ALL - Interim Guideline v3

CYP ALL
Interim Guidelinev3 July 2011
GUIDELINES FOR TREATMENT OF CHILDREN AND YOUNG PERSONS WITH ACUTE LYMPHOBLASTIC LEUKAEMIA AND LYMPHOBLASTIC LYMPHOMA
These guidelines are for use in the treatment of patients during the gap between UKALL 2003 and UKALL 2011. They have been drafted by the chief investigators of the two trials with input from the NCRI childhood and adult ALL sub-groups as well as the CCLG leukaemia special interest group.
Account has been taken of the preliminary results of UKALL 2003 and other recent studies in drafting these guidelines. There are significant changes from UKALL 2003 in risk classification and overall treatment, although the composition of the various phases of treatment remains the same.
Risks of intrathecal therapy

All medical staff involved in the care of patients with leukaemia MUST be aware that the inadvertent administration of vincristine by the intrathecal route is invariably FATAL. Vincristine should NOT BE AVAILABLE when an intrathecal needle is in situ. This protocol has been written to provide separation of intrathecal methotrexate administration from intravenous vincristine administration in time. An additional precaution is that the two drugs should not be administered in the same place. It is appreciated that not all centres will be able to administer the drugs in the suggested order within a given week, and therefore local factors may determine an alternative scheme. The single most crucial element in avoiding errors is the appropriate education and training of all personnel involved in the administration of chemotherapy.
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CYP ALL AND LBL TREATMENT GUIDELINE Summary and Brief Justification for Recommendations Recommendation Justification Day 8/15 stratification should no longer be Day 29 MRD reveals heterogeneity of employed except in patients without an MRD outcome within groups stratified by 8/15 results response. MRD low risk patients have a > 95% 5 year EFS regardless of day 8/15 marrow response and MRD defines a high risk sub-group of patients with a rapid early response. Amendment of MRD risk stratification as The new stratification is based on detailed analysis of outcome by MRD in UKALL follows: 2003 which demonstrates that the chosen threshold better defines MRD risk groups. Day 29 MRD > 5 x 10-5 = MRD High Risk Day 29 MRD < 5 x 10-5 = MRD Low Risk No MRD result = MRD indeterminate. This small group will be stratified by Day 8/15 marrow response as in UKALL 2003 but with change of treatment for SERs at day 35 Results of recent US COG trials (1991 and All patients should receive a single DI. 1961) have shown that there is no benefit of a second DI in patients who have received a dexamethasone containing induction or augmented post-remission therapy. Additionally, in UKALL 2003, there is no difference in 5 year EFS for MRD low risk patients who received 1 or 2 DI. MRD high risk patients should receive Regimen C with 1 DI and low risk patients NCI risk directed induction and consolidation followed by 1 DI. Results of the UKALL 2003 high risk randomisation remain blinded so we do not yet know if Regimen C is of benefit to MRD high risk patients. However, CCG 1961 has shown that NCI high risk patients benefit from augmented therapy regardless of early marrow response and NCI standard risk patients have a better outcome with Capizzi MTX interim maintenance compared with standard maintenance. It is therefore reasonable to assume that MRD high risk patients will have a better outcome with Regimen C. Patients with lymphoblastic lymphoma UKALL 2011 will recruit patients with should receive Regimen C with 1 DI lymphoblastic lymphoma as their outcome wth ALL therapy is excellent and will receive Regimen C because it most resembles the Euro-LB schedule they have received in the past.
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CYP ALL AND LYMPHOBLASTIC LYMPHOMA INTERIM GUIDELINES At Diagnosis: LYMPHOBLASTIC LYMPHOMA ALL BCR-ABL? No MLL rearrangement ? no Hypodiploid < 40 chromosomes ? no iAMP21? no 10 years ? no WBC 50x109/l ? no REGIMEN A At Day 29 (Morphology) Regimens A or B >5% but <25% blasts (M2) > 25% blasts (M3) <5% blasts (M1) yes yes REGIMEN B yes REGIMEN C yes yes Regimen C with 1DI
(See page 7)
yes REGIMEN C INDUCTION FOLLOWED BY ESPHALL OR UKALL 14 REGIMEN C
yes
REGIMEN C
yes
REGIMEN B
yes yes
transfer to Regimen C R3 High Risk Arm
Day 29 MRD (Molecular. Please do not use flow for risk stratification)
MRD HIGH RISK no MRD LOW RISK no MRD INDETERMINATE yes Day 8/15 SER no
yes
REGIMEN C WITH 1 DI
yes
REGIMEN A/B WITH 1DI
yes
REGIMEN C WITH 1DI
REGIMEN A/B WITH 1DI
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CONTENTS ..................................................................................
Page Summary of recommendations .................................................................................. 2 Treatment Allocation Flow Chart ...3 Index of Contents ........................................................................................................4 Author addresses .........................................................................................................5 Treatment of CNS & Testicular disease at presentation .............................................6 Traumatic LP, formulation of IT MTX and post LP care...6 Management of patients with amplified RUNX1 (iAMP21) and E2A-HLF ..............7 Indications for and Timing of Bone Marrow Transplant ........................................... 7 Treatment of Lymphoblastic Lymphoma7 Essential investigations at diagnosis ..........................................................................8 MRD Sample Collection and Transport ....................................................................8 General management of all regimens ........................................................................10 Regimen A introduction..........................................................................................11 Regimen A treatment details induction...................................................................13 Consolidation .......................................................................................................15 Interim maintenance 1..........................................................................................15 Delayed Intensification 1 .....................................................................................16 Maintenance .........................................................................................................17 Regimen B introduction ..........................................................................................18 Regimen B treatment details - induction ...................................................................20 Standard BFM Consolidation ...........................................................................21 Interim maintenance 1.......................................................................................23 Delayed intensification 1 ..................................................................................24 Maintenance ......................................................................................................25 Regimen C introduction ..........................................................................................26 Regimen C details of treatment induction ..............................................................28 Augmented BFM Consolidation .......................................................................30 Escalating Capizzi maintenance 1 ....................................................................31 Delayed intensification 1 ..................................................................................32 Maintenance ......................................................................................................33
Appendices
A. B. C D E F G H I J K L Measurement of weight; management of obese patients ..................................34 General drug information ..................................................................................36 Mercaptopurine and Methotrexate dose alterations ..........................................40 Pneumocystis prophylaxis (including Co-trimoxazole alternatives) ................43 Dose Modifications for Toxicity.......................................................................44 Recommendations for Treatment of Downs syndrome patients... 46 Erwinase in patients with reactions to Oncospar ..............................................48 Management of encephalopathy related to IT MTX.........................................50 Drug Interactions with Cytotoxics ....................................................................51 Management of Thrombosis .............................................................................54 Cranial radiotherapy guidelines ........................................................................58 Testicular radiotherapy guidelines ....................................................................59 Relapse ..............................................................................................................59
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For queries about this guideline please contact: Professor Ajay Vora Dept. of Haematology Sheffield Childrens Hospital Western Bank SHEFFIELD S10 2TH Phone 0114 271 7358 Fax 0114 276 2289 [email protected] For age 16 24 years Dr Clare Rowntree Consultant Haematologist University Hospital of Wales Cardiff CF14 4XN Secretary 029 20744327 Fax 029 20745442 Mobile 07796 614977
[email protected]
Dr Chris Mitchell, Paediatric Oncology, John Radcliffe Hospital, Headington, OXFORD OX3 9DU Phone 01865 221066 Fax 01865 221083
[email protected]
Dr Nick Goulden Great Ormond Street Hospital London WC1N 3JH

[email protected]
Dr Rachael Hough Consultant Haematologist University College Hospital, 1st Floor West Wing, 6th Floor Central 250 Euston Road, London. NW1 2PQ Tel: 020 7380 9952 Fax: 020 7380 9064 Mobile: 07711157526
[email protected]
Mobile: 07921 718866 Tel 0207 8298831 Fax 0207 8138410
CYP ALL SPECIAL CATEGORIES:
1. CNS disease at presentation (CNS3): These include patients with 1) CNS3 - the presence of >5/cumm unequivocal lymphoblasts in the CSF or 2) cranial nerve palsy, parenchymal brain infiltrate or ocular infiltrate even in the absence of CSF blasts. CNS3 patients should start treatment on an NCI-risk directed induction regimen but receive weekly intrathecal methotrexate until two consecutive clear CSFs have been obtained for a total of 4 intra-thecals during weeks 1 4. Subsequent treatment will depend on treatment response during induction: 1) If CSF is clear of blasts after 2 ITs AND rapid marrow response at day 8/15 AND MRD low risk or indeterminate at day 29 continue NCI-risk directed therapy. 2) If CSF is clear of blasts after 2 ITs BUT slow marrow response at day 8/15 OR MRD high risk at day 29 transfer to Regimen C. 3) Persistent blasts in CSF after 2 ITs regardless of marrow response transfer to Regimen C + cranial radiotherapy as below. In addition to the extra intra-thecals during induction as above, patients with ocular disease should receive ocular radiotherapy and patients with parenchymal brain infiltrates should receive 24Gy cranial radiotherapy in 15 daily fractions during weeks 5-8 (see appendix K) with three concurrent intrathecal methotrexate injections. Following radiotherapy they should receive intrathecal methotrexate as prescribed in the relevant regimen. The individual regimens provide specific timing and dosages. 2. Traumatic or CNS2 LP at diagnosis There is evidence that a traumatic LP with blasts (TLP+) or CNS2 (atraumatic with < 5 blasts/microlitre) tap at diagnosis is associated with a higher risk of CNS relapse, possibly because of poor penetration of MTX into the meningeal space at subsequent treatments due to a small extra-dural haematoma at the LP site. Therefore, patients with > 10 red cells/microlitre and blasts in their CSF or CNS2 tap at diagnosis should receive weekly IT MTX for a total of 4 intra-thecals during weeks 1-4 of induction. Traumatic tap without blasts in the CSF should receive standard IT therapy. 3. Formulation of IT MTX and post-LP care Some centres may be using a highly concentrated formulation of Methotrexate which results in insufficient volume to fill the dead space and reach ventricular spaces. Methotrexate for intra-thecal use should be made up at a maximum concentration of 2.5mg/ml so as to provide an adequate volume of distribution across the CNS. We recommend laying the patient prone for at least 1 hr after the intra-thecal procedure. Experiments in primate models indicate better ventricular distribution of intra-thecal chemotherapy if the subject lies prone for this period after the procedure.
4. Testicular Disease at Diagnosis Patients with clinically enlarged testis at presentation should be assumed to have testicular disease. Biopsy is not required to confirm the presence of infiltrate. Routine ultrasound of the testis should not be performed to detect sub-clinical enlargement. Patients with testicular disease should start induction according to age and WCC. Those patients with persistent enlargement at day 28 should be transferred to the next more intensive schedule i.e. Regimen A to B or Regimen B to C. Testicular radiotherapy should only be given to those children
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who still have a clinically enlarged testis at week 8. In these patients, 24 Gy should be given in 12 fractions between weeks 9 to 12 while continuing with other treatment.(Details in Appendix L) 5. Amplified RUNX1 (also called iAMP21) Not all patients with multiple copies of RUNX1 on FISH fit into this category. Please discuss result with your cytogenetics laboratory and, if any doubt, contact Dr Harrison at the Cytogenetics Co-ordinating Laboratoy. Analysis of ALL97 indicates that dup (21)(q?) with amplification of the AML1 gene detected by FISH is associated with a poor prognosis. . Patients with this abnormality should start treatment on Regimen C. 6. t(17;19) (E2A-HLF) A variant of the t(1;19) (E2A-PBX), t(17;19) (E2A-HLF) is a rare cytogenetic abnormality associated with a very high risk of early refractory relapse. All 4 ALL97 patients relapsed between 5 and 18 months from diagnosis and subsequently died. Limited literature on the abnormality is in concordance with the ALL 97 experience. Hence, the ALL task force has decided to stratify these patients as very high risk and recommends that they receive Regimen C followed by allogeneic transplant after recovery from consolidation using any available donor. It can be detected by routine karyotyping and FISH, and cytogenetics laboratories have been notified by the LRF reference laboratory to report it as a high risk abnormality. 7. First remission allogeneic transplantation: Allogeneic transplant in first CR is recommended for the following groups: 1. iAMP21 with >5% blasts at day 29. 2. MLL rearrangement positive or hypodiploid < 44 with M2 marrow (>5% blasts) at day 29. 3. M3 marrow at day 28. 4. BCR:ABL positive, follow guidance within Philadelphia ALL protocol. 5. t(17;19) (E2A-HLF) positive The optimal timing of transplant, as recommended by the CCLG BMT Group, is on recovery from the consolidation phase of Regimen C at around weeks 14 16. Where there is a delay beyond this time point, it is recommended that patients should receive standard maintenance therapy, rather than Cappizzi maintenance, during the interim. In due course, we may be able to identify patients with persistent high level MRD at the end of consolidation for further cyto-reductive therapy prior to transplant. 8. Lymphoblastic Lymphoma Patients with T or B lymphoblastic lymphoma should receve Regimen C with 1 DI if they show a >35% reduction in tumour volume at the end of induction but should be taken off protocol if the reduction is < 35%. Patients should receive hyperhydration and rasburicase and be monitored for tumour lysis syndrome according to local guidelines.
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ESSENTIAL INVESTIGATIONS AT DIAGNOSIS: Centres treating patients with leukaemia are expected to have appropriate investigation protocols for the pre-treatment assessment of new patients, for monitoring progress during treatment and once therapy has ended, and for dealing with any complications that may arise. In addition to a blood count, mandatory investigations at the time of diagnosis include:
(a) a bone marrow aspirate with material being sent for: i) ii) iii) morphology (locally and by central review - see footnote) immunophenotyping Cytogenetic and molecular cytogenetic analysis: These will be performed locally and must include standard G-banded analysis, as well as FISH tests for the following rearrangements: ETV6-RUNX1 (TEL-AML1) / amplification of RUNX1 (AML1), BCR-ABL and MLL. These tests must be carried out as soon as possible as positive findings may exclude the patient from the trial or alter therapy. A copy of the reports of all diagnostic and relapse cytogenetic, FISH and genetic testing must be sent to the cytogenetic co-ordinating centre. From time to time the cytogenetic co-ordinating centre may request left-over fixed cell suspension, DNA, RNA or other material from the local genetics laboratory or the treating clinician to undertake further cytogenetic, molecular cytogenetic and genetic testing (including but not restricted to FISH, array CGH and RT-PCR) to refine the definition of known abnormalities and characterise novel subgroups. All these additional tests will be performed with the full knowledge of the trial coordinators baseline bone marrow sample for MRD NB. if any of these tests have been omitted on the first diagnostic sample, a second sample must be taken before treatment starts, unless prevented by clinical circumstances. A trephine biopsy is required if an adequate sample cannot be obtained by aspiration.
iv) v)
Lymphoblastic Lymphoma patients should have CT imaging of the tumour sites at diagnosis and end of induction. The clinical significance of residual PET abnormalities is unknown and we recommend against routine PET scanning in this group. MRD SAMPLE COLLECTION AND TRANSPORT At diagnosis 2 - 5mls of bone marrow from all children with suspected leukaemia should be placed into the ACD containers supplied by your local MRD network lab. Do NOT use EDTA or other transport media. In patients with peripheral white counts greater than 20 x109 /litre, 5mls of blood collected into ACD is also acceptable at diagnosis. Please note that peripheral blood is of no value as an MRD sample at other time points. At the end of induction 5mls of bone marrow should be placed into ACD (and only as a last resort into EDTA). Peripheral blood is NOT an acceptable alternative. Request forms These will be supplied with the ACD bottles. They have been designed to provide sufficient information for each patient to be reliably identified whilst at the same time attempting to blind the network lab to clinical risk. Thus whilst the date of birth is required for identification and in due course the immunophenotype for directed PCR screening, we will
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not require information about WCC or treatment arm. We do wish to know if the patient has Philadelphia positive ALL so we can make RNA for MRD analysis.
Sample processing On receipt of bone marrow aspirates, the MRD laboratory will assign the patient and the sample a unique number according to the standard operating procedure. Cell counts will be recorded and DNA extracted within 24 hours of receipt of the sample. A minimum of 10micrograms of DNA is required at diagnosis and 5 micrograms at end of induction. In the event that an inadequate sample is obtained then a further sample will be requested.
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GENERAL MANAGEMENT OF ALL REGIMENS: Please use UKALL 2003 flow charts adapted for 1DI.
The instructions set out in this document must be followed strictly. The drugs must be given at full dosage at all times unless there is intolerance when the dosage must only be modified according to the instructions set out in this protocol. In exceptional circumstances, the responsible clinician may decide, in consultation with a trial co-ordinator that exact adherence is unjustifiably hazardous for the patient. Doses must be returned to that specified in this document thereafter and dosages must be regularly increased as the patient grows. All drugs used in continuing therapy must be started at maximum dosage as specified in the protocol. In addition, in patients on daily thiopurine in whom no toxicity is evident, the thiopurine dose should be increased until toxicity occurs (see Appendix C). If the 12 week maintenance therapy cycle includes gaps when treatment has been stopped because of toxicity or infection the omitted oral thiopurine and methotrexate, are counted as given and not made up; i.e. the clock does not stop when the drugs are stopped. In this way, cycles are maintained at 12 weeks; gaps in therapy and total dosage per cycle can be related to outcome. Because of drug preparation and dosage variations, it is essential that the protocol is discussed with pharmacies at participating hospitals. NB: MRD indeterminate patients with obvious gross residual marrow disease (more than 25% unequivocal blasts) at day 8 (regimen B) or day 15 (regimen A), to be confirmed by another haematologist, will transfer to schedule C post-induction. This marrow must not be done before D8 or 15. It can be done up to D10 or 18. There is 30 years experience of doing LPs without checking clotting in children with ALL receiving asparaginase and we do not know of a single case of LP related serious haemorrhage among several thousand children treated worldwide. Therefore, IN THE ABSENCE OF SYMPTOMS OR SIGNS SUGGESTIVE OF A COAGULOPATHY, we recommend AGAINST doing routine clotting screens prior to LPs in patients receiving asparaginase. We also recommend against checking LFTs routinely, especially during the maintenance phase of treatment. Moderate elevation of aminotransferases is common during this period, and, in the absence of overt jaundice/hyperbilirubinaemia, is not a reason for dose modification
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CYP ALL UKALL 2003 REGIMEN A.
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NCI Stratification Patients treated on regimen A must be before their 10th birthday and have a highest white cell count before starting treatment less than 50x109/L. MRD Stratification MRD High Risk patients will receive Regimen C with one delayed intensification and should change treatment at day 35. MRD Low Risk patients will receive one delayed intensifications. MRD Indeterminate patients will receive Regimen C with 1 DI (from D35) if slow responders and Regimen A with 1 DI if rapid responders at day 15 NCI SR
Age <10 + WCC <50
Day 29 MRD
NEG Regimen A 3-drug induction POS< 5 x 10-5
MRD Low Risk

REG A1 DI
INDETERMINATE
MRD Indeterminate
RER = REG A 1 DI SER = REGC 1DI
POS>5 x 10-5
REG C 1DI
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Summary of Regimen A. Regimen A consists of the following phases: 1. 2. 3. 4.

5.
Three drug induction (duration 5 weeks) with dexamethasone as steroid of choice. Intensification/CNS-directed phase (duration 3 weeks) with 6-mercaptopurine; Interim maintenance I (duration 8 weeks) with dexamethasone and 6-mercaptopurine; Delayed intensification I (duration 7 weeks) with 6-mercaptopurine in reconsolidation; Maintenance chemotherapy with dexamethasone and 6-mercaptopurine to end of week 112 for girls and end of 164 for boys.
Induction
CNS + IM I
DI I
CT girls = week 112 boys = week 164
1-5
6-8
9-16
17-23
(24)
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UKALL 2003 REGIMEN A: DETAILS OF TREATMENT. Schedule A - Remission induction phase I (See flowchart 1.) This phase runs for 35 days from day 1 (beginning of week 1) to day 35 inclusive (end of week 5) (i.e. 5 weeks in total). a) Fluids All patients should be adequately hydrated (at least 2-2.5 l/m2/24hrs. given parenterally for the first 48 hours. Allopurinol 100 mg/m2 oral three times daily should start 24 hours before chemotherapy and continue for 5 days. Dexamethasone 6 mg/m2/day (maximum dose 10 mg/day in induction only) for 28 days and then tapered over the next 7 days. The steroid should be divided into two doses per day. Vincristine 1.5 mg/m2 (maximum single dose 2 mg) IV weekly for five weeks starting on day 2 and continuing on days 9, 16, 23 and 30. Pegylated L-asparaginase (Oncaspar) 1000iu/m2 IM , on day 4 and day 18 Intrathecal methotrexate On days 1, 8 and 29. Dose by age:<2yrs: 8mg; 2yrs: 10mg; 3yrs or more: 12 mg. NB Patients who have CNS disease at presentation should receive weekly doses until two clear CSF samples are obtained- see page 24. Do not schedule vincristine on the same day as the intrathecal methotrexate. 6-mercaptopurine 75 mg/m2/day orally starting on day 29 (beginning week 5) (if neutrophils > 0.75 and platelets > 75) and continuing for 4 weeks in total (to end of consolidation, week 8) Doses should be taken at least one hour after the evening meal, without milk products. Dose adjustments are described in Appendix C. Bone marrow Aspirates Bone marrow should be checked at day 8, 15 and 29.
b)
c)
d)
e) f)
g)
h)
Patients with adverse risk cytogenetics should switch to Regimen C at day 15. Day 29 BM2 and MRD High Risk patients and MRD indeterminate patients with slow early response at day 15 should switch to Regimen C at day 35. Day 29 BM3 patients are offprotocol. i) Co-trimoxazole (trimethoprim and sulphamethoxazole) This drug is given as PCP prophylaxis orally on 2 consecutive days throughout treatment from the start of induction. This dosage is lower than that recommended in previous studies, but has been found to be equally effective in CCG studies. The dose is tabulated below. Please ensure separation of the days on which oral Methotrexate and Cotrimoxazole doses are given during maintenance courses. If a child remains cytopenic after being off chemotherapy for three weeks or more, then stop the co-trimoxazole. Reintroduce co-trimoxazole once both thiopurine and methotrexate are back at standard dose. If cytopenias recur once the co-trimoxazole is reintroduced, then it should be stopped for at least two months and an alternative form
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of prophylaxis used instead (see below). The alternative drug should then be continued for the duration of the antileukaemic therapy The maintenance of adequate doses of thiopurine and methotrexate should take precedence over continuing co-trimoxazole. If co-trimoxazole is stopped, however, it must be remembered that the child is at increased risk of PCP. Nebulised pentamidine or oral Dapsone are alternative drugs. Surface area 0.5-0.75 m2 0.76-1.0 m2 over 1.0 m2 Co-trimoxazole 240 mg bd 360 mg bd 480 mg bd Trimethoprim 40 mg bd 60 mg bd 80 mg bd Sulphamethoxazole 200 mg bd 300 mg bd 400 mg bd
See also appendix D for details of alternative PCP prophylaxis regimens. Permitted dose modifications for toxicity see Appendix E
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Regimen A: Consolidation/CNS phase, phase II (See flowchart 2.) This phase runs for 21 days from day 1 (beginning of week 6) to day 21 inclusive (end of week 8) i.e. 3 weeks. Patients should have an ANC >0.75 x109/L and platelets of >75x109/L. Patients with refractory CNS disease at diagnosis will receive cranial irradiation during consolidation starting at day 36.
a) Intrathecal methotrexate Days 1, 8 and 15 Dose by age:<2yrs: 8mg; 2yrs: 10mg; 3yrs or more: 12 mg. Do not schedule vincristine on the same day as the methotrexate. b) 6-mercaptopurine 75mg/m2/day orally continuing to day 21 (end of week 8) Doses should be taken at least one hour after the evening meal, without milk products. Dose adjustments are described in Appendix C.
Regimen A: Interim maintenance I phase III (See flowchart 3.) This phase runs from day 1 (beginning of week 9) to day 56 inclusive (end of week 16) (i.e. 8 weeks). Patients should have an ANC >0.75 x109/L and platelets of >75 x109/L to start. a) Dexamethasone 6 mg/m2/day orally, divided into twice-daily doses each day on days 1-5 (week 9) and days 29-33 (week 13). Vincristine 1.5 mg/m2 (maximum single dose 2 mg) IV on day 1 (week 9) and day 29 (week 13). 6-mercaptopurine 75 mg/m2/day orally, daily on days 1-49 (weeks 9-15) but not days 50-56 (week 16). Doses should be taken at least one hour after the evening meal without milk products. Dose adjustments are described in Appendix C. The omission of 6-mercaptopurine for days 50-56 is in line with the relevant CCG protocol. Oral methotrexate 20 mg/m2 orally weekly during weeks beginning on days 1, 8, 22, 29, 36, 43 and 50 (weeks 9-16). Note none is given day 15 as an intrathecal dose is given during that week Should be a single dose taken with 6-mercaptopurine. Dose adjustments are described in Appendix C. Intrathecal methotrexate on day 1 week 11. Dose by age: <2yrs: 8mg; 2yrs: 10mg; 3yrs or more: 12 mg. Do not schedule vincristine on the same day as IT methotrexate.
b)
c)
d)
e)
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Regimen A: Delayed intensification I phase IV (See flowchart 4.) This phase runs from day 1 (beginning of week 17) to day 49 inclusive (end week 23) i.e. 7 weeks. To start, ANC should be >0.75x109/L and platelets of >75x109/L. Once begun, therapy during weeks 17 20 is not interrupted for myelosuppression alone. Therapy due day 1, week 21 should be delayed until ANC >0.75x109/L and platelets of >75x109/L and once begun should not be interrupted solely for myelosuppression. Any serious infection, such as Varicella, pneumocystis pneumonia, or neutropenia with fever, and presumed or proven infection, warrants chemotherapy interruption at any time during DI. Part 1; weeks 17 20: a) Dexamethasone 10mg/m/day orally for 7 days on days 2- 8 (week 17) and 16-22 (week 19). No taper. Divide into two daily doses, adjusted upward to nearest 0.25 mg, as tablet size dictates. (Liquid preparation is acceptable). b) Vincristine 1.5 mg/m (2.0 mg max) IV push on days 2 (week 17), 9 (week 18) and 16 (week 19). Doxorubicin (Adriamycin) 25 mg/m IV on days 2 (week 17),9 (week 18) and 16 (week 19) given over a period of 1 hour. Pegylated L-Asparaginase (Oncaspar) 1000 iu/m2 IM on day 4 (week 17) Intrathecal methotrexate on day 1 (week 17). Dose by age: <2yrs: 8mg; 2yrs: 10mg; 3yrs or more: 12 mg. Do not schedule vincristine on the same day as IT methotrexate.
c)
d) e)
Part 2; weeks 21-23: f) Cyclophosphamide 1,000 mg/m IV over 20-30 min day 29 (week 21). Give 125mls/m2 /hr of Dextrose /Saline infusion for 30 minutes before the cyclophosphamide and for 3.5 hours afterwards, i.e. 4 hours in total. Do not add potassium. Mesna is not needed. Mercaptopurine. All patients receive MP 60 mg/m2/day during delayed intensification. The drug is given daily by mouth for 14 days from day 29 (beginning of week 21) to day 42 (end of week 22). No dose adjustments are made during this block.Doses should be taken at least one hour after the evening meal, without milk products. Cytarabine (ara-C). 75mg/m2/day by IV push or subcutaneously 8 doses in two pulses of 4 days each; days 30-33 (week 21) and days 37-40 (week 22). Intrathecal methotrexate. Days 29 (week 21) and 36 (week 22). Dose by age: <2yrs: 8mg; 2yrs: 10mg; 3yrs or more: 12 mg.
g)
h)
i)
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Regimen A: Maintenance phase V (See flowchart 7.) Maintenance runs from day 1 cycle 1 (beginning of week 24) in 12-week cycles to end of week 112 for girls and end of week 164 for boys. The cycle in progress is stopped when the end of therapy is reached. This period equates to 2 years from the start of interim maintenance I for girls and 3 years for boys. Maintenance should begin when the ANC is >0.75 x 109/l and the platelet count is >75 x 109/l. Only 6-mercaptopurine and oral methotrexate will be interrupted for myelosuppression and not made up. Days off therapy for intercurrent infections are counted as days of maintenance and not made up. Omit the Vincristine and steroid pulse if it falls in the last week of therapy. Anaemia occurring in the course of maintenance therapy should be treated with transfusion and the dose of drug is maintained. If persistent anaemia occurs (i.e., haemoglobin below 8 g/dl) investigate for Parvovirus infection. Please contact trial coordinators for advice. Dexamethasone 6 mg/m2/day orally, divided into twice-daily doses on days 1-5, 29-33 and 57-61 of each cycle. Vincristine each cycle. 1.5mg/m2 (maximum single dose 2 mg) IV on days 1, 29, and 57 of
a)
b)
c)
6-mercaptopurine 75mg/m2/day orally daily throughout maintenance. Doses should be taken at least one hour after the evening meal without milk products. Dose adjustments are described in Appendix C. Oral methotrexate 20 mg/m2 orally during weeks beginning days 1, 8, 22, 29, 36, 43, 50, 57, 64, 71 and 78 of each cycle. Note none is given in the third week of each cycle as an intrathecal dose is given during that week. Dose adjustments are described in Appendix C. Intrathecal methotrexate on day 15 of each cycle. Dose by age: <2yrs: 8mg; 2yrs: 10mg; 3yrs or more: 12 mg. Do not schedule vincristine for the same day as intrathecal methotrexate.
d)
e)
f)
Bone marrow examination should be carried out at the same time as the End of Treatment intrathecal methotrexate. NB the end of treatment marrow should always be done BEFORE chemotherapy is stopped to prevent confusion due to rebound marrows.
END OF REGIMEN A
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CYP ALL 16. UKALL 2003 REGIMEN B.
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NCI Stratification This regimen (B) is for patients defined as at high risk of relapse because of their age (10 years) or presenting white cell count (50x109/L).
MRD Stratification MRD Low Risk patients will receive one delayed intensification. MRD High Risk patients will receive Regimen C with 1 DI and should change treatment at day 35. MRD Indeterminate patients will continue on Regimen B + 1DI if they have a rapid response and Regimen C + 1 DI (from D35) if they have a slow response at day 8.
NCI HR
Age > 10 Or WCC > 50
Day 29 MRD
NEG Regimen B 4-drug induction POS< 5 x10-5
MRD Low Risk

REG B 1 DI
INDETERMINATE
MRD Indeterminate
RER = REG B 1DI SER = REG C 1DI
POS>5 x 10-5
MRD High Risk

REG C 1DI
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CYP ALL Summary of Regimen B.
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Regimen B consists of the following phases: 1. 2. 3. 3. 4. Four drug induction (duration 5 weeks) with dexamethasone as steroid of choice. Standard BFM consolidation (duration 5 weeks) with 6-mercaptopurine; Interim maintenance I (duration 8 weeks) - dexamethasone and mercaptopurine; Delayed intensification I (duration 7 weeks); 6-mercaptopurine in reconsolidation; Maintenance chemotherapy with dexamethasone and 6-mercaptopurine to end of week 114 for girls and end of week 166 for boys.
MRD
Induction BFM consol + CNS.
IMI
DI I
CT girls = week 114 boys = week 166
1-5
6-10
11-18
19-25
26
Prevention of Tumour Lysis Treatment centres should have a policy for the prevention and treatment of Tumour Lysis syndrome in patients with high white cell counts or bulky disease. Consideration should also be given to the use of Recombinant Urate Oxidase (Rasburicase) instead of Allopurinol in patients with very high white cell (> 100 x 109/l) counts or bulky disease (Mediastinal mass or large abdominal lymph nodes).
19
CYP ALL
20
UKALL 2003 REGIMEN B: DETAILS OF TREATMENT. The convention for day/week numbering is that a new module of therapy begins on day 1 of whatever week of treatment has been reached. Regimen B: Remission induction phase I (See flowchart 8.) This phase runs for 35 days from day 1 (beginning of week 1) to day 35 inclusive (end of week 5). a) Fluids: All patients should be adequately hydrated (at least 2-2.5 l/m2/24hrs given parenterally for the first 48 hours). Allopurinol: 100 mg/m2 oral three times daily should start 24 hours before chemotherapy and continue for 5 days. Dexamethasone: 6 mg/m2/day (maximum dose 10 mg/day in induction only) for 28 days and then tapered over the next 7 days. The steroid should be divided into two doses per day. Vincristine: 1.5 mg/m2 (maximum single dose 2 mg) IV bolus weekly for five weeks starting on day 2 and continuing on days 9, 16, 23 and 30. Daunorubicin: 25 mg/m2 IV over 1 hour on days 2, 9, 16, and 23. Pegylated L-asparaginase: (Oncaspar) 1000 iu/m2 IM, on day 4 and day 18. Intrathecal methotrexate: On days 1, 8 and 28 Dose by age: <2yrs: 8mg; 2yrs: 10mg; 3yrs or more: 12 mg. NB Patients who have CNS disease at presentation should receive weekly doses - see page 24. Do not schedule vincristine on the same day as the intrathecal methotrexate. 6-mercaptopurine: 60 mg/m2/day orally starting on day 29 (beginning week 5) (if neutrophils > 0.75 and platelets > 75) and continuing for five weeks in total (to end of week 9). Doses should be taken at least one hour after the evening meal without milk products. Do not increase dosage for ANC>2.0. Bone marrow: Check marrow status on days 8 and 29. Send Day 29 Marrow for MRD .
b)
c)
d)
e) f) g)
h)
i)
Patients with M3 marrow at day 29 are off protocol and should continue therapy on high risk arm of R3. Day 29 BM2, MRD High Risk and MRD indeterminate patients with slow early response at day 8 should change to regimen C at day 35.
20
CYP ALL j)
21
Co-trimoxazole (trimethoprim and sulphamethoxazole) This drug is given as PCP prophylaxis orally on 2 consecutive days throughout treatment from the start of induction. The dose is tabulated below. Please ensure separation of the days on which oral Methotrexate and Cotrimoxazole doses are given during maintenance courses. If a child remains cytopenic after being off chemotherapy for three weeks or more, then stop the co-trimoxazole. Reintroduce co-trimoxazole once both thiopurine and methotrexate are back at standard dose. If cytopenias recur once the co-trimoxazole is reintroduced, then it should be stopped for at least two months and an alternative form of prophylaxis used instead (see below). The alternative drug should then be continued for the duration of the antileukaemic therapy The maintenance of adequate doses of thiopurine and methotrexate should take precedence over continuing co-trimoxazole. If co-trimoxazole is stopped, however, it must be remembered that the child is at increased risk of PCP. Nebulised pentamidine or oral Dapsone are alternative drugs. Surface area 0.5-0.75 m2 0.76-1.0 m2 over 1.0 m2 Co-trimoxazole 240 mg bd 360 mg bd 480 mg bd Trimethoprim 40 mg bd 60 mg bd 80 mg bd Sulphamethoxazole 200 mg bd 300 mg bd 400 mg bd
See also appendix D for details of alternative PCP prophylaxis regimens. Permitted dose modifications for toxicity see Appendix E:
21
CYP ALL
22
Regimen B: Standard BFM Consolidation phase II (See flowchart 9.) This phase runs for 35 days from day 1 (beginning of week 6) to day 35 inclusive (end of week 10) i.e. 5 weeks. To be eligible to enter standard BFM consolidation, patients must be in remission, and have an ANC >0.75x109/L and platelets of >75x109/L. If the blood count has not recovered and marrow is hypocellular M1, delay the start of consolidation one week and repeat the bone marrow to confirm M1 status. Patients with refractory CNS disease at diagnosis will receive cranial irradiation during consolidation starting at day 36. a) Cyclophosphamide: 1,000 mg/m IV over 20-30 minutes on days 1 and 15. Give125mls/m2/hr of Dextrose/ Saline infusion for 30 minutes before cyclophosphamide and for 3.5 hours afterwards, i.e. 4 hours in total. Do not add potassium. Mesna is not needed. Cytarabine (ara-C): 75mg/m2/day by IV push or subcutaneously 16 doses in four pulses of 4 days each; days 2-5, 9-12, 16-19 and 23-26. 6-Mercaptopurine: Continue 6-mercaptopurine, 60mg/m2/day to Day 28 of standard BFM consolidation. (5 weeks in total from the start in week 5 of induction). Doses should be taken at least one hour after the evening meal without milk products. Do not increase dosage for ANC>2.0. Intrathecal methotrexate: once a week for three doses on days 1, 8 and 15. Dose by age: <2yrs: 8mg; 2yrs: 10mg; 3yrs or more: 12 mg. These doses are in line with CCG recommendations. There is no intravenous vincristine in this phase.
b)
c)
d)
22
CYP ALL
23
Regimen B: Interim maintenance I phase III (See flowchart 10.) This phase runs from day 1 (beginning of week 11) to day 56 inclusive (end of week 18) i.e. 8 weeks. Patients should have an ANC >0.75 x109/L and platelets of >75x109/L. a) Dexamethasone: 6 mg/m2/day orally, divided into twice daily doses each day on days 2-6 (week 11) and days 30-34 (week 15). Vincristine: 1.5 mg/m2 (maximum single dose 2 mg) IV on day 2 (week 11) and day 30 (week 15). 6-mercaptopurine: 75 mg/m2/day orally, daily on days 1-49 (weeks 11-17), but not days 50-56 (week 18). Doses should be taken at least one hour after the evening meal without milk products. Dose adjustments are described in Appendix C. The omission of 6-mercaptopurine for days 50-56 is in line with the relevant CCG protocol. Oral methotrexate 20 mg/m2 oral weekly during weeks beginning on days 8, 15, 22, 36, 43 and 50 as single dose taken with 6-mercaptopurine. Dose adjustments are described in Appendix C. Intrathecal methotrexate on days 1 and 29. Dose by age: <2yrs: 8mg; 2yrs: 10mg; 3yrs or more: 12 mg. Do not schedule vincristine on the same day as IT methotrexate.
b)
c)
d)
e)
23
CYP ALL
24
Regimen B: Delayed intensification I phase IV (See flowchart 11.) This phase runs from day 1 (beginning of week 19) to day 49 inclusive (end week 25) i.e. 7 weeks. Patients should have an ANC >0.75x109/L and platelets of >75x109/L. Once begun, therapy during weeks 19-22 is not interrupted for myelosuppression alone. Therapy due day 1 week 23 should be delayed until ANC >0.75x109/L and platelets of >75x109/L. and once begun should not be interrupted solely for myelosuppression. Any serious infection, such as Varicella, pneumocystis pneumonia, or neutropenia with fever, and presumed or proven infection, warrants chemotherapy interruption at any time during DI. Part 1; weeks 19 22: a) Dexamethasone 10 mg/m/day orally for 7 days on days 2-8 (week 19) and 16-22 (week 21). No taper. Divide into two daily doses, adjusted upward to nearest 0.25 mg, as tablet size dictates. (Liquid preparation is acceptable). b) Vincristine 1.5 mg/m (2.0 mg max) IV push on days 2 (week 19), 9 (week 20) and 16 (week 21). c) Doxorubicin (Adriamycin) 25 mg/m IV on days 2 (week 19), 9 (week 20) and 16 (week 21) given over a period of 1 hour. d) Pegylated L-Asparaginase: (Oncaspar) 1000 iu/m2 IM on day 4 (week 19)
e) Intrathecal methotrexate on day 1 (week 19). Dose by age: <2yrs: 8mg; 2yrs: 10mg; 3yrs or more: 12 mg. Do not schedule vincristine on the same day as intrathecal methotrexate. Part 2; weeks 23 25: f) Cyclophosphamide 1,000 mg/m IV over 20-30 min day 29 (week 23). Give 125mls/m2 /hr of Dextrose /Saline infusion for 30 minutes before the cyclophosphamide and for 3.5 hours afterwards, i.e. 4 hours in total. Do not add potassium. Mesna is not needed. g) Mercaptopurine. All patients receive MP 60 mg/m2/day during delayed intensification 1. The drug is given daily by mouth for 14 days from day 29 (beginning of week 23) to day 42 (end of week 24). No dose adjustments are made during this block. Doses should be taken at least one hour after the evening meal, without milk products. Cytarabine (ara-C). 75mg/m2/day by IV push or subcutaneously 8 doses in two pulses of 4 days each; days 30-33 (week 23) and days 37-40 (week 24). Intrathecal methotrexate. Days 29 (week 23) and 36 (week 24). Dose by age: <2yrs: 8mg; 2yrs: 10mg; 3yrs or more: 12 mg.
h)
i)
24
CYP ALL
25
Regimen B: Maintenance Phase V (See flowchart 14.) Maintenance begins from day 1 cycle 1 (beginning of week 26 ) in 12-week cycles to end of week 114 for girls and to the end of week 166 for boys. The cycle in progress is stopped when the end of therapy is reached. Omit the Vincristine and steroid pulse if it falls in the last week of therapy. This period of continuing treatment equates to 2 years from the start of interim maintenance I for girls and 3 years for boys. Maintenance should begin when the ANC is >0.75 x 109/l and the platelet count is >75 x 109/l. Only 6-mercaptopurine and oral methotrexate will be interrupted for myelosuppression and not made up. Days off therapy for intercurrent infections are counted as days of maintenance and not made up. Anaemia occurring in the course of maintenance therapy should be treated with transfusion and the dose of drug is maintained. If persistent anaemia occurs (i.e., haemoglobin below 8 g/dl) investigate for parvovirus infection. Please contact trial co-ordinators for advice. a) Dexamethasone: 6 mg/m2/day orally, divided into twice-daily doses on days 1-5, 29-33 and 57-61 of each cycle. Vincristine: 1.5 mg/m2 (maximum single dose 2 mg) IV on days 1, 29, and 57 of each cycle. 6-mercaptopurine: 75 mg/m2/day orally, daily throughout maintenance. Doses should be taken at least one hour after the evening meal without milk products. Dose adjustments are described in Appendix C. Oral methotrexate: 20 mg/m2 orally during weeks beginning on days 1, 8, 22, 29, 36, 43, 50, 57, 64, 71 and 78 of each cycle. Note none is given in the third week of each cycle as an intrathecal dose is given during that week. Dose adjustments are described in Appendix C. Intrathecal methotrexate: On day 15 of each cycle. Dose by age: <2yrs: 8mg; 2yrs: 10mg; 3yrs or more: 12 mg. Bone marrow examination should be carried out at the same time as the end of treatment intrathecal methotrexate. NB the end of treatment marrow should always be done BEFORE chemotherapy is stopped to prevent confusion due to rebound marrows.
b)
c)
d)
e)
f)
END OF REGIMEN B
25
CYP ALL 17. UKALL 2003 REGIMEN C. Eligibility.
26
To be eligible for regimen C, patients must either a) Be MRD High Risk or have BM2 marrow at day 29. b) Be Day 8/15 SER if MRD Indeterminate c) Have unfavourable cytogenetics.
High-risk cytogenetic features that mandate a switch to regimen C are hypodiploidy (<40chromosomes); BCR-ABL gene rearrangement; Amplified AML1 (iAMP21) or MLL gene rearrangement. No other cytogenetic features are eligible. These patients should switch to Regimen C at day 15 if on Regimen A and at day 35 if on Regimen B induction. Patients with M2 marrows at day 29 (blasts 5-25%) should continue with regimen C (augmented BFM consolidation) and should only be taken off protocol if they are not in remission at the end of consolidation.
26
CYP ALL Summary of Regimen C.
27
Regimen C consists of the following phases: 1. Completing a four drug induction with dexamethasone as steroid of choice; 2. Augmented BFM consolidation (duration 9 weeks); all patients receive 6 mercaptopurine; 3. Interim Capizzi maintenance I (duration 8 weeks) using Pegylated asparaginase and escalating doses of IV methotrexate; 4. Delayed intensification I (duration 8 weeks); 6-mercaptopurine in reconsolidation; Pegylated asparaginase; 5. Maintenance chemotherapy with dexamethasone and 6-mercaptopurine to the end of week 118 for girls and end of week 170 for boys. Delays accrued during phases I-VI are taken off the maintenance period. . Patients having a bone marrow transplant in first remission should receive Regimen C up to the beginning of week 14, i.e. to the beginning of Escalating Capizzi I, but should then be given standard maintenance chemotherapy until the time of their transplant. It is not necessary for them to have either the delayed intensification blocks, or the Capizzi maintenance prior to transplant.
MRD
Induction BFM consol + CNS. Capizzi IMI DI I CT girls week 118 boys week 170
1-5
6-14
15-22
23-30
31
27
CYP ALL
28
UKALL 2003 REGIMEN C: DETAILS OF TREATMENT. The convention for day/week numbering is that a new module of therapy begins on day 1 of whatever week of treatment has been reached. Induction begins on day 1 (week 1) of schedule A or B prior to transfer, consolidation on day 1 (week 6), and so on. Each module runs for a number of days and induction therefore finishes on day 35 (end of week 5), interim maintenance on day 56 (end of week 22) and delayed intensification on day 56 (end of week 30). Regimen C Phase 1: Remission induction- see flowchart 15a. Patients switching to this protocol from Regimen A at day 15 will have cytogenetically adverse features identified on the bone marrow sample taken at diagnosis. This phase runs for 21 days from day 15 (beginning of week 3) to day 35 inclusive (end of week 5) (i.e. 3 weeks in all). a) Dexamethasone: 6mg/m2/day (maximum dose 10 mg/day in induction only) for a total of 28 days from commencing regimen A which is then tapered over the next 7 days, i.e. to stop on day 35. The steroid should be divided into two doses per day. Vincristine: 1.5 mg/m2 (maximum single dose 2 mg) IV weekly on days 16, 23 and30. Daunorubicin: 45mg/m2 over 1 hour on days 16, and 23. Note that this dose is higher than that in regimen B and is for two doses only. Pegylated L-asparaginase: (Oncaspar) 1000 iu/m2 IM, on day 18). Intrathecal methotrexate : On day 28. Dose by age:<2yrs: 8mg; 2 yrs: 10mg; 3yrs or more: 12mg. NB Patients who have CNS disease at presentation should receive weekly doses until two clear CSF samples are obtained see page 24. Do not schedule vincristine on the same day as the intrathecal methotrexate. 6-mercaptopurine: 60mg/m2/day starting on day 29 (beginning week 5) (if neutrophils > 0.75 and platelets > 75) and continuing for three weeks (end of week 2 of Augmented BFM consolidation). Doses should be taken at least one hour after the evening meal without milk products. Do not increase dosage for ANC>2.0 Bone Marrow: Check marrow status at day 29 and send sample for MRD. Patients with persistent M3 marrow at day 29 are off protocol. Co-trimoxazole (trimethoprim and sulphamethoxazole). This drug is given as PCP prophylaxis orally on 2 consecutive days throughout treatment from the start of induction. See below for doses. Please ensure separation of the days on which oral Methotrexate and Cotrimoxazole doses are given during maintenance courses. If a child remains cytopenic after being off chemotherapy for three weeks or more, then stop the co-trimoxazole. Reintroduce co-trimoxazole once both thiopurine and methotrexate are back at standard dose. If cytopenias recur once the co-trimoxazole is reintroduced, then it should be stopped for at least two months and an alternative form of prophylaxis used instead (see below). The alternative drug should then be continued for the duration of the antileukaemic therapy The maintenance of adequate doses of thiopurine and methotrexate should take precedence over continuing co-trimoxazole. If co-trimoxazole is stopped, however, it must be remembered that the child is at increased risk of PCP. Nebulised pentamidine or oral Dapsone are alternative drugs. Surface area 0.5-0.75 m2 Co-trimoxazole 240 mg bd Trimethoprim 40 mg bd Sulphamethoxazole 200 mg bd
b) c) d) e)
f)
g) h)
28
CYP ALL 0.76-1.0 m2 over 1.0 m2 360 mg bd 480 mg bd
29 60 mg bd 80 mg bd
Interim Guidelinev3 July 2011 300 mg bd 400 mg bd
See also appendix D for details of alternative PCP prophylaxis regimens. Permitted dose modifications for toxicity see Appendix E.
29
CYP ALL
30
Regimen C: Consolidation - Augmented BFM - phase II see flowchart 16 Patients on regimens A or B who are MRD high risk at day 29 should switch to Regimen C from day 35. Patients who have already switched to regimen C due to adverse cytogenetics continue with augmented BFM consolidation. Patients with refractory CNS disease at diagnosis will receive cranial irradiation during augmented BFM, starting at day 36 This phase runs from day 1 (beginning of week 6) to day 63 inclusive (end of week 14) i.e. 9 weeks. The block of treatment should be started at day 36 from diagnosis (week 6), or when the peripheral blood count recovers to an absolute neutrophil count (ANC) of >0.75x109/L and platelets of >75x109/L. Once consolidation has begun it can be interrupted for myelosuppression (ANC<0.75x109/l or platelets <75x109/l) at day 29, but once the cyclophosphamide has been given at day 1or 29, therapy should continue, except in patients who are febrile and proven to have infection (i.e. do not stop because of neutropenia alone). Treatment should restart when signs of infection have abated. Cyclophosphamide: 1000 mg/m2 IV over 20-30 minutes on days 1 and 29. Give 125mls/m2 /hr of Dextrose /Saline infusion for 30 minutes before the cyclophosphamide and for 3.5 hours afterwards, i.e. 4 hours in total. Do not add potassium. Mesna is not needed. Cytarabine: 75mg/m2 IV or SC - 16 doses in four pulses of 4 days each; days 2-5, 9-12, 30-33 and 37-40 6-Mercaptopurine: All patients receive 6-mercaptopurine 60mg/m2, PO, for 21 days, beginning week 5 of induction to end week 2 consolidation, and for 14 days on days 29-42 of consolidation. Mercaptopurine should be taken at least half an hour after evening meal,. Do not increase dose for neutrophils > 2.0. Vincristine: 1.5 mg/m2 IV (maximum of 2 mg) on day 16, 23, 44 and 51. PEG-Asparaginase (Oncaspar): 1000 units/m2 IM on days 16 and 44 Intrathecal methotrexate: On days 1, 8 and 15. The dose is related to CSF volume as follows: 1-2 years: 8mg; 2-3 years: 10mg; over 3 years: 12 mg. Do not schedule vincristine on the same day as IT methotrexate. Bone marrow aspirate on day 1 of Capizzi Interim Maintenance. Patients with M2 marrows at the end of augmented BFM are off protocol.
a)
a)
b)
c) d) e)
f)
30
CYP ALL
31
Regimen C: Escalating Capizzi Maintenance Phase III see flowchart 17. This block of treatment should start at day 1 (beginning of week 15), or when blood count recovers to ANC >0.75x109/L and platelets of >75x109/L, and lasts until day 56 inclusive (end of week 22) i.e. for 8 weeks. During phase III, therapy should be interrupted for serious infection such as Varicella or pneumocystis. Day 42 will be the last day of treatment in phase III, regardless of the number of methotrexate doses that have been omitted. The timings of administration of the drugs are important; do not reschedule any of the components. About 10-15% of patients are able to escalate the methotrexate dose to the maximum of 300mg/m2. About 30-40% are able to make some escalation. The major toxicity is likely to be mucositis. The full toxicity grading is included in the section on toxicity assessment and reporting. Start Capizzi I at a methotrexate dose of 100mg/m2. Increase the dose for each subsequent course by 50mg/m2, as tolerated, to a maximum dose, in Capizzi I, of 300mg/m2. Prior to each course the patient will need to be assessed for oral, haematological, hepatic and renal toxicity, and the dosage modified as outlined below. Doses of vincristine and PEGasparaginase should only be omitted for serious intercurrent illness. Oral : For grade 2 mucositis of over 3 days duration, decrease IV MTX dose by 30%. For grade 3-4, mucositis, withhold IV MTX until resolved; resume at 50% of the previously attained dose and subsequently escalate to 75% to 100% dose at 10 day intervals provided grade 3-4 toxicity does not recur. Consider culturing lesions for herpes simplex if mucositis persists or recurs. Haematological: omit methotrexate if ANC<0.75x109/L or platelets <75x109/L; it should be reinstituted on the first due date following the omitted dose when ANC>0.75x109/L and platelets >75x109/L, and the dosage should be decreased by 20% from the previously administered dose. Missed doses will not be made up. If counts do not recover within 21 days, check bone marrow status. Liver Dysfunction: If bilirubin is >50 micromoles/L omit IV MTX until it is less than 20 micromoles/L, and then restart at half of the previously attained dose. Escalate from 50% to 75% to 100% dose at 10-day intervals provided hyperbilirubinaemia does not recur. Do not modify dosage for elevated aminotransferases. Kidney Dysfunction (Grade 3-4): Omit IV MTX until grade 0 toxicity (i.e. completely resolved). Resume at 100% of the previously attained dose and continue at 10-day intervals. (a) Vincristine: 1.5 mg/m2 IV (maximum 2 mg) as a single dose on day 2, 12, 22, 32, and 42. Methotrexate: 100mg/m2 IV over 10-15 minutes as initial dose on day 2. Escalate subsequent doses by 50mg/m2 to toxicity and modify dosage as necessary according to the above guidelines on days 12, 22, 32 and 42. PEG asparaginase(Oncaspar): 1000 units/m2 IM on days 3 and 23. Intrathecal methotrexate: on day 1 and 31. Dose by age: <2yrs: 8mg; 2yrs: 10mg; 3yrs or more: 12 mg. Do not schedule vincristine on same day as IT methotrexate.
(b)
(c) (d)
31
CYP ALL
32
Regimen C: Delayed intensification (Phase IV) see flowchart 18. This phase consists of reinduction and reconsolidation. For all patients in remission at the completion of phase III, phase IV begins on day 57 of phase III, day 1(beginning of week 23) or when ANC >0.75x109/L and platelets of >75x109/L, whichever occurs later, and lasts until day 56 inclusive (end of week 30) i.e. 8 weeks. Once started, reinduction and reconsolidation are not interrupted for myelosuppression alone. Reconsolidation is scheduled to begin on day 29, but should be delayed until ANC >0.75x109/L and platelets >75x109/L. Treatment may be interrupted for serious infection such as Varicella, pneumocystis, or proven infection with neutropenia with fever. Bone marrows, which may be indicated because of persistent cytopenias, are often difficult to interpret in this phase. Pancytopenia is inevitable and M2 recovery marrows are common. Note that delayed intensification in regimen C includes PEG asparaginase and additional doses of vincristine in the reconsolidation phase. Reinduction (weeks 23-26) (a) Vincristine: 1.5 mg/m2 IV (maximum 2 mg) on days 2, 9 and 16. (b) (c) (d) Doxorubicin: 25mg/m2 IV over 1 hour on days 2, 9 and 16. Dexamethasone 10mg/m2/day divided into two doses on days 2-8 and 16-22. Intrathecal methotrexate on day 1. Dose by age: <2yrs: 8mg; 2yrs: 10mg; 3yrs or more: 12 mg. Do not schedule vincristine on the same day as IT methotrexate. PEG asparaginase(Oncaspar): 1000 units/m2 IM on day 4.
(e)
Reconsolidation (weeks 27-30) a) Cyclophosphamide 1000 mg/m2 IV over 20-30 minutes on day 29. Give 125mls/m2 /hr of Dextrose /Saline infusion for 30 minutes before the cyclophosphamide and for 3.5 hours afterwards, i.e. 4 hours in total. Do not add potassium. Mesna is not needed. b) Mercaptopurine. All patients receive MP 60 mg/m2/day during delayed intensification 1. The drug is given daily by mouth for 14 days from day 29 (beginning of week 27) to day 42 (end of week 28). No dose adjustments are made during this block. Doses should be taken at least one hour after the evening meal, without milk products. c) Cytarabine 75mg/m2 IV or SC on days 30-33 (four doses) and 37-40 (four doses). d) Vincristine 1.5mg/m2 IV on days 43 and 50. e) PEG asparaginase(Oncaspar) 1000 units/m2 IM on day 43. f) Intrathecal methotrexate on days 29 and 36. Dose by age: <2yrs: 8mg; 2yrs: 10mg; 3yrs or more: 12 mg.
32
CYP ALL
33
Regimen C: Maintenance. (See flowchart 21.) This phase runs from day 1 cycle 1 (week 31) in 12-week cycles to end of week 118 for girls, and end of week 170 for boys. The cycle in progress is stopped when the end of therapy is reached. This equates to 2 years from the start of interim maintenance I for girls and 3 years for boys. Maintenance should begin when the ANC is >0.75 x 109/l and the platelet count is >75 x 109/l. Only 6-mercaptopurine and oral methotrexate will be interrupted for myelosuppression and not made up. Days off therapy for intercurrent infections are counted as days of maintenance and not made up. Anaemia occurring in the course of maintenance therapy should be treated with transfusion and the dose of drug is maintained. If persistent anaemia occurs (i.e., haemoglobin below 8 g/dl) investigate for parvovirus infection. Please contact trial co-ordinators for advice. a) Dexamethasone: 6 mg/m2/day orally, divided into twice daily doses on days 1-5, 29-33 And 57-61 of each cycle. Vincristine: 1.5mg/m2 (maximum single dose 2 mg)IV on days 1, 29, and 57 of each cycle. 6-mercaptopurine: 75 mg/m2/day orally daily throughout maintenance. Dose adjustments are described in Appendix C. Methotrexate 20 mg/m2 orally during weeks beginning days 1, 8, 22, 29, 36, 43, 50, 57, 64, 71 and 78 of each cycle. Note none is given in the third week of each cycle as an intrathecal dose is given during that week. Dose adjustments are described Appendix C. Intrathecal methotrexate given on day 15 of each cycle. On the final cycle, girls on cycle 6 can be given IT MTX either at day 15 or day 77 with the end of treatment BM, while boys will have their final dose on day 15 cycle 11. Dose is by age: 1-2 years: 8mg; 2-3 years: 10mg; over 3 years: 12 mg
b)
c)
d)
e)
Bone marrow examination should be carried out at same time as the end of treatment intrathecal methotrexate. NB the end of treatment marrow should always be done BEFORE chemotherapy is stopped to prevent confusion due to rebound marrows. Treatment ends on the due date, whether or not a cycle is complete. Patients should have a final bone marrow aspirate and diagnostic lumbar puncture to confirm complete remission. All therapy, including prophylactic Septrin, should then stop.
END OF REGIMEN C
33
CYP ALL
34
APPENDIX A
Determining weight for dosage calculations
All children should be weighed in underclothes and scales should be calibrated regularly. To ensure that children are treated effectively, without overdosing due to treatment related fat deposition, the Body mass index (BMI) should be checked at diagnosis, at the end of the 2nd delayed intensification and at 1 year and 2 years from diagnosis. Calculate using the formula BMI= weight(kg)/Height 2 (m x m) The BMI can then be compared to the standard Child Growth foundation BMI charts* for the appropriate sex. For children with a BMI that falls within the 2nd-98th percentiles, dose by actual weight using the UKCCSG weight/surface area (SA) charts to determine the surface area (SA) for dose calculation. These weights should be taken -At diagnosis -Immediately prior to each delayed intensification -At the time of the intrathecal injection on each maintenance cycle For children who have a BMI > 98th percentile read off the BMI at 98th percentile for their age. Calculate the dosing weight using the formula Dosing weight (kg) = BMI x Ht2 (m x m) Use the UKCCSG Wt/SA charts to determine the SA for dose calculation. For children < 2nd percentile, repeat as above reading the BMI at the 2nd percentile for calculation. For children who have considerable weight loss due to illness during treatment it may be necessary to re- assess their BMI and dosing weight prior to recommencing treatment. Rationale for frequency of weighing for determination of changes in drug dosage. A normal child aged 2-10 years gains only 2-6kg/year1. This equates to an average of 1kg every 3 months (maximum 1.5kg). If children are weighed fully clothed rather than in underclothes, the extra weight will be greater than the quarterly change in weight. Scales, even regularly calibrated, also carry a measurement error. These errors, coupled with weight variation due to physical, endocrine, nutritional, and psychosocial effects make repeated measurements inaccurate2. Children having repeat doses of steroids will have greater than average weight gain, but this is primarily deposited as fat- particularly truncal fat3. Unless drug treatment is with very lipophilic drugs the weight gain should not affect the therapeutic doses required to treat ALL. Only Daunorubicin, doxorubicin and vincristine have longer T1/2 and larger volume of
34
CYP ALL
35
distribution, indicating major transfer to body compartments other than the blood. Both anthracyclines are ionic compounds and they and their active metabolites are highly protein bound, which would suggest less deposit into fat than into lean mass. Vincristine is highly water soluble and readily distributed into tissues. As it is predominantly renally excreted it is again unlikely that it is highly deposited in fat4. Do not adjust doses on the basis of weight change any more frequently than every 3 months. In practice the changes should equate to: Prior to induction Pre- 1st Delayed intensification Pre-2nd Delayed intensification Prior to starting each cycle of maintenance. The UKCCSG Surface area charts have been validated for children with an understanding that they are less accurate at the extremes of obesity and underweight. There is no defined cut off. There is no defined BMI for obesity in children, but children with BMI > 98th percentile for age have been shown to have an increased risk of related morbidity in adult life5. The Child growth foundation BMI charts for boys and girls mark the 9th and 98th percentiles so it would logical to use these cut off points Doses have traditionally been based on total weight rather than lean weight, so to change to lean body weight dosing could result in under-treatment. Dexamethasone is likely to cause greater weight gain than prednisolone1. This may be compounded by the secular changes in UK society. It would therefore seem prudent to have a defined maximum BMI percentile, for dosing; weight percentiles taking no account of tall or small stature children. References 1. Clinical Paediatric endocrinology. Brook and Hindmarsh. 2. Short term growth: rhythms, chaos or noise? Wales J et al Archives Dis Child 1994 71: 84-89 3. Bodyweight change as an adverse effect of drug treatment- Mechanisms and management Pijl H et al Drug Safety 1996 14(5); 329-42 4. Micromedex Drug database September 2004 5. Use of weight for height indices in children to predict adult overweight: the Bogalusa Heart Study Int J Obesity 1996 21:715-21
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APPENDIX B
General drug information
ALL DRUGS ARE USED WITHIN THE TREATMENT REGIMENS ARE STANDARD THERAPY FOR ALL AND ARE THEREFORE NOT DEFINED AS INVESTIGATIVE MEDICINES. THE SOURCE OF SUPPLY IS AT THE DISCRETION OF THE PRESCRIBER/PHARMACIST BUT ENSURING EQUIVALENCE AND MAINTENANCE OF GMP STANDARDS OF MEDICINES TO THOSE USED WITHIN THE COMPETED ALL 2003 CLINICAL TRIAL IS RECOMMENDED.
Risks of chemotherapy for females of child bearing potential All chemotherapy agents can cause harm to the fetus and may be excreted in breast milk. Therefore, females of child bearing potential should be counselled about this risk and asked to adopt appropriate measures to prevent pregnancy whilst on treatment with this protocol. 1) PREDNISOLONE To be used only for patients who experience serious dexamethasone toxicity. Please specify clearly on the prescription charts that prednisolone and not prednisone is to be used and that tablets must not be enteric coated. Formulation 1 mg, 5mg and 25 mg (scored ordinary and scored soluble) tablets available. Dose 40 mg/m2 po daily in place of dexamethasone Storage At room temperature. Administration 40 mg/m2 orally daily in two divided doses, with or after food. Toxicity Obesity, hirsutism, fluid and salt retention, hypertension, irritability, glycosuria, avascular necrosis of bone and hyperglycaemia. 2) DEXAMETHASONE Formulation Storage Administration 0.5 mg, 2 mg tablets, oral solution 2mg/5ml (licensed formulation). At room temperature. 6 mg/m2 (during induction, interim maintenance and maintenance phases, 10 mg/m2 during intensification) orally daily in two divided doses. Dose is capped at 10 mg/day during induction. As for prednisolone, with or after food.
Toxicity
3) VINCRISTINE SULPHATE Formulation Storage Administration 1mg/ml injection solution. At 2-8C in refrigerator. 1.5mg/m2 by bolus intravenous injection. Ensure that the needle is well into the vein and avoid extravasation. Children >10 years must have vincristine diluted to 0.1mg/ml unless the centre has signed a waiver with local PCT. Local necrosis if extravasation occurs. Jaw pain, paresis, constipation,
Toxicity
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37 systemic neurotoxicity and alopecia.
NB. Vincristine, given by the wrong route of administration, causes ascending myelitis, excruciating pain, paralysis and death, given into the CSF. The drug should not be drawn up or available in the same room to anyone performing a lumbar puncture.
4) DOXORUBICIN (ADRIAMYCIN) Formulation Storage Mixing Stability Administration 2mg/ml Red solutions in 10, 20 or 50 mg vials, or 10 or 50 mg vials of freeze dried powder. Refrigerated at 2-80C. Protect from light. Dissolve powder in sodium chloride for injection to give concentration of 2mg/ml. Depends on formulation/concentration 25 mg/m2 diluted in 0.9% saline and given IV slowly over 1 hr, or in young adults as a slow bolus alongside a fast running fluid infusion. NB avoid extravasation. Protect from light Local necrosis if extravasation occurs. Myelosuppression, alopecia, cardiotoxicity. Small risk of secondary AML.
Toxicity
5) DAUNORUBICIN Formulation Red lyophilised powder for intravenous administration following addition of sterile water for injections. Each vial contains 20mg of daunorubicin base. Protected from light at less than 25 degrees C. After reconstitution at 2-8 degrees C protected from light. Dissolve powder in 4mls of water for injection to give concentration of 5mg/ml. Concentration dependent. 25-45mg/m2 diluted in 0.9% saline or dextrose saline and given IV slowly over 1 hr, or in young adults as a slow bolus alongside a fast running fluid infusion. NB avoid extravasation Local necrosis if extravasation occurs. Myelosuppression, mucositis, alopecia, cardiotoxicity. Small risk of secondary AML.
Storage Mixing Stability Administration
Toxicity
6) ERWINASE- Only for use in patients with allergy to E-coli Asparaginase. Formulation Crisantaspase (Asparaginase from Erwinia chrysanthemi; Erwinia Lasparaginase), 10,000 Units/vial. Freeze-dried powder for reconstitution. Store between +2C and +8C. Reconstitute contents of each vial in 1 ml of Sodium Chloride for Injection BP and dissolved by gentle mixing. Administer within 15 minutes of reconstitution or within 8 hours in a latex free syringe, if aseptically prepared. 20000u/m2 by intramuscular or subcutaneous injection. (see appendix
Storage Mixing Stability Administration F)
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38
Hypersensitivity including anaphylaxis. Patients with systemic reactions should not be re-exposed to Erwinase. Acute pancreatitis; hyperglycaemia; liver dysfunction and coagulopathy.
7) METHOTREXATE a) MTX Injection (YELLOW LIQUID) Formulation Ready mixed vials in the following strengths: 2.5 mg in 1 ml, 25mg/ml, 100mg/ml in various vial sizes. NB Check label carefully before administration. These vials contain sodium chloride and sodium hydroxide adjusted to a pH of 8.5; there is no preservative present. Stability After the vial has been used, discard remaining contents as there is no preservative, unless prepared in an aseptic facility. Administration Variable, as per protocol. 100mg/ml strength is hypertonic- dilute before administration. Administer intrathecal doses at a concentration of not more than 2.5mg/ml. Toxicity Neurotoxicity, mucositis, liver dysfunction, bone marrow depression. b) MTX for oral use Formulation Storage Stability Administration Toxicity 2.5 mg and 10 mg scored tablets, 10mg/5ml suspension. At room temperature in a dark place. Please note the expiry date. 20 mg/m2 orally weekly all tablets taken together. Omit dose in the week of IT methotrexate. As for the injectable form.
8) MERCAPTOPURINE Formulation Storage Stability Administration 10 and 50 mg scored tablets, 100mg/5ml suspension At room temperature Please note expiry date 75 mg/m2 (titratable) in regimen A and B IM 1 and 2, maintenance (all regimens) and 60 mg/m2 (non-titratable) in regimen B and C consolidation. Doses to be taken once a day one hour after food in the evening. Toxicity Bone marrow depression, liver dysfunction NB Do not give allopurinol when the patient is on mercaptopurine as allopurinol blocks the major catabolic pathway of mercaptopurine. 9) CO-TRIMOXAZOLE Formulation Paediatric suspension: 40 mg trimethoprim + 200 mg sulphamethoxazole BP in each 5 ml. . Tablets: 80 mg trimethorprim BP and 400 mg sulphamethoxazole. Storage At room temperature. Stability Please note expiry date. Administration .Twice daily on 2 consecutive days each week. See main protocol.
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39
Marrow depression in some cases. Hypersensitivity to sulphonamide
Vials containing freeze-dried powder of 100 mg cytarabine. Injection solution 100mg/5ml At room temperature. With supplied diluent as recommended. 48 hours at room temperature. By direct iv injection (slow bolus) 75 mg/m2 daily. Bone marrow suppression, nausea, vomiting, oral ulceration, fever and arthralgia.
NB Intrathecal (if substituted for Methotrexate): Only preservative free cytarabine 20mg/ml (NOT Depocyte/liposomal cytarabine) should be given. The dose is 20mg <2yrs, 25mg 2-3 years and 30mg >3yrs. Rare side effects include aseptic meningitis and myelitis. Solution reconstituted with preservative free saline should be discarded after 8 hours if not used. 11) CYCLOPHOSPHAMIDE 200 mg, 500 mg and 1 G vials for reconstitution. At room temperature. 1000mg/m2 IV bolus or infusion with a minimum 4 hours of iv Myelosuppression, alopecia, cystitis, vomiting.
Formulation Storage Administration hydration. Toxicity
12) PEG ASPARAGINASE (MEDAC - ONCOSPAR) PEG asparaginase dose 1000 units/m2 if SA>0.6 m2 IM, NOT SUBCUTANEOUSLY. Formulation 3,750 units per 5ml vial. DO NOT SHAKE Storage At 2-8C in refrigerator. Administration By intramuscular injection. No more than 2 mls in any one site. Side-Effects Anaphylaxis, coagulopathy, pancreatitis, liver dysfunction Precautions The drug is given while there may be thrombocytopenia. Platelets may be necessary to cover the injection, but if it is given with extra local pressure they may not be needed. Note. Pegylated asparaginase has different pharmacokinetics dependent on the asparaginase and the pegylation process. Oncaspar (imported through UDG) is recommended
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APPENDIX C.
Mercaptopurine and methotrexate dose alterations
Only MP and MTX will be interrupted for myelosuppression. The omitted doses will not be made up. The oral doses of MP and MTX should be adjusted to maintain ANC between 0.75 and 1.5 x 109/l and platelets between 75 and 150 x 109/l. TPMT Genotype and Thiopurine Dose Adjustment Blood samples (5 ml lithium heparin) should be taken at diagnosis and at a convenient point from the end of week 10 to 15 (reg A), 14 to 17 (reg B) and at the end of week 11 and any time after week 49 for reg C. Forward to: Dr Lynne Lennard, Clinical Pharmacology, Floor M, Room M126, Royal Hallamshire Hospital, Sheffield, S10 2JF. The wild-type allele gives a high TPMT activity (H) and the variant allele a low activity (L). Results will be reported as Low/Low (L/L), High/Low (H/L) and High/High (H/H). Unless the analysis is suggestive of L/L genotype, the report will be issued after the analysis of the second sample. Low/Low genotype patients should start mercaptopurine at 10% dose (7.5 mg/m2/day) in Consolidation/Interim Maintenance I and adjust by monthly 10% increments to maintain ANC > 0.5 x 109/l and platelets > 50 x 109/l. Interim Maintenance II and continuing maintenance therapy starting dose should be the same as the dose tolerated at end of Interim Maintenance I. These patients should also receive only 10% (6 mg/m2) dose of mercaptopurine during Delayed Intensifications. For the purpose of thiopurine dose adjustment, patients with H/L and H/H genotypes will be categorised as non-variant genotype and treated the same:
Adjustment of mercaptopurine and methotrexate during consolidation in regimen A and interim maintenance I and II in regimens A and B. Note: MP dose during Regimen B and C consolidation is not count dependent and these rules do not apply.
Start at 100% MP (75 mg/m2/day) and MTX (20 mg/m2/week) and do not escalate. Follow dose reduction guidelines as described below. Escalation of mercaptopurine and methotrexate during continuing maintenance therapy in all Regimens. The aim is to adjust doses to maintain the ANC between 0.75 and 1.5 x 109/l and the platelet count between 75 and 150 x 109/l. If the ANC was > 1.5 x 109/l and platelets > 150 x 109/l throughout IMI and II, the dose of mercaptopurine should be escalated by 25% (from 75mg/m2/day) at the start of continuing maintenance therapy. If the subsequent monthly ANC is: 1) ANC > 1.5 x 109/l (and platelets > 150 x 109/l), keep mercaptopurine at the 125% dose and increase methotrexate by 25% to 25 mg/m2/dose. 2) Continue to increase the mercaptopurine and methotrexate dose in 25% steps alternately every eight weeks as outlined above if ANC > 1.5 x 109/l and platelets > 150 x 109/l persists. There are no maximum doses for mercaptopurine and methotrexate.
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Reductions of mercaptopurine and methotrexate during regimen A consolidation, interim maintenance in regimens A and B and continuing maintenance in regimens A, B and C: i) If the neutrophil count falls to between 0.5 and 0.75 x 109/l HALVE the dose of mercaptopurine and methotrexate: if < 0.5 x 109/l, STOP mercaptopurine and methotrexate. ONLY RESTART when the count is over 0.75 x 109/l. Restart at 100% of protocol dose (not dose at which counts fell) when neuts > 0.75 x 109/l. ii) The same dose modifications apply to falling platelet counts. If the count is less than 75 but more than 50 x 109/l HALVE dose as (i) above; if less than 50 x 109/l, STOP mercaptopurine and methotrexate. REINTRODUCE as above when the count is greater than 75 x 109/l. iii) If counts seesaw wildly when restarting @ 100% dose after cytopenias, starting at 50% and titrating upwards is permissible to avoid frequent interruptions to mercaptopurine exposure. (This manoeuvre is not often necessary). NOTE: Tolerance of 150% or more of the target protocol mercaptopurine dose for prolonged periods may be indicative of partial or non-compliance, and is potentially dangerous if the patient suddenly starts to comply fully. Metabolite assays in such circumstances can be helpful to exclude non-compliance and can be arranged with Dr. Lennard (contact address on p.68). Rare individuals (1 in 300) taking thiopurine who are congenitally lacking intracellular TPMT will show profound myelosuppression at standard dose. These patients will be identified prospectively at the time of diagnosis, and advice on dosing will be given by the trial co-ordinators.
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42 Thumb rules for maintenance Dose Reduction If ANC <0.5 or platelets <50
Stop both thiopurines and oral methotrexate
Weekly FBC When ANC>0.75 and platelets >75, restart at 100% of protocol (NOT TOLERATED) dose
If ANC >0.5 <0.75 or platelets >50 <75 Reduce dose of both thiopurines and methotrexate to 50% of protocol (NOT TOLERATED) dose
Weekly FBC ANC>0.75 and platelets >75
Increase dose to 100% Dose Escalation If ANC>1.5 and platelets >150 throughout previous eight weeks
Increase the mercaptopurine dose by 25%
If ANC>1.5 and platelets >150throughout the 4 weeks following mercaptopurine dose escalation, increase MTX dose by 25%
Repeat above MP/MTX 25% dose escalation in alternating eight week cycles if ANC >1.5and platelets >150
(see protocol guidance for those with persistent neutropenia or those with wildly see-sawing counts)
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APPENDIX D
Pneumocystis Carinii Pneumonitis (PCP) Prophylaxis
Co-trimoxazole (trimethoprim and sulphamethoxazole) This drug is given as PCP prophylaxis orally on 2 consecutive days throughout treatment from the start of induction. This dosage is lower than that recommended in previous studies, but has been found to be equally effective in CCG studies. The dose is tabulated below. Please ensure separation of the days on which oral Methotrexate and Cotrimoxazole doses are given during maintenance courses. If a child remains cytopenic after being off chemotherapy for three weeks or more, then stop the co-trimoxazole. Reintroduce co-trimoxazole once both thiopurine and methotrexate are back at standard dose. If cytopenias recur once the cotrimoxazole is reintroduced, then it should be stopped for at least two months and an alternative form of prophylaxis used instead (see below). The alternative drug should then be continued for the duration of the antileukaemic therapy. The maintenance of adequate doses of thiopurine and methotrexate should take precedence over continuing co-trimoxazole. If co-trimoxazole is stopped, however, it must be remembered that the child is at increased risk of PCP. Nebulised pentamidine or oral Dapsone are alternative drugs. Surface area 0.5-0.75 m2 0.76-1.0 m2 over 1.0 m2 Co-trimoxazole 240 mg bd 360 mg bd 480 mg bd Trimethoprim 40 mg bd 60 mg bd 80 mg bd Sulphamethoxazole 200 mg bd 300 mg bd 400 mg bd
Alterative PCP Prophylaxis If a child must stop cotrimoxazole because of repeated cytopenias or other inability to tolerate it, PCP prophylaxis should continue with one of the alternative drugs. Data from HIV populations suggests that Dapsone is a more effective choice than nebulised Pentamidine or Atovaquone. Dapsone 2mg/kg (maximum dose 100mg) once daily or 4mg/kg weekly (maximum dose 200mg), orally is recommended as the alternative agent in patients who cannot tolerate cotrimoxazole. Side effects of dapsone include fever, rash, and haemolytic anaemia. G6PD qualitative assay should be performed before starting dapsone therapy. For patients who cannot tolerate dapsone, nebulised pentamidine or atovaquone is recommended. Nebulised Pentamidine 300 mg per month is given by nebuliser, using 6 ml sterile water delivered at 6 L/min until the reservoir is dry, usually over 45 minutes. Atovaquone is given at a dose of 30mg/kg for children orally once a day with food. Side effects include gastrointestinal intolerance, rash, headache, and fever. Pentamidine 4mg/kg IV every 2-4 weeks could be used if none of the other alternatives are suitable.
Table 1. Comparison of PCP Prophylaxis Regimens Issue CoTMox Dapsone NP Atovaquone high moderate moderate moderate moderate low yes no low-moderate low ? no high high no yes low very high no no
Efficacy
Toxicity Cost Bacterial infection protection Risk of extrapulmonary pneumocystosis
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APPENDIX E
DOSE MODIFICATIONS FOR TOXICITY Steroids Hypertension: Steroid should not be reduced. Sodium restriction and anti-hypertensives should be employed in an effort to control hypertension. Malignant Hypertension: Reduce dose 33%. Sodium restriction and antihypertensive drugs may also be utilized. Hyperglycemia: Steroids should not be reduced if the patient develops clinical signs of diabetes. Rather, insulin therapy should be employed to control the blood glucose level such that symptoms and signs are minimal. Pancreatitis: Do not modify dose. Psychosis: Administer half dosage of steroid. Suspected steroid-induced myopathy: Measure CPK with isoenzymes, consider EMG studies Avascular necrosis: Contact Trial Coordinators if AVN develops before Maintenance therapy has begun. Omit further steroids if AVN develops during maintenance. Varicella Zoster: Steroids should be held during active infection except during Induction (Discuss with co-ordinators). They should not be held during incubation period following exposure to varicella. Severe dexamethasone intolerance - change to Prednisolone 40 mg/m2. Vincristine (See also drug interactions Appendix K) Seizures: Hold 1 dose, then reinstitute. Severe foot drop, paresis or ileus: Hold dose(s); institute aggressive regimen to treat constipation (except enemas if neutropenic), if present. When symptoms abate, resume at 1.0 mg/m; escalate to full dose as tolerated. Jaw pain: Treat with analgesics; do not modify vincristine dose. Hyperbilirubinemia: Check LFTs only if patient jaundiced. Withhold if total bilirubin > 50. Administer 50% of dose if total bilirubin 25 - 50. Do not alter dose for abnormal transaminases. Asparaginase Anaphylaxis
PEG-asparaginase should be discontinued if the patient develops a Grade 2 4 toxicity (see toxicity criteria Appendix F p69 - allergy). Send blood samples to Professor Tim Edens laboratory (see
or anaphylactoid reactions: Appendix M) for asparaginase antibodies and change to Erwinase (see Appendix ). Symptomatic pancreatitis: Discontinue L-asparaginase in the presence of symptomatic pancreatitis documented by an elevated serum amylase or lipase level or ultrasonographic abnormalities. Do not give further doses if there is a prior history of asparaginase induced pancreatitis. Hyperglycemia: Do not modify dose. Administer Insulin as required. Ketoacidosis: Hold L-Asparaginase until blood glucose can be regulated with insulin. Coagulopathy When significant symptomatic coagulopathy occurs, withhold L-asparaginase until resolved. Routine clotting screens are not recommended. Coagulopathy without bleeding is not an indication to withhold L-asparaginase. Management of Asparaginase associated thrombosis is described in Appendix - . Liver Dysfunction: Check LFTs only if patient jaundiced. Withhold if total bilirubin > 50. Do not alter dose for abnormal transaminases.
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Anthracyclines (Doxorubicin and Daunorubicin) Hyperbilirubinemia: If total bilirubin > 120 omit dose; if > 90 but 120 give 25% of dose. If > 50 but 90 give 50% of dose, and if 50 give full dose. Check LFTs only if patient jaundiced. Do not alter dose for abnormal transaminases. Intrathecal Methotrexate Any significant neurotoxicity not due to lumbar puncture syndrome (low opening pressure, slow CSF flow, orthostatic symptoms) should be reported. Systemic toxicity: The dosage for IT methotrexate will not be reduced for systemic toxicity (myelosuppression, mucositis, etc.). Viral, bacterial, or fungal meningitis: Omit until resolved. Encephalopathy attributed to intrathecal methotrexate: See appendix . Oral and Intravenous Methotrexate Mucositis : For grade 2 mucositis of over 3 days duration, decrease MTX dose by 30%. For grade 3-4, mucositis, withhold MTX until resolved; resume at 50% of the previously attained dose and subsequently escalate to 75% to 100% dose at 10 day intervals provided grade 3-4 toxicity does not recur. Consider culturing lesions for herpes simplex if mucositis persists or recurs. Liver: Check LFTs only if patient jaundiced. If bilirubin is >50 micromoles/L omit MTX until it is less than 20 micromoles/L, and then restart at half of the previously attained dose. Escalate from 50% to 75% to 100% dose at 10-day intervals provided hyperbilirubinaemia does not recur. Do not modify dosage for elevated aminotransferases. Kidney (Grade 3-4): Omit MTX until grade 0 toxicity (i.e. completely resolved). Resume at 100% of the previously attained dose and continue at 10-day intervals. Cyclophosphamide Prior history of gross haematuria or microscopic haematuria: Hydrate at 125 ml/m/hr for 24 hours after dose and use Mesna 360 mg/m pre, and 4, 7, 11 hours post dose. Acute fluid retention: Treat with frusemide and saline; do not modify dose. Cytarabine Hyperbilirubinaemia: If total bilirubin > 120 omit dose; if > 90 but 120 give 25% of dose. If > 50 but 90 give 50% of dose, and if 50 give full dose. Check LFTs only if patient jaundiced. Do not alter dose for abnormal transaminases.
Mercaptopurine Hyperbilirubinaemia and Mucositis: As for oral MTX.
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Downs Syndrome Treatment Recommendations Background In ALL 97, Downs Syndrome (DS) patients had a significantly worse EFS compared to nonDS patients (48% vs 78%) primarily because of a higher risk of CR death (28% vs <5%) due to sepsis. The majority of deaths occurred in consolidation and DIs. The increased risk of non-relapse mortality has persisted in UKALL 2003 and is also evident in ongoing COG trials. EFS of DS patients is also worse in BFM (58%) and NOPHO (54%) studies but not due to increased incidence of septic deaths. Details of incidence, causes and timing of non-relapse deaths in DS patients in UKALL 2003 as of October 2010 are as below DS mortality October 2010 Total entered: 5 year EFS: Relapse: Non-relapse deaths: Male Female Median age NCI SR/HR Induction 74 63% 6 13 (17%) 10/52 3/22 5 years 7/41, 6/33 4 (6%) (1 Reg A, 2 Reg B, 1 Reg C) (1 parainfluenza pneumonitis, 1 NEC + sepsis, 1 pseudomonas, 1 pneumonia and haemetemesis) 8(15%) 1 (Reg B aspergillus) 1 (Reg A sepsis) 1 (Reg A sepsis) 5 (56, 89, 100, 112 and 140 weeks)
CR: Consolidation DI1 DI2 Maintenance Treatment modifications
In view of the high non-relapse mortality, the following modifications will apply to the treatment regimens for Downs syndrome patients, including those with lymphoblastic lymphoma (LBL): Daunorubicin should be omitted from induction for DS NCI High Risk and LBL patients. They should all receive the same 3 drug induction as NCI Low Risk patients (i.e. Regimen A induction). However, for Downs syndrome patients with NCI HR BCP ALL and all cases of T-ALL if the day 15 BM shows a slow early response in ALL or there is concern over slow resolution of bulk disease in LBL, then in the absence of established serious morbidity, switch to Regimen C induction.
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Post-induction-treatment for DS patients Post-induction, DS patients should treated as following depending on their MRD response: Post-induction therapy is based on NCI Risk category & MRD Risk. MRD Low Risk and MRD No Result patients who had a rapid early response at day 15 receive Regimen A/B consolidation, depending on NCI risk, followed by a SINGLE DI. MRD High Risk patients and MRD No result patients who had a slow early response should receive Regimen C (in the absence of serious morbidity during induction) with a SINGLE DI. Boys should stop maintenance therapy after two years same as girls. Supportive care as per induction for Regimen B and C Consolidation and all DI blocks.
Supportive care The following supportive care is recommended: During induction: Administer prophylactic antibiotics. Ciprofloxacin 10mg/kg twice daily is recommended but individual centres may wish to use alternatives based on local infection and resistance patterns in discussion with their microbiologists. Review 3 times a week if an out-patient. Treat all febrile neutropenia episodes as high risk if using risk stratified policy for admission/intravenous antibiotics. DS patients may not present with classic signs of sepsis such as pyrexia. Treat nonspecifically unwell patients as septic until proven otherwise. Be alert to early signs of shock in septic patients and refer promptly for intensive care.
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APPENDIX F
Guidance on Use of Erwinia Asparaginase (Erwinase) in patients with systemic reactions to Oncospar.
1. A licensed preparation of Erwinia Asparaginase (Erwinase) is now available, thus providing an effective alternative for patients with hypersensitivity to E.Coli Asparaginase. 2. Erwinase.will be marketed and distributed by Eusa pharmaceuticals. 3. Erwinase should be used in place of native or Pegylated E. Coli Asparaginase in the following circumstances: Systemic hypersensitivity reactions to native (Medac asparaginase) or Pegylated E.Coli Asparaginase (Oncaspar). This includes patients with generalised rash with or without anaphylactic symptoms, but not those with only local pain or redness at the site of injection. Patients with previously documented systemic reactions to E.Coli Asparaginase should receive Erwinase in any remaining Asparaginase containing courses.
4. Each dose of Pegylated Asparaginase (Oncaspar) should be replaced with 6 doses of 20,000 Units/m2 Erwinase given on Mondays, Wednesdays and Fridays. 5. Each dose of native E.Coli Asparaginase (Medac E.Coli Asparaginase) should be replaced with a single dose of 20,000 Units/m2 of Erwinase. 6. Erwinase should be administered by intra-muscular injection. For older patients requiring large volumes, the individual dose may be split between two injection sites.
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Table for converting from Peg-Asparaginase to Erwinase
Peg-asparaginase
Induction (all regimens) Peg Asparaginase 1000 units/m2 IM on day 4 and 18
Erwinase
Induction (all regimens) Day 4 N/A Day 18: Erwinase 20,000 units/m2 IM on day 18 and then Mon/Wed/ Friday for 6 doses in total
Consolidation Reg C Peg Asparaginase 1000 units/m2 IM on day 16 and 44
Consolidation Reg C Erwinase 20,000 units/m2 IM on day 16 and then Mon/Wed/ Friday for 6 doses in total Erwinase 20,000 units/m2 IM on day 44 and then Mon/Wed/ Friday for 6 doses in total
Capizzi maintenance (Reg C only) Peg Asparaginase 1000 units/m2 IM on day 3 and 23
Capizzi maintenance (Reg C only) Erwinase 20,000 units/m2 IM on day 3 and then Mon/Wed/ Friday for 6 doses in total Erwinase 20,000 units/m2 IM on day 23 and then Mon/Wed/ Friday for 6 doses in total
Delayed intensification (all regimens) Peg Asparaginase 1000 units/m2 IM on day 4 (Reg C only) Peg Asparaginase 1000 units/m2 IM on day 43
Delayed intensification (all regimens) Erwinase 20,000 units/m2 IM on day 4 and then Mon/Wed/ Friday for 6 doses in total Erwinase 20,000 units/m2 IM on day 43 and then Mon/Wed/ Friday for 6 doses in total
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APPENDIX G
Management of Encephalopathy related to intra-thecal Methotrexate
Background Up to August 2005, 22 cases of Encephalopathy related to intra-thecal Methotrexate had been reported in patients entered on UKALL 2003. Typical presentation is with seizures, focal neurological deficit or loss of consciousness occurring within 1 21 days (average 3 days) of exposure to IT MTX. Full recovery within 48 hrs of the episode is the norm. Although episodes have occurred in all courses, just over half have been during the consolidation phase of Regimens B/C or part 2 of the Delayed Intensifications. This raises the possibility of an interaction with Ara-C in some patients. After discussion, the ALL task force and CLWP meetings approved the following recommendations for managing such patients:
Management Encephalopathy during Regimen B/C consolidation or part 2 of Delayed Intensification. No further IT MTX should be administered while patient is also receiving Ara-C (including in future courses containing Ara-C). Re-expose, and in the absence of recurrence, administer missed doses during interim maintenance or maintenance. In the event of recurrence, change to IT Ara-C + hydrocortisone in the doses given below. Encephalopathy during other courses. Re-expose as above and continue IT MTX if no recurrence. Change to IT Ara-C and hydrocortisone if problem recurs. Doses as below. Doses: Age 1 2 3+ Ara- C 20 mg 25 mg 30 mg Hydrocortisone 7.5 mg 10 mg 12.5 mg
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APPENDIX H
DRUG INTERACTIONS WITH CYTOTOXIC AGENTS
These guidelines aim to address the more commonly reported and potentially serious drug interactions that may be encountered when using this protocol. These guidelines are not intended to be a comprehensive list of all potential drug interactions and normal precautions should be taken when prescribing any combination therapy.
INTERACTIONS WITH POTENTIALLY SERIOUS CLINICAL CONSEQUENCES
DRUG
Vincristine
POTENTIAL INTERACTION
Itraconazole
COMMENTS
Causes inhibition of the cytochrome P450 3A4 enzyme system resulting in increased incidence of peripheral neuropathy1,2. Hyponatraemia associated with SIADH has been reported with concomitant use of vincristine and azole anti-fungal agents2 Nifedipine has been reported to enhance these effects. Fluconazole/voriconazole are not reported to have the same adverse effects although could be predicted to have similar adverse effects
+/- Nifedipine
Fluconazole/voriconazole
RECOMMENDATION: AVOID USE OF AZOLE ANTI-FUNGALS WITHIN ONE WEEK OF VINCRISTINE IF POSSIBLE. IF USED SUSPEND 48 HRS BEFORE AND AFTER VINCRISTINE DOSE. Anti-convulsants including phenytoin, carbamazepine, phenobarbitone Possible reduced chemotherapy efficacy An association between increased risk of relapse in children with B-lineage ALL and concomitant treatment with anticonvulsant therapy has been reported (EFS hazards ratio 2.67 95% CI 1.5-4.76, p=0.0009)3 Many anti-convulsants induce hepatic enzyme activity. Significantly increased clearances of methotrexate and teniposide in patients receiving anticonvulsant therapy have been reported 3. Also see Phenytoin/Dexamethasone interaction.
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Phenytoin Dexamethasone
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Phenytoin and dexamethasone mutually lower the efficacy of the other drug: Phenytoin increases hepatic enzyme metabolism of dexamethasone and lowered levels o f phenytoin are reported with concomitant dexamethasone therapy RECOMMENDATION: AVOID THE USE OF PHENYTOIN, CARBAMAZEPINE AND PHENOBARBITONE IF POSSIBLE. POSSIBLE ALTERNATIVE ANTICONVULSANTS INCLUDE GABAPENTIN WHICH IS RENALLY EXCRETED AND DOES NOT INDUCE HEPATIC ENZYMES. CLONAZAPAM, CLOBAZAM OR VALPROATE HAVE NO KNOWN CLINICALLY RELEVANT INTERACTIONS WITH CYTOTOXIC DRUGS NB VALPROATE HEPATOTOXICTY IS REPORTED
OTHER POTENTIAL INTERACTIONS WHICH REQUIRE CLOSE MONITORING
DRUG
Anti-coagulants Warfarin
POTENTIAL INTERACTION
Concurrent chemotherapy, especially 6-MP and steroids, INCREASES INR Cotrimoxazole DECREASES INR
COMMENTS
The use of low molecular weight heparin for prophylactic therapy post thrombus formation would be preferable 4
6-mercaptopurine
Allopurinol
Methotrexate
Non Steroidal AntiInflammatory Drugs (NSAIDs) (including COX II inhibitors)
Avoid concurrent use. Can cause a 5 fold increase in AUC of 6-MP Increase in methotrexate levels due to competition for excretory pathways RECOMMENDATION: AVOID DURING CAPIZZI MAINTENANCE AND HIGH DOSE METHOTREXATE NB NSAIDs have adverse effects on platelet function
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Penicillins, Co-Amoxiclav
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penicillins reduce methotrexate excretion. RECOMMENDATION: AVOID DURING CAPIZZI MAINTENANCE AND HIGH DOSE METHOTREXATE NB Clavulenic acid is hepatotoxic Increased methotrexate toxicity through displacement of methotrexate from plasma binding sites NB Tetracyclines should be avoided in children under 7 years due to discolouration of teeth Uptake of flucytosine by fungi may be inhibited by cytarabine Duration and effect of neuromuscular blockade may be increased 5
Tetracyclines
Cytarabine Cyclophosphamide
Flucytosine Suxamethonium
References
1. 2. 3. 4. Sathiapalan R. K., El-Solh H. Enhanced vincristine neurotoxicity from drug interactions: case report and review of the literature. Pediatric Hematology and Oncology 2001,18: 543-6 Kamaluddin M., et al Potentiation of vincristine toxicity by intraconazole in children with lymphoid malignancy. Acta Paediatrica 2001 90: 1204-08 Relling M.V., et al Adverse effects of anticonvulsants on efficacy of chemotherapy for ALL Lancet 2000 356 28590 Martin L.A., Mehta S.D., Diminishes anti-coagulant effects of warfarin with concomitant mercaptopurine therapy Phamacotherapy 2003 23(2): 260-4 KOSEGOGLU V. ET AL ACQUIRED PEUDOCHOLINESTRERASE DEFICIENCY AFTER HIGH-DOSE CYCLOPHOSPHAMIDE BONE MARROW TRANSPLANTATION 1999 24(12): 1367-8
5.
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APPENDIX I
GUIDELINES FOR THE INVESTIGATION AND MANAGEMENT OF THROMBO-EMBOLIC EVENTS
Background Thrombosis is a recognised complication of the treatment and management of ALL. The true prevalence in this patient population is unknown and varies with the method of assessment. The PARKAA study (Cancer 2003, Vol.97, 2) reported a prevalence of symptomatic events of 5% and asymptomatic events of 36.5% in children undergoing induction chemotherapy for ALL with a central venous catheter insitu. Asymptomatic events were diagnosed by screening with bilateral venography or MRI, echocardiography and a MRI of the head on completion of induction chemotherapy. Whilst the authors recommend carefully designed clinical trials of primary prophylaxis for the prevention of TEs in this patient population, there is at present insufficient data from children treated on UK protocols to support this. However, the need to collect such information to judge the appropriateness of prophylaxis is recognised. In general, primary prophylaxis for children with CVL cannot be recommended at this time, because there is no evidence for the efficiency or safety of this approach. Asparaginase therapy and the presence of a central venous catheter are accepted as the main predisposing factors. The literature on the role of inherited thrombophilia in predisposing to thrombotic events in these children is conflicting, with the BFM reporting a significant association, and the Canadians and other major groups, no association. It is, therefore, considered premature to recommend universal screening or primary prophylaxis, although it may be prudent to try to identify less common high-risk abnormalities eg AT deficiency, PC deficiency.
Screening 1 2 Universal thrombophilia screening is not recommended. A careful family history of thrombosis should be taken. Children with a first or second degree relative with Protein C or A.T. deficiency should be screened for the relevant deficiency, as prophylaxis may be indicated. The literature is inconclusive for risk conferred by other inherited thrombophilias. Teenage girls on the combined oral contraceptive pill should stop the pill and change to a low dose progesterone only preparation, or norethisterone.
Catheter (CVL) Related Thrombosis 1 Loss of CVL patency Inability to withdraw blood +/- inability or impaired ability to infuse
If there is no evidence to suggest displacement of the catheter tip and there are no signs to suggest the presence of occlusive thrombosis, proceed with urokinase (UK) lock
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Procedure: UK 2,500 iu each lumen for 2-4 hours. Failure to restore patency or recurrent loss of patency CXR to check position of catheter tip Linogram to assess CVL patency If the linogram demonstrates the presence of a fibrin sheath with no evidence of significant clot formation around the tip, proceed to UK infusion. Procedure: UK 150 iu/kg/hr via each lumen for 12-24 hours. Monitor coagulation prior to and every 8 hours during infusion Low dose t-PA(0.1mg/kg/hr for 4 6 hrs) may be considered as an alternative thrombolytic agent Repeat linogram following infusion to confirm resolution. If the linogram demonstrates (or is suspicious of) the presence of significant clot formation around the catheter tip, or of vessel thrombosis, proceed with further imaging studies. Imaging: consider doppler or MR venography. Comments on imaging Linograms have been shown to be relatively insensitive for the detection of large vessel CVL related thrombosis. In the presence of persistent line dysfunction despite a normal linogram, further imaging is indicated. Doppler is a sensitive technique for imaging jugular veins, but has poor sensitivity for central intrathoracic veins. MRV is less well evaluated but is likely to provide good sensitivity. Some children are likely to require a GA for this technique.
Doppler or Venography confirms the presence of large vessel thrombosis. Complete thrombosis toxicity form If the CVL is no longer required or is non-functioning it should be removed. If CVL access is required and the CVL is still functioning then the CVL can remain insitu. Unless otherwise contraindicated, anticoagulant therapy should be commenced. Comments on treatment
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Low molecular weight heparin (LMWH) is probably the anticoagulant of choice for initial therapy in most cases. LMWH dosing: Enoxaparin (Clexane) 1mg/kg/bd by s/c injection. Monitor using anti-Xa levels taken at 4 hours post dose, therapeutic range 0.5-1.0 iu/ml. (LMWH pharmacokinetics for children have only been established [published] for enoxaparin and reviparin [not available in the UK] but the use of other LMWH may be acceptable with monitoring) Prior to a lumbar puncture, or any other invasive procedure, the preceding two doses of LMWH should be omitted. If there is occlusive thrombus in a major vessel e.g. IVC, consider local thrombolytic therapy prior to anticoagulation and/or catheter removal. Lowdose t-PA (0.1mg/kg/hr) may be administered locally via the CVL but higher doses (0.5mg/kg/hr) are required for systemic therapy. t-PA should be administered for 4 6 hours, followed by re-imaging. Following the initial 3 months of therapy for children with a first CVL-related DVT, prophylactic doses of oral anticoagulants (INR 1.5 to 1.8) or LMWH (anti-factor Xa levels of 0.1-0.3) is an option until the CVL is removed. Children with recurrent CVL related DVT should have prophylactic anticoagulation until the removal of the CVL. Some children will be scheduled to receive Asparaginase as per protocol having had an earlier catheter-related thrombotic event. Consideration should be given to removal of the CVL but those children receiving Asparaginase with a CVL in-situ should receive prophylactic anticoagulation for the duration of their Asparaginase therapy. Thrombophilia screening should be performed following completion of anticoagulant therapy and should include Protein C, Protein S, AT, FV Leiden, lupus screen, anticardiolipin antibodies and prothrombin gene 20210A.
Clinical symptoms/signs of CVL related thrombosis Arrange imaging to confirm the presence and extent of thrombosis. Imaging: consider doppler, venography or MR venography. Complete thrombosis toxicity form If the CVL is no longer required or is non-functioning it should be removed. If CVL access is required and the CVL is still functioning then the CVL can remain insitu. If Doppler or Venography confirms the presence of large vessel thrombosis anticoagulant therapy should be commenced.
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Comments on treatment Low molecular weight heparin (LMWH) is probably the anticoagulant of choice for initial therapy in most cases. LMWH dosing: Enoxaparin (Clexane) 1mg/kg/bd by s/c injection. Monitor using anti-Xa levels taken at 4 hours post dose, therapeutic range 0.5-1.0 iu/ml. (LMWH pharmacokinetics for children have only been established [published] for enoxaparin and reviparin [not available in the UK] but the use of other LMWH may be acceptable with monitoring) The platelet count should be maintained around 50x 109/l for the period of anticoagulation. Prior to a lumbar puncture, or any other invasive procedure, the preceding two doses of LMWH should be omitted. If there is occlusive thrombus in a major vessel e.g. IVC, consider local thrombolytic therapy prior to anticoagulation and/or catheter removal t-PA 0.1 mg/kg/hr for 4-6 hours and re-image. Following the initial 3 months of therapy for children with a first CVL-related DVT, prophylactic doses of oral anticoagulants (INR 1.5 to 1.8) or LMWH (anti-factor Xa levels of 0.1-0.3) is an option until the CVL is removed. Children with recurrent CVL related DVT should have prophylactic anticoagulation until the removal of the CVL. Some children will be scheduled to receive Asparaginase as per protocol having had an earlier catheter-related thrombotic event. Consideration should be given to removal of the CVL but those children receiving Asparaginase with a CVL in-situ should receive prophylactic anticoagulation for the duration of their Asparaginase therapy. Thrombophilia screening should be performed following completion of anticoagulant therapy and should include Protein C, Protein S, AT, FV Leiden, lupus screen, anticardiolipin antibodies and prothrombin gene 20210A.
CNS Thrombosis Use of anticoagulants for treatment of the acute phase is contentious. Asparaginase should be suspended from that particular course but can be given in subsequent courses under prophylactic anticoagulant cover as described above.
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APPENDIX J
Cranial radiotherapy guidelines
These guidelines only apply to patients with resistant or parenchymal CNS disease at presentation. Children under 2 years of age do not receive cranial irradiation. a) Megavoltage Apparatus should be used, preferably a linear accelerator. b) All fields should be treated on each treatment day. c) Midplane dose 24 Gy in 15 fractions of 1.6 Gy each, in 15-21 days. (Treatment may start on any day except Friday). d) Lateral opposed fields are used to include all cranial meninges including those surrounding the optic nerve in the retro-orbit, and extending down the spinal cord to level of C2. The dose of 24 Gy has been chosen rather than 18 Gy, as this therapy is for patients with overt CNS disease an hence is an essential part of treatment, rather than being prophylactic in nature. The preferred technique is one which ensures adequate coverage of the whole of the cranial meninges while ensuring that the lens dose is kept as low as possible. The patient should be treated immobilized in a supine shell. A technique that centres on the orbit and uses customized lead blocks to minimise beam divergence is therefore preferred. A treatment centre is selected clinically which is symmetrical and lies 15 mm behind the cornea on each side. Using a simulator these 2 points are opposed and a simulator film taken for the production of customised lead blocks. These should be designed so as to treat the cervical cord down to the level of C2 and to ensure adequate treatment to the origin of the facial nerve. The use of this technique necessitates either the use of asymmetric jaws to block the lower part of the neck or else the use of a very large amount of lead. It may therefore not be possible at all centres and in such cases a similar blocking arrangement using field centred in the midcranium are acceptable. A third alternative is to use a rectangular field with one edge running parallel to Rieds baseline. (b) Treatment to additional fields, eg nasal electrons to the cribriform plate may be used at the discretion of the clinician. If such modifications are used they should be specified on the enquiry sheet and the reason they were considered necessary given. (c) Dose to the lens. Although there is uncertainty as to whether thermoluminescent dosimetry can adequately estimate the dose to the lens, it is nonetheless recommended that such dosimetry be performed and the results recorded, as it is intended to use the data collected to study cataractogenesis in long term survivors. TLDs should be placed on the patient underneath the shell, both on the eyelid in front of the position of the lens, and at the outer canthus of the eye. If possible the dose to the lens should be less than 10% of the mid-plane dose, although it is recognised that this may not always be achievable with adequate treatment of the cribriform plate. Where estimated doses are high, they should be discussed with the radiotherapy co-ordinator. (d) Quality control. An initial simulator film should be taken for planning purposes. Shielding block positions should where possible be checked at a second simulator session. Beam films should be taken on the treatment set to verify block positions. Simulator and beam films will be requested for review following the completion of treatment.
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i) Interruptions to radiotherapy Interruptions to radiotherapy should be kept to minimum. Treatment need not be interrupted for cytopenia unless the patient is unwell. In such cases treatment should be re-commenced as soon as possible. Interruptions longer than 48 hours should be discussed with the radiotherapy co-ordinator. The patient will be on continuation thiopurine during cranial irradiation. Priority should be given to the continuation of the radiation rather than the thiopurine if cytopenias arise. j) Recording of data A separate sheet will be circulated for completion.
APPENDIX K
Testicular radiotherapy guidelines (Patients with testicular disease at diagnosis) a) Megavoltage or Orthovoltage apparatus may be used. b) As in previous MRC studies, the volume should include the testes and the spermatic cord to the level of the deep inguinal ring with lead shielding to surrounding tissues including the penis. c) The dose will be 24 Gy in 12 daily fractions of 2 Gy. This should be given during weeks 5-8 (consolidation). Patients also receiving cranial RT should be given their testicular irradiation concomitantly with the cranial irradiation.
APPENDIX L
Relapse
Patients who relapse in any way and at any stage while on this treatment should be taken off treatment and entered into UKALL R3 or an equivalent adult protocol.
59

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CYP ALL

Interim Guidelinev3 July 2011

Risks of intrathecal therapy

Interim Guidelinev3 July 2011

Interim Guidelinev3 July 2011

transfer to Regimen C R3 High Risk Arm

REGIMEN A/B WITH 1DI

REGIMEN C WITH 1DI

REGIMEN A/B WITH 1DI

Interim Guidelinev3 July 2011

Interim Guidelinev3 July 2011

Dr Nick Goulden Great Ormond Street Hospital London WC1N 3JH

Mobile: 07921 718866 Tel 0207 8298831 Fax 0207 8138410

CYP ALL SPECIAL CATEGORIES:

Interim Guidelinev3 July 2011

Interim Guidelinev3 July 2011

Interim Guidelinev3 July 2011

Interim Guidelinev3 July 2011

CYP ALL 12.

Interim Guidelinev3 July 2011

CYP ALL UKALL 2003 REGIMEN A.

Interim Guidelinev3 July 2011

NEG Regimen A 3-drug induction POS< 5 x 10-5

MRD Low Risk

Interim Guidelinev3 July 2011

Summary of Regimen A. Regimen A consists of the following phases: 1. 2. 3. 4.

CT girls = week 112 boys = week 164

Interim Guidelinev3 July 2011

Interim Guidelinev3 July 2011

Interim Guidelinev3 July 2011

Interim Guidelinev3 July 2011

Interim Guidelinev3 July 2011

CYP ALL 16. UKALL 2003 REGIMEN B.

Interim Guidelinev3 July 2011

NEG Regimen B 4-drug induction POS< 5 x10-5

MRD Low Risk

MRD High Risk

CYP ALL Summary of Regimen B.

Interim Guidelinev3 July 2011

CT girls = week 114 boys = week 166

Interim Guidelinev3 July 2011

Interim Guidelinev3 July 2011

Interim Guidelinev3 July 2011

Interim Guidelinev3 July 2011

Interim Guidelinev3 July 2011

Interim Guidelinev3 July 2011

CYP ALL 17. UKALL 2003 REGIMEN C. Eligibility.

Interim Guidelinev3 July 2011

CYP ALL Summary of Regimen C.

Interim Guidelinev3 July 2011

Interim Guidelinev3 July 2011

CYP ALL 0.76-1.0 m2 over 1.0 m2 360 mg bd 480 mg bd

Interim Guidelinev3 July 2011 300 mg bd 400 mg bd

Interim Guidelinev3 July 2011

Interim Guidelinev3 July 2011

Interim Guidelinev3 July 2011

Interim Guidelinev3 July 2011

Interim Guidelinev3 July 2011

Interim Guidelinev3 July 2011