switch to Erwinase, with the same recommendations as in phase IA (see 9.2. Protocol IA).

ARA-C: 3 h I.V. infusion every 12 h, twice a day (total dose = 8 g/m2).

9.8. Maintenance -

Purinethol (6-MP): 50 mg/m² P.O. in one administration, in the evening.

-

Methotrexate (MTX): 20 mg/m² in one weekly per oral administration, except on week 4 when triple I.T. chemotherapy is administered (for AR1, AR2 and VHR patients).

-

Dexamethasone (DXM) is given in two divided doses, P.O.

-

Vincristine (VCR) is given in bolus I.V. injection, 1.5 mg/m² (maximum dose 2.0 mg)

-

High dose methotrexate (HD-MTX) with Leucovorin rescue is given as described under “8.4. Interval”

-

PEG-asparaginase 1000 IU/m² is given I.V. over one (or two) hour, after completion of HD-MTX (maximum dose per infusion: 3750 IU). If for any reason Erwinase has to be given, the dose will be 25,000 U/m2 given twice at 2 days interval (d23, d25).

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-

Maintenance chemotherapy is not interrupted during the VCR + DXM pulses. The dosage of 6-MP and of per oral MTX is to be adjusted to the leukocyte-count, either downward or upward. It is recommended to tailor the dose in order to maintain the leukocyte count between 2 and 3x109/l. Following rule may be applied: Leukocyte x 109/l 10x109/l) may occur during the VCR + corticosteroid pulses. The leukocyte count usually reverts to usual values shortly after completion of the pulse. During the 2-week period starting at the initiation of the pulse, the increased leukocyte count should not be taken into account for upward adjustment of the 6-MP or MTX dose. Indeed, this could result in marked myelosuppression. It is recommended to give all patients Cotrimoxazole (TMP-SMX) as Pneumocystis Carini ou Jiroveci prophylaxis. The dose is calculated on the Trimethoprim (TMP at 5 mg/kg/day and is given in 2 doses per day and during 3 days a week. It also better not coinciding with the day of MTX administration. Duration of Maintenance : For VLR and AR patients: the total duration of maintenance is 74 weeks. In case no delay has occurred in the sequential administration of protocol I, Interval and protocol II, the theoretical duration of which is 30 weeks. Overall, maintenance therapy will be completed at 2 years of diagnosis. If any delay has occurred, either during one of the pre-maintenance phases or during maintenance therapy, the latter should be continued in order to encompass a total duration of 74 weeks as mentioned above. There is however less evidence that this in necessary for T ALL and for VHR Patients we advise here to stick to a total duration of treatment of exactly 2 year VHR patients who will not be transplanted will receive the same maintenance treatment as VLR patients (no IT and no pulses)

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10 General drug information 10.1. Adriamycin (= Doxorubicin) (ADR) Toxicity: local necrosis if extravasation occurs, bone marrow depression, particularly leucopenia (nadir at day 10-14), emesis lasting 1-2 days, mucositis leading to mouth and GI ulcers, “red urine” (usually 1-2 days), hyperpigmentation of nail beds. Late toxicity, usually after a higher than 500 mg/m² cumulative dose: cardiomyopathy with heart failure.

10.2. Asparaginase (PEG-asparaginase and Erwinase) General Anorexia, fever and chills, reversible hepatotoxicity, hypoalbuminemia, hypofibrinogenemia, disturbance of exocrine pancreas function (steatorrhea) and of endocrine pancreas function (non-ketotic hyperglycemia, glucosuria, diabetes, dehydration), allergic reactions including rash, wheezing, shock Allergic reaction mainly occur after repeated administrations, with the highest risk at the start of protocol II. PEG-Asparaginase Very common (≥ 1/10)

 Mild to moderate gastro-intestinal reactions  Changes in blood lipid values; increase in blood urea  Alterations of liver parameters, fatty liver, hypoalbuminemia  Pain at site of injection, oedema

Common (≥ 1/100, ≤ 1/10)

 Increase in blood amylase  Mild to moderate myelosuppression; coagulation disorders, bleeding, disseminated intravascular coagulation or

thrombosis;

seizures,

headache or loss of consciousness  CNS dysfunction (agitation, depression,…)  Acute pancreatitis, disorders of the exocrine pancreatic function  Allergic skin reactions  Alterations in endocrine pancreatic function  Increased body temperature increased, pain Uncommon (≥ 1/1000, ≤

 Parotitis

1/100)

 Increase in uric acid blood levels, hyperammonemia

Rare (≥ 1/10000, ≤ 1/1000)

 Seizures and severe impairment of consciousness  Reversible posterior leukoencephalopathy syndrome

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 Hemorrhagic or necrotising pancreatitis  Acute renal failure  Hyperpyrexia  Cholestasis, icterus, hepatocellular necrosis and hepatic failure Very rare (≤ 1/10000)

 Hemolytic anemia  Mild tremor of the fingers  Pseudocysts of the pancreas, pancreatitis with fatal outcome, pancreatitits with simultaneous acute parotitis  Toxic epidermal necrolysis  Transient secondary hypothyroidism; decrease in thyroxine binding globulin; hypoparathyroidism

In case of ≥ grade 2 allergic reaction to PEG-asparaginase, one has to switch to Erwinia asparaginase (Erwinase). Switching from PEG-asparaginase to Erwinase requires an increase in the dosage (from 2500U/m² to 20000 U/m²) and in the frequency of administration (three times a week rather than bi-weekly). Except for maintenance where one PEG-asparaginase administration of 1000 IU/m² has to be replaced by 2 administrations of Erwinase at a dose of 25000 U/m². Erwinase In the UK Erwinase is licensed for IV use and has directions to give as a bolus directly from reconstitution but also clinicians often run as an infusion. In terms of administration, the current SPC (summary of product characteristics) recommends a direct injection (bolus or push) by IV or IM routes, i.e. without dilution after reconstitution with 1-2 mL of NaCl. Nevertheless, in real practices some hospitals dilute the reconstituted product in 50-100 mL NaCl, and infuse the product within 1 hour. However, there are no stability data after dilution. Following reports from Germany, describing a precipitate forming in Erwinase after reconstitution and further dilution for intravenous infusion, it was decided to exclude intravenous infusion as a means of administration until further notice. Intravenous injection, intramuscular injection and subcutaneous injection will remain as the recommended routes of administration. The solution should be administered within 15 minutes of reconstitution. If a delay of more than 15 minutes between reconstitution and administration is unavoidable, the solution should be withdrawn into a glass or polypropylene syringe for the period of the delay. In this case, the solution should be administered within 8 hours.

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10.3. Cyclophosphamide (CPM) Toxicity: bone marrow depression (nadir at 7-14 days), alopecia, mucositis leading to mouth and GI ulcers, skin rash, facial flushing during injection, eosinophilia, inadequate secretion of antidiuretic hormone (ISADH). Hemorrhagic cystitis has to be prevented by hyperhydration and concomitant administration of MESNA.

10.4. Cytosine-arabinoside (ARA-C) Toxicity: bone marrow depression, emesis, flue-like syndrome, fever, liver toxicity. With high doses: mucositis, diarrhea, conjunctivitis, facial flushing, cerebellar ataxia.

10.5. Daunorubicin (DNR) Toxicity: same as for Adriamycin (cf. 5.7.1.).

10.6. Etoposide (VP-16) Toxicity: myelosuppression, emesis, diarrhea, mucitis, anorexia, alopecia, hypertension following rapid intraveneous infusion. Transient liver functioin abnormalities. Anaphylactic-like reaction with fever, chills, bronchospasm, dyspnea and tachycardia. Peripheral neuropathy.

10.7. Corticosteroids Toxicity: fluid and salt retention, hypertension, hyperglycemia and glycosuria, potassium depletion, obesity, psychic disturbances (euphoria or depression, irritability, psychotic symptoms), gastric ulcers, intracranial hypertension coincident with tailing off and/or stopping of the course, aseptic bone necrosis.

10.8. Methotrexate (MTX) Toxicity: depends on the dose and duration of exposure. Bone marrow depression and megaloblastosis, mucositis leading to mouth and Gl ulcers, hepatotoxicity, osteoporosis, malabsorption, pneumonitis. More particularly after high doses: precipitation in renal tubules, renal failure, severe mucositis, rash (“lobster syndrome”), leucoencephalopathy. Interaction with numerous other drugs (salicylates, sulfonamides, etc.)

10.9. 6-mercaptopurine (6-MP) Toxicity: bone marrow depression, mouth ulcers, stomatitis, macular-papular rash, liver dysfunction. Interaction with Allopurinol, which delays 6-MP metabolism and increases its potency.

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10.10.

6-thioguanine (6-TG)

Toxicity: bone marrow depression, mouth ulcers, stomatitis, liver dysfunction (hepatocellular or obstructive liver disease), loss of vibration sensitivity and unsteady gait, diarrhea, mild atopic dermatitis. If 6-TG is not available, 6-mercaptopurine in the same dose should be substituted for it.

10.11.

Vincristine (VCR)

Toxicity: local necrosis if extravasation occurs. Peripheral neuropathy, paresis, jaw pain, muscle pain, constipation, paralytic ileus, inadequate secretion of ADH, convulsions, alopecia, sleeplessness.

10.12.

Vindesine (VDS)

Toxicity: local necrosis if extravasation occurs. Neurologic side effects are usually less severe and less progressive than those observed with VCR. Paralytic ileus, constipation, finger paresthesia, loss of reflexes, peripheral neuropathy, paresis, jaw pain, headache, convulsions. Bronchospasm with acute dyspnea. Alopecia. Muscle pain. Granulopenia.

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11 Definitions and treatment medullary involvement

of

initial

extra-

Introduction The definitions used in these guidelines are based on the international accepted definitions. There are clear definitions of CNS status concerning the CSF findings on the first lumbar puncture. Apart from the CNS status there are also CNS involvement definitions (taking in to account other involvements). Any lumbar punction (and certainly the diagnostic lumbar punction) must be done under a stable hemostatic condition.   

This means that the level of platelets shortly before lumbar punction must be at least > 50 000/mm³; The volume that must be injected with the medication must be not less than 6 ml (this is the same volume that is re-drawned during the punction) Just after the lumbar punction the patient must be brought or stays in prone position during at least 1 hour.

Because it is important to avoid blood contamination in the lumbar first punction, it is of great importance that this technical procedure is done by an experienced physician.

11.1. Initial CNS status (CSF findings at Day 1) For non-traumatic punctures, CNS status is defined as follows:   

CNS 1: nontraumatic puncture, ≤ 5 WBC/μl CSF without leukemic cells on cytospin. CNS 2: nontraumatic puncture, ≤ 5 WBC/μl CSF with identifiable leukemic cells on cytospin. CNS 3: nontraumatic puncture, > 5 WBC/μl CSF with identifiable leukemic cells on cytospin.

For traumatic lumbar punctures, CNS status is defined as follows: A traumatic lumbar puncture (TLP) is defined as 10 or more erythrocytes/μl CSF or as CSF macroscopically contaminated with blood. (see cytospin instructions below)  

TLP + : traumatic lumbar puncture with leukemic cells on cytospin. TLP - : traumatic lumbar puncture without leukemic cells on cytospin. Patients TLP- are classified as CNS-1.

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11.2. Final CNS status (CSF findings after the first IT injection, see table below)   

“Late CNS-1”: Patients with initial CNS-2 or TLP + becoming CSF negative at D4 of prephase “Persistent CNS 2” : Patients with initial CNS-2 remaining CNS2 or TLP + at D4 of prephase “Persistent TLP +”: Patients with initial TLP + remaining TLP + or CNS2 at D4 of prephase

11.3. CNS involvement at diagnosis:   

"CNS 3" status (including patients with initial CNS-2 or TLP + but becoming CNS 3 at D4 of the prephase) OR intracerebral or meningeal leukemic (proven or probably) mass seen on the MRI or CT scans OR cranial nerve palsy (irrespective of CSF or imaging findings)

Final CNS status according to the results of day 1 and day 4 (if applicable) lumbar punctures Day 1

Day 4

Final status

CNS 1

no LP at day 4

CNS 1

CNS 1

LATE CNS 1

CNS 2

PERSISTENT CNS 2

CNS 3

CNS 3

TLP -

LATE CNS 1

TLP +

PERSISTENT CNS 2

CNS 1

CNS 3

CNS 2

CNS 3

CNS 3

CNS 3

TLP -

CNS 3

TLP +

CNS 3

no LP at day 4

CNS 1

CNS 1

LATE CNS 1

CNS 2

PERSISTENT TLP +

CNS 3

CNS 3

TLP -

LATE CNS 1

TLP +

PERSISTENT TLP +

CNS 2

CNS 3

TLP -

TLP +

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11.4. Treatment of CNS involvement (see table page 55) 11.4.1. Initial CNS involvement (see 11.3. CNS involvement definition): -

Systemic treatment: o VLR and AR1 patients with CNS involvement will receive AR2 group treatment o AR2 and VHR patients will continue the VHR protocol.

-

i.t. treatment: o Every 4 days until complete remission.  Usually 2 or 3 injections suffice to induce CNS CR.  Patients will receive:  day 1: injection with MTX alone;  day 4 : injection with TIT  If CNS CR is not obtained at day 8, it will be evaluated at day 12 and additional i.t. injections will be given if necessary. o Supplementary i.t. injections will be added during:  If AR2  induction (IA): D18  re-induction (IIA): D1; D18 Total number of i.t. injections in case of initial CNS-involvement: 21 +/- D8 if necessary  If VHR  induction (IA): D18  re-induction (IIA N°1 et N°2): D1; D18 Total number of i.t. injections in case of initial CNS-involvement: 23 +/- D8 if necessary o No CNS irradiation will be given during front-line therapy.

11.4.2. CNS 2 status: a. Late CNS-1 (no blast in the CSF on day 4) -

Systemic treatment: patients initially allocated to VLR group will receive AR1 treatment.

-

i.t. treatment: o Additional i.t. injections will be given on day : D18 of Induction IA Total i.t. during induction: D1, D4 (MTX alone), D12, D18, D25 b. Persistent CNS 2 (blasts in the CSF on day 4)

-

Systemic treatment: patients initially allocated to VLR group will receive AR1 treatment.

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i.t. treatment: o Every 4 days until complete remission  Usually 2 or 3 injections suffice to induce CR  Patients will receive :  day 1: injection with MTX alone;  day 4: injection with MTX alone;  day 8: injection with TIT o Additional i.t. injections will be given on day : D8 (because of persistent blasts on D4) + D18 Total i.t. during induction: D1, D4 (MTX alone), D8, D12, D18, D25

11.4.3. TLP + status a. Late CNS-1 (no blast in the CSF on day 4) -

Systemic treatment: patients initially allocated to VLR group will receive AR1 treatment.

-

i.t. treatment: o Additional i.t. injections will be given on day : D18 Total i.t. during induction: D1, D4 (MTX alone), D12, D18, D25 b. Persistent TLP + (blasts in the CSF on day 4)

-

Systemic treatment: Patients initially allocated to VLR group will receive AR1 treatment.

-

i.t. treatment: o every 4 days until complete remission  Usually 2 or 3 injections suffice to induce CR  Patients will receive day 1 and day 4 injections with MTX alone and day 8 triple i.t. o Additional i.t. injections will be given on day : D8 (because of persistent blasts on D4) + D18 Total i.t. during induction: D1, D4 (MTX alone), D8, D12, D18, D25

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Treatment recommendations according to the initial risk group and the final CNS status FINAL CNS STATUS ACCORDING TO THE RESULTS OF DAY 1 AND DAY 4 (IF APPLICABLE) LUMBAR PUNCTURES

PERSISTENT CNS 2 INITIAL RISK GROUP

CNS 1

LATE CNS 1

OR

CNS 3

PERSISTENT TLP + AR2-B AR1 VLR

VLR

Additional D4 (MTX of induction

AR1 alone)

and

IT: D18

Additional D4 (MTX alone), of induction

D8

and

IT: D18

Additional IT every 4 (D1 MTX alone, then TIT)

days

until

CR

days

until

CR

days

until

CR

until

CR

Supplementary IT : D18 of induction D1 and D18 of re-induction AR2-B

AR1 AR1

AR1

Additional D4 (MTX of induction

AR1 alone)

and

IT: D18

Additional D4 (MTX alone), of induction

D8

and

IT: D18

and

IT: D18

AR2 AR2 AR2

AR2

Additional D4 (MTX of induction

alone)

and

IT: D18

Additional IT every 4 (D1 MTX alone, then TIT) Supplementary IT : D18 of induction D1 and D18 of re-induction

VHR

Additional D4 (MTX alone), D8 of induction for AR2-T

D4 (MTX alone), D9 and D18 of induction for AR2-B (because of the HD-MTX given on day 8)

Additional IT every 4 (D1 MTX alone, then TIT)

Supplementary IT : D18 of induction D1 and D18 of re-inductions 1 and 2

VHR VHR VHR

VHR

Additional D4 (MTX of induction

VHR alone)

and

IT: D18

Additional D4 (MTX alone), of induction

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and

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IT: D18

Additional IT every 4 (D1 MTX alone, then TIT)

days

Supplementary IT : D18 of induction D1 and D18 of re-inductions 1 and 2

11.5. Cytocentrifugation technique (cytospin) and instructions for cerebro-spinal fluid (CSF) as recommended by Dr AM. Manel and Dr MP. Pages for trial 58951 and modified in July 2010 by Dr S. Girard (Hematology Laboratory, Hospital Edouard Herriot, Lyon).

Quantitative cytology     

The CSF sample should be homogenized by slow up and down rotating mobilization of the tube. Introduce the undiluted CSF sample into the upper compartment of the Nageotte’s cell. Dilute a part of CSF sample in acetic blue (1/2) and introduce it in the lower compartment of the Nageotte’s cell. Let it stand for about 10 minutes in a humid room, then count the erythrocytes and the leucocytes along 4 bands. The cumulated counts over the 4 bands, when divided by 5, provide the number of cells per mm³ (1 band = 1.25 mm³) Particular cases: if the CSF appears hemorrhagic or trouble, or if the number of erythrocytes is > 200 per band, dilute the CSF with normal saline solution.

Qualitative cytology Cytospin    

The CSF sample should be homogenized by slow up. Whatever the leucocyte count (even if < 2/mm³), try to obtain 2 cytospin pellets. Note that we have decided NOT to add Fetal Calf Serum or Bovin Serum Albumin. The volume of CSF to be centrifuged depends on the cell count.

Number of nucleated cells per mm³ > 600 > 200   600 > 30   200

Procedure 2 drops of undiluted CSF (approx. 35 µL) 3 drops of undiluted CSF (approx. 55 µL) 7 drops of undiluted CSF (approx. 125 µL)

0 to  30

10 drops of undiluted CSF (approx. 180 µL)

1 drop = 18 µL and 14 drops = 250 µL Spin at 600 RPM during 6 minutes or 1000 RPM during 5 minutes.

Staining   

Let the slides dry for a few minutes. Classical staining with May-Grünwald Giemsa or Wright. When the smears were dried and before examining those under the microscope cover it with a cover glass.

Microscopy 

Utilize the 10 X magnification for evaluating the cell count and the 100 X magnification for analyzing the stained slides.

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11.6. Gonadal involvement: Definition of Testicular Involvement See the study 58081

Treatment of Testicular Involvement -

Patients with gonadal involvement cannot be classified as VLR or AR low. The non-VHR patients with gonadal involvement are included in AR high risk group (see risk groups) VHR patients stay VHR. There is no local irradiation foreseen in the frontline treatment.

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12 MRD guidelines 12.1. How to measure MRD? 

MRD is measured by quantitative PCR (ASO-PCR or Genescan) of a specific DNA marker. The DNA marker used can be clono-specific rearrangements of the immunoglobulin and T-cell receptor genes (IG/TCR), or oncogenic DNA markers (MLL genomic breakpoint, TALd, ...). ASO-PCR is performed and interpreted as described in up-to-date EuroMRD guidelines [van der Velden et al., Leukemia. 2007 Apr;21(4):604-11].



In case MRD is not possible or failed by these technics, flow cytometry-based MRD can be accepted.

12.2. When MRD measurements? MRD to be performed for all patients after IA and after IB 

For VHR patients: 



MRD to be tested after each block until BMT

For non-VHR patients: MRD at further timepoints performed only if MRDIB ≥10-4. (However, if MRD after IA ≥10-2 and MRD after IB