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ALL-BFM-Studienzentrale Kontakt: Prof Dr. M. Schrappe

ALL-BFM-Studienzentrale Kontakt: Prof Dr. M. Schrappe

Tel.

Fax.

(0049) (0) 431-597 4024 /-1620

(0049) (0) 431-597 4034

Universitätsklinikum Schleswig-Holstein, Campus Kiel

Universitätsklinikum Schleswig-Holstein, Campus Kiel
Universitätsklinikum Schleswig-Holstein, Campus Kiel

Klinik für Allgemeine Pädiatrie Arnold-Heller-Str. 3, Haus 9 D-24105 Kiel

Pädiatrie Arnold-Heller-Str. 3, Haus 9 D-24105 Kiel e-mail: all-bfm-studie@pediatrics.uni-kiel.de oder:

e-mail: all-bfm-studie@pediatrics.uni-kiel.de

3, Haus 9 D-24105 Kiel e-mail: all-bfm-studie@pediatrics.uni-kiel.de oder: m.schrappe@pediatrics.uni-kiel.de
oder: m.schrappe@pediatrics.uni-kiel.de

oder: m.schrappe@pediatrics.uni-kiel.de

oder: m.schrappe@pediatrics.uni-kiel.de

AIEOP-BFM ALL 2009

Internationales kooperatives Behandlungsprotokoll für Kinder und Jugendliche mit akuter lymphoblastischer Leukämie

Fassung für BFM-Teilnehmerkliniken in Deutschland

Protokollversion: 1.3

(inklusive der nicht substantiellen Amendments vom 15.04.2011 und vom 07.01.2013)

Datum: 07. Januar 2013

EudraCT Number AIEOP-BFM ALL 2009: 2007-004270-43

Sponsor: Universitätsklinikum Schleswig-Holstein, Campus Kiel

TEIL I

Internationaler Protokollteil AIEOP-BFM ALL 2009

TEIL II

Deutschsprachiger Teil des Therapieprotokolles AIEOP-BFM ALL 2009

AIEOP-BFM ALL 2009

T-ALL/ non-HR
T-ALL/
non-HR

pB-ALL # / non-HR

T-ALL HR pB-ALL #
T-ALL
HR
pB-ALL #
± pCRT * IA D IB M II IA SR II IB M II IA
± pCRT *
IA D
IB
M II
IA
SR
II
IB
M
II
IA
MR
R
R 2
1 §
II
IA’
bestimmte Patienten $
IA CPM
IB
± pCRT *
H
H
H
R
R
R
R
III
III
III
HR
1‘
2‘ 3‘
IB ASP+ IA
IB ASP+
IA
R R R R III III III HR 1‘ 2‘ 3‘ IB ASP+ IA SZT DNX-FLA

SZT

SZT DNX-FLA + SZT

DNX-FLA + SZT

DNX-FLA + SZT
III HR 1‘ 2‘ 3‘ IB ASP+ IA SZT DNX-FLA + SZT 1 10 12 20
III HR 1‘ 2‘ 3‘ IB ASP+ IA SZT DNX-FLA + SZT 1 10 12 20

1 10

12

20

22

31

43

53

104 Wo.

IA
IA

Prot. IA mit Prednison und 4 DNR Gaben (Tag 8, 15, 22 und 29)

IA’
IA’

Prot. IA‘ mit Prednison und 2 DNR Gaben (Tag 8, 15)

IA CPM
IA CPM

Prot. IA-CPM mit 1 Gabe CPM (Tag 10)

Prot. IA D mit Dexamethason und 4 DNR Gaben (Tag 8, 15, 22 und 29) D mit Dexamethason und 4 DNR Gaben (Tag 8, 15, 22 und 29)

IB-ASP+: Prot. IB mit 4 x 2500 E PEG-L-ASPmit Dexamethason und 4 DNR Gaben (Tag 8, 15, 22 und 29) PEG-L-ASP, verabreicht über 20

PEG-L-ASP, verabreicht über 20 Wochen verabreicht über 20 Wochen

# oder Immunphänotyp unklar * pCRT 12 Gy wenn Alter 2 J. / in ausgewählten Subgruppen (siehe Protokoll) keine pCRT, aber 6x MTX i.th. in Erh.-Therapie / bei initialem ZNS-Befall (CNS 3) tCRT mit 12 bzw. 18 Gy (Dosis nach Alter) § siehe Protokoll für Einschlusskriterien für Randomisierung $ Patienten, die erst nach Tag 8 als HR-Patienten identifiziert werden (siehe Protokoll)

AIEOP-BFM ALL 2009

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I

AIEOP-BFM ALL 2009

INTERNATIONAL COLLABORATIVE TREATMENT PROTOCOL FOR CHILDREN AND ADOLESCENTS WITH ACUTE LYMPHOBLASTIC LEUKEMIA

Version 1.3 of therapy protocol from January 7, 2013 including the non-substantial Amendments from April 15, 2011 and January 7, 2013

Start of patient recruitment

01.06.2010

End of trial

31.05.2020

Sponsor according to GCP:

University Hospital Schleswig-Holstein, Campus Kiel, Brunswiker Str. 10, 24105 Kiel, Germany

Coordinating Principal Investigator and representative of the sponsor: Prof. Dr. Martin Schrappe, Kiel, Germany Phone:
Coordinating Principal Investigator and representative of the sponsor:
Prof. Dr. Martin Schrappe, Kiel, Germany
Phone: +49 431 597 1620, Fax: +49 431 597 3966, E-Mail: m.schrappe@pediatrics.uni-kiel.de
Date:
Signature:

Investigator:

Herewith I confirm that I have read the study protocol carefully and declare my consent to it. I

will treat and examine the patients in accordance with the study protocol, the national

applicable laws, the international guidelines of good clinical practice (ICH-GCP) and the

Declaration of Helsinki.

Date:

Name:

Signature:

AIEOP-BFM ALL 2009

Version 1.3, 07.01.2013

II

AIEOP-BFM ALL 2009

INTERNATIONAL COLLABORATIVE TREATMENT PROTOCOL FOR CHILDREN AND ADOLESCENTS WITH ACUTE LYMPHOBLASTIC LEUKEMIA

Collaborative groups:

AIEOP (Italy)

BFM-A (Austria)

BFM-G (Germany)

BFM-CH (Switzerland)

ANZCHOG (Australia)

National Coordinators:

Valentino Conter

Clinica Pediatrica dell’ Università di Milano-Bicocca Ospedale S. Gerardo Via Pergolesi 33

20052 Monza (MI), Italy

Tel.: +39-039-233 3575 E-Mail: v.conter@hsgerardo.org

Georg Mann

St. Anna Kinderspital Kinderspitalgasse 6

1090 Wien, Austria

Tel.: +43-1-40470 250 E-Mail: georg.mann@stanna.at

Martin Schrappe

Universitätsklinikum Schleswig-Holstein, Campus Kiel Klinik für Allgemeine Pädiatrie Arnold-Heller-Str. 3, Haus 9

24105 Kiel, Germany

Tel.: +49-431-597 1620 E-Mail: m.schrappe@pediatrics.uni-kiel.de

Felix Niggli Universitäts-Kinderklinik Steinwiesstr. 75

8032 Zürich, Switzerland

Tel.: +41-44-266 7823 E-Mail: felix.niggli@kispi.uzh.ch

Draga Barbaric Centre for Children’s Cancer and Blood Disorders Sydney Children’s Hospital High Street, Randwick, NSW, 2031, Australia Tel.: +61-2-9382 1721 E-Mail: draga.barbaric@sesiahs.health.nsw.gov.au

AIEOP-BFM ALL 2009

Version 1.3, 07.01.2013

III

CPH (Czech Republic)

INS (Israel)

Jan Stary Department of Pediatric Hematology and Oncology University Hospital Motol V Uvalu 84 150 06 Praha 5, Czech Republic

Tel.: +420-2-24436401

E-Mail: jan.stary@lfmotol.cuni.cz

Batia Stark Schneider Children’s Medical Center of Israel Pediatric Hematology Oncology Petah-Tikva 49202, Israel Tel.: +972-3-925 3669 E-Mail: bstark@clalit.org.il

AIEOP-BFM ALL 2009

Version 1.3, 07.01.2013

IV

Trial Office BFM-Germany

Postal Address Trial Office

Coordinating Principal Investigator, National Coordinator, BFM-G

Clinical Trial Manager Safety Desk Diagnostics

Administrative Trial Manager

Statistical Office

SCT Coordination/MRD

Reference Neuroradiologist

Lab and Research Coordination

Data Management/Monitoring

Study center-associated laboratories Cytomorphology

Tissue Bank, MRD HR Group

Universitätsklinikum Schleswig-Holstein, Campus Kiel Klinik für Allgemeine Pädiatrie AIEOP-BFM ALL 2009 Studienzentrale Arnold-Heller-Str. 3, Haus 9, 24105 Kiel E-Mail: all-bfm-studie@pediatrics.uni-kiel.de Prof. Dr. Martin Schrappe Tel.: +49 - 431 - 597 1620 Fax: +49 - 431 - 597 3966 E-Mail: m.schrappe@pediatrics.uni-kiel.de Dr. Anja Möricke Tel.: +49 - 431 - 597 4028 E-Mail: a.moericke@pediatrics.uni-kiel.de Dr. Julia Alten E-Mail: julia.alten@uk-sh.de Tel.: +49 - 431 - 597 4024 Dr. Katja Meyer-Schell E-Mail: katja.meyer-schell@uksh.de Dipl.-Betr. Lile Bauer E-Mail: lile.bauer@uksh.de Tel.: 0431 - 597 4028 Dr. Martin Zimmermann Tel.: +49 - 511 - 532 3764 E-Mail: zimmermann.martin@mh-hannover.de Dr. Julia Alten Tel.: +49 - 431 - 597 4024 E-Mail: julia.alten@uksh.de

Prof. Dr. Olav Jansen Tel.: +49 - 431 - 597 4808 E-Mail: o.jansen@neurorad.uni-kiel.de Prof. Dr. Martin Stanulla Tel.: +49 - 431 - 597 1628 E-Mail: martin.stanulla@uksh.de PD Dr. Gunnar Cario Tel.: +49 - 431 - 597 1834 E-Mail: g.cario@pediatrics.uni-kiel.de Dipl.-Dok. Melanie Gerzmehle E-Mail: melanie.gerzmehle@pediatrics.uni-kiel.de Dipl.-Dok. Katja Schulte E-Mail: k.schulte@pediatrics.uni-kiel.de Susanne Timm E-Mail: susanne.timm@pediatrics.uni-kiel.de Lisa Schmied E-Mail: lisa.schmied@pediatrics.uni-kiel.de Tanja Schindelmeiser E-Mail: t.schindelmeiser@pediatrics.uni-kiel.de Tel.: +49 - 431 - 597 4033 / 4026 Fax: +49 - 431 - 597 4034

Dietlinde Hille, Bärbel Pagel, Sabine Prigge Tel.: +49 - 431 - 597 7196 Fax: +49 - 431 - 597 7197 Martina Kähler, Corinna Greve, Alexandra Pfaff, Christian Bretscher, Ilka Meck, Christiane von Grade Tel.: +49 - 431 - 597 7193 Fax: +49 - 431 - 597 7197

AIEOP-BFM ALL 2009

Version 1.3, 07.01.2013

V

Members of the National Group Study Committee AIEOP-BFM ALL-G/A/CH (Stand 1.06.2010)

Prof. Dr. Claus Bartram, Heidelberg Prof. Dr. Joachim Boos, Münster PD Dr. Gudrun Fleischhack, Bonn Dr. Jeanette Greiner, St. Gallen PD Dr. Bernd Gruhn, Jena Prof. Dr. Rupert Handgretinger, Tübingen Prof. Dr. Jochen Harbott, Gießen Prof. Dr. Günter Henze, Berlin Prof. Dr. Thomas Klingebiel, Frankfurt Prof. Dr. Bernhard Kremens, Essen Prof. Dr. Andreas Kulozik, Heidelberg PD Dr. Thorsten Langer, Erlangen Prof. Dr. Wolf-Dieter Ludwig, Berlin Dr. Eberhard Maaß, Stuttgart PD Dr. Georg Mann, Wien Prof. Dr. Charlotte Niemeyer, Freiburg Prof. Dr. Felix Niggli, Zürich Prof. Dr. Alfred Reiter, Gießen Prof. Dr. (em) Hansjörg Riehm, Hannover PD Dr. Claudia Rössig, Münster Prof. Dr. Paul-Gerhard Schlegel, Würzburg Dr. Hansjörg Schmid, Hannover Prof. Dr. Christian Urban, Graz

AIEOP-BFM ALL 2009

Version 1.3, 07.01.2013

VI

AIEOP-BFM ALL 2009

Version 1.3, 07.01.2013

AIEOP-BFM ALL 2009

T/non- HR
T/non-
HR

pB # / non-HR

T-ALL HR pB-ALL #
T-ALL
HR
pB-ALL #
± pCRT * IA D IB M II IA SR II IB M II IA
± pCRT *
IA D
IB
M II
IA
SR
II
IB
M
II
IA
MR
R 2
R 1 §
II
IA’
selected patients $
IA CPM
IB
± pCRT *
H
H
H
R
R
R
III
III III
R HR
1‘
2‘
3‘
IB ASP+
IA
IA
H R R R III III III R HR 1‘ 2‘ 3‘ IB ASP+ IA SCT

SCT

SCT DNX-FLA + SCT

DNX-FLA + SCT

DNX-FLA + SCT
R HR 1‘ 2‘ 3‘ IB ASP+ IA SCT DNX-FLA + SCT 1 10 12 20
R HR 1‘ 2‘ 3‘ IB ASP+ IA SCT DNX-FLA + SCT 1 10 12 20

1 10

12

20

22

31

43

53

104 wks.

IA
IA

Prot. IA (with Pred and 4 DNR doses on day 8, 15, 22 and 29)

IA’
IA’

Prot. IA‘ (with Pred and 2 DNR doses on day 8 and 15)

IA CPM
IA CPM

Prot. IA CPM (with Pred, 4 DNR doses and 1 dose CPM on day 10)

Prot. IA D (with Dexa and 4 DNR doses on day 8, 15, 22 and 29) D (with Dexa and 4 DNR doses on day 8, 15, 22 and 29)

Prot. IB-ASP+ (with 4 x 2500 E PEG-L-ASP) PEG-L-ASP)

PEG-L-ASP given for 20 weeks8, 15, 22 and 29) Prot. IB-ASP+ (with 4 x 2500 E PEG-L-ASP) # or immunophenotype

# or immunophenotype unknown * pCRT 12 Gy if age 2 yrs / in selected subgroups no pCRT + 6x i.th. MTX / in patients with CNS disease (CNS 3) tCRT with 12 Gy or 18 Gy (dose age-adapted) § for eligibility for randomization see protocol $ see protocol

AIEOP-BFM ALL 2009

Version 1.3, 07.01.2013

Trial Synopsis

VIII

AIEOP-BFM ALL 2009: Study Synopsis

Title

International collaborative treatment protocol for children and adolescents with acute lymphoblastic leukemia

Patients

Children and adolescents 1 year of age with acute lymphoblastic leukemia

Stratification

- T/non-HR: T-ALL in absence of any HR criteria (see below)

- pB/non-HR: pB-ALL in absence of any HR criteria (see below).

o

SR (PCR-MRD-SR or, if no PCR-MRD result available, FCM d15 < 0.1%)

o

MR (no SR)

- HR: Prednisone poor-response, FCM 10% on day 15, non-remission on day 33, positivity for MLL/AF4 or t(4;11), hypodiploidy (< 45 chromosomes), high risk by PCR-MRD response

Primary study

- Non-HR pB-ALL patients with TEL/AML1-negative ALL or unknown TEL/AML1 status and FCM-MRD in bone marrow on day 15 < 0.1 % or with TEL/AML1- positive ALL (randomized study question): can the daunorubicin dose in Protocol IA be safely reduced by 50 % with a non-inferior EFS and a reduction of toxicity (treatment-related mortality and AE/SAE in Protocol I)?

- Patients with precursor-B ALL and risk group MR (randomized study question):

questions

can the clinical outcome be improved by protracted asparagine depletion achieved through application of intensified pegylated L-asparaginase during reintensification and early maintenance?

- HR patients (as identified by day 33 - randomized study question): can the clinical outcome be improved by protracted exposure to PEG-L-asparaginase during Protocol IB?

Secondary

- SR patients identified by at least one sensitive marker: Is the clinical outcome comparable to that obtained in SR patients (identified with two sensitive markers) in AIEOP-BFM ALL 2000, or can the outcome even be improved with the use of PEG-L-asparaginase instead of native E. coli L-asparaginase?

- T-ALL non-HR patients: Can the high level of outcome (pEFS) which was obtained for these patients in study AIEOP-BFM ALL 2000 be preserved or even improved with the use of PEG-L-ASP instead of native E.coli L-ASP?

study questions

- HR patients with persistingly high MRD levels despite the use of the HR blocks in the intensified consolidation phase “MRD Non-Responders”: Is it possible to improve the outcome and to achieve a further reduction of leukemic cell burden by administration of an innovative treatment schedule (DNX-FLA)? NOTE: if new drugs or therapeutic options become available, the experimental treatment planned in this patient group may change during the course of the study.

- Patients participating in the randomized asparaginase studies (pB-ALL/MR, HR): Are asparaginase activity and asparaginase antibodies associated with development of allergic reactions, and do they have an effect on the outcome of the patients?

- What is the relative value of different methods of MRD monitoring in the definition of alternative stratification systems within a BFM-oriented protocol?

Primary

- Randomization R1: Event-free survival from time of randomization

endpoints

- Randomization R2: Disease-free survival from time of randomization

- Randomization R HR : rate of MRD highly positive patients (MRD 10 -3 ) at TP2 (week 12)

- Historical comparison SR: Disease-free survival from start of Protocol M

- Historical comparison non-HR T-ALL: Event-free survival from diagnosis

- Historical comparison “MRD Non-Responders”: Event-free survival from start of DNX-FLA (morphological non-response after HR-3’ is no event for this study question)

AIEOP-BFM ALL 2009

Version 1.3, 07.01.2013

Trial Synopsis

IX

Secondary

- All randomized and historical comparisons: Survival; treatment-related mortality in induction or CCR (overall and by chemotherapy/SCT); incidence and frequency of adverse events of interest and serious adverse events

- Randomization R HR : Event-free survival from time of randomization

endpoints

- “MRD Non-Responders”: MRD levels after DNX-FLA

Study design

International multicenter open-label randomized clinical trial (Phase III)

Treatment

AIEOP (Italy) BFM-A (Austria) BFM-G (Germany) BFM-CH (Switzerland) CCACN-NSW (Australia) CPH (Czech Republic) INS (Israel)

groups

Study size

The participating groups are expected to recruit 950 study patients per year, resulting in the recruitment of 4750 patients during the study duration of 5 years.

Study duration

5 years

Eligibility

- newly diagnosed acute lymphoblastic leukemia

criteria

- age 1 year (> 365 days) and < 18 years (up to 17 years and 365 days) 1

- no Ph+ (BCR/ABL or t(9;22)-positive) ALL 2

- no evidence of pregnancy or lactation period

- no participation in another clinical study

- patient enrolled in a participating center

- written informed consent

Exclusion

- pre-treatment with cytostatic drugs

criteria

- steroid pre-treatment with 1 mg/kg/d for more than two weeks during the last month before diagnosis

- treatment started according to another protocol

- underlying diseases that prohibit treatment according to the protocol

- ALL diagnosed as second malignancy

1 Patients <1 year of age are eligible for the study INTERFANT 06

2 Patients with Ph+ ALL are eligible for the study EsPhALL

AIEOP-BFM ALL 2009

Version 1.3, 07.01.2013

X

AIEOP-BFM ALL 2009

Version 1.3, 07.01.2013

Contents

1

Table of Contents

1 Introduction and Summary 11

2 Background 13

2.1 Important results of previous studies prior to AIEOP-BFM ALL 2000 13

2.1.1 ALL-AIEOP studies 13

14

2.2 Interim Results of AIEOP-BFM ALL 2000 15

2.2.1 Minimal Residual Disease (MRD) 15

2.2.2 Randomized questions (interim analyses) 16

2.1.2 ALL-BFM studies

2.2.3 Indications for allogeneic hematopoietic stem cell transplantation

17

2.2.4 MRD negativity with only one sensitive MRD marker

17

2.2.5 Prognostic impact of MRD in the High Risk group 17

2.2.6 MRD by flow cytometry (add-on study)

18

2.3

Rationale of the study concept of AIEOP-BFM ALL 2009

18

2.3.1 Stratification 18

2.3.2 Randomized questions

20

2.3.3 PEG-L-asparaginase as first-line L-asparaginase product

22

2.3.4 Addition of a CPM dose during Protocol IA in T-ALL/PPR patients 23

2.3.5 Intensified treatment before SCT in “MRD Non-Responders”

2.3.6 Omission of pCRT in specific subgroups of T-ALL and HR patients and in

23

patients younger than 2 years of age

24

3 Differences to the Previous Study AIEOP-BFM ALL 2000

25

3.1 Stratification 25

3.2 MRD risk group classification criteria 25

3.3 Treatment

25

3.3.1 Choice of steroid preparation in Protocol IA

25

3.3.2 Choice of PEG-L-asparaginase as first-line L-asparaginase product 25

3.3.3 Addition of a cyclophosphamide dose during Protocol IA in T-ALL/PPR

patients

25

3.3.4 Reintensification therapy in SR and MR

25

3.3.5 Intensified consolidation (HR blocks) and reintensification in HR 25

3.3.6 Intrathecal drugs in HR blocks 26

3.3.7 Length of dexamethasone phase in Protocol IIIA

26

3.3.8 Dosage of Erwinia asparaginase

26

3.3.9 Timing of i.th. methotrexate during high-dose methotrexate 26

3.3.10 Cranial

radiotherapy

26

3.3.11 Retinal

involvement

26

3.4

Diagnostics

26

4 Definitions of Response and Remission Status 27

AIEOP-BFM ALL 2009

Version 1.3, 07.01.2013

Contents

2

4.1

Prednisone response 27

4.2

Complete remission 27

4.3

Late-Response

27

4.4

Morphological Non-Response (resistance to protocol)

27

4.5

Response by PCR-MRD and resulting PCR-MRD risk groups 27

4.6

Response by FCM-MRD

28

4.7

Relapse

28

5 Study Objectives 29

5.1

Primary objectives

29

5.2

Secondary objectives

29

5.3

Add-on studies 29

6 Study Design

31

6.1

Type of study

31

6.2

Registration and eligibility 31

6.2.1 Registration 31

31

6.2.2 Eligibility/exclusions

6.3 Stratification 32

6.3.1 Basics of stratification

32

6.3.2 Definition of high-risk group

32

6.3.3 Definition of standard-risk and medium-risk groups

32

6.3.4 Indications for allogeneic stem cell transplantation

35

6.4 Randomized study questions (see also sections 2.3.2 and 9) 35

6.4.1 Randomization R1 in Protocol IA 35

6.4.2 Randomization R2 in reintensification phase 36

6.4.3 Randomization R HR in Protocol IB 36

38

7.1 CNS status and CNS disease 38

7.1.1 CNS status 38

7.1.2 CNS disease 39

7 Definition of Organ Involvement

7.2

Testicular involvement 39

7.3

Mediastinal mass 39

7.4

Other organ involvement

39

8 Diagnostics

40

8.1

Initial diagnostics

40

8.1.1 Diagnosis and biological characterization of ALL

40

8.1.2 General diagnostics and diagnostics of extramedullary disease

41

8.2 Response Evaluation 42

8.2.1 Cytomorphological response and remission evaluation in BM and PB 42

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3

43

8.2.3 Minimal Residual Disease (MRD) 44

8.3 Asparaginase monitoring 46

46

8.3.2 Processing of the samples 49

8.4 Monitoring of toxicity 49

8.2.2 Response evaluation of extramedullary manifestations

8.3.1 Sampling time points

 

8.4.1 Toxicity during treatment

49

8.4.2 Follow-up, late side effects

49

9

Treatment Schedule

50

 

9.1

Protocol I

50

9.1.1 Cytoreductive prephase 52

9.1.2 Protocol IA, Protocol IA’, Protocol IA-CPM

52

9.1.3 Protocol IA-Dexa (IA D )

54

9.1.4 Protocol

IB

54

9.1.5 Protocol IB-ASP+ 55

9.2 Protocol

M

57

9.3 Protocol

II

59

9.3.1 Protocol IIA

59

9.3.2 Protocol IIB

60

9.4 Protocol II-ASP+ 62

9.4.1 Protocol IIA-ASP+ 62

9.4.2 Protocol IIB-ASP+ 63

64

9.5 High Risk courses (HR’)

9.5.1 HR-1’ 64

9.5.2 HR-2’ 66

9.5.3 HR-3’ 68

9.6

Protocol III

70

9.6.1 Protocol IIIA

70

9.6.2 Protocol IIIB

71

9.7 DNX-FLA

73

9.8 Interim Maintenance (only HR patients)

74

9.9 Maintenance

76

9.10 CNS-directed treatment

79

9.10.1 Intrathecal therapy

79

9.10.2 Cranial irradiation 79

82

10 Drug Modification 83

10.1 Dose modification in specific patient groups 83

9.11 Allogeneic stem cell transplantation

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4

83

10.1.2 Obese patients 83

10.1.1 Low-weight children

10.1.3 Down syndrome patients

84

10.2

Modification for toxicity

84

11 Contraception

84

12 Chemotherapeutic Drugs 85

13 Guidelines for Supportive Care and Emergency Situations 85

14 Safety

85

14.1

Serious Adverse Events (SAE), SUSAR

85

14.1.1 Relevant AEs including most common SAE

85

14.1.2 Definition of SAE (including exceptions) 86

14.1.3 Reporting of SAE and other toxicity 87

88

14.1.5 Annual safety report 88

14.1.4 SUSAR assessment

14.2

Data and Safety Monitoring Committee (DSMC) 88

15 Statistical Considerations

89

15.1

Study Questions

89

15.2

Endpoints 89

89

15.2.2 Secondary Endpoints 90

15.2.1 Primary Endpoints

15.3 Recruitment

90

15.4 Analysis

90

15.4.1 Study question R1

90

15.4.2 Study question R2

91

15.4.3 Study question R HR

91

15.4.4 Study questions from observational studies

91

15.4.5 General considerations

91

15.5

Sample size

91

15.5.1 Study question R1

91

15.5.2 Study question R2

92

15.5.3 Study question R HR

93

15.5.4 Observational study on SR patients

93

15.5.5 Observational study on “MRD Non-Responders” patients 93

15.6

Interim Analysis

94

15.6.1 Study question R1

94

15.6.2 Study question R2

94

15.6.3 Study question R HR

94

15.7

Analysis of toxicity

94

AIEOP-BFM ALL 2009

Version 1.3, 07.01.2013

Contents

5

16 Organizational Aspects and Documentation 97

16.1 Status of the study 97

16.2 Registration

97

16.3 Randomization 97

97

16.5 Organizational structure of the trial 98

16.4 Data collection and study forms

16.5.1 Trial Steering Committee (TSC)

98

16.5.2 Trial Research Committee (TRC)

99

16.5.3 Trial Diagnostics Committee (TDC)

99

16.5.4 Trial Data Analysis Committee (TDAC)

99

16.5.5 Data and Safety Monitoring Committee (DSMC) 99

17 Add-On Studies

17.1 Microarray analysis-based studies in BFM 100

104

17.3 Prospective evaluation of genetic aberrations and genetic variants of currently

105

17.4 PAX5 abnormalities: functional roles of PAX5/fusion proteins (AIEOP) 105

17.5 Infectious disease-associated toxicity 106

17.6 Relapse-predicting value of increasing MRD levels during and after maintenance therapy in patients with relevant risk of relapse in 1 st CR 106

17.7 ALL in Down syndrome – a model for high-risk B cell precursor leukemias 106

18 Publication Rules 107

19 Ethical, Regulatory and Administrative Principles

107

20 Wichtiger Hinweis zum Studienprotokoll 110

21 Adressen der Studienzentrale und der Labore für BFM Deutschland

112

22 Logistik 114

114

22.2 Zuordnung zu Risikogruppe und Therapiegruppe (siehe Kapitel 6.3, Seite 32) 114

115

100

17.2 Comprehensive characterization of extramedullary disease (BFM, AIEOP)

unknown prognostic value (AIEOP, BFM)

22.1 Erstmeldung an die Studienzentrale und Registrierung

22.3 Logistik der Randomisierungen

23 Dokumentation 116

116

23.2 Therapie- und Toxizitätsdokumentation 116

23.2.1 Alle Patienten 116

23.2.2 Randomisierungen 116

23.3 Meldung von SAE und anderen unerwünschten Ereignissen 116

24 Therapieelemente 118

24.1 Protokoll I 118

24.1.1 Zytoreduktive Vorphase 118

24.1.2 Protokoll IA, Protokoll IA’, Protokoll IA D , Protokoll IA-CPM 118

23.1 Ersterhebungsbogen

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24.1.3 Protokoll IB, Protokoll IB-ASP+ 128

24.2 Protokoll M 132

24.3 Protokoll II 135

24.3.1 Protokoll IIA

135

24.3.2 Protokoll IIB

136

24.4

Protokoll II-ASP+

138

24.4.1 Protokoll IIA-ASP+ 138

24.4.2 Protokoll IIB-ASP+ 140

24.5 Hochrisiko-Blöcke (HR’)

24.5.1 HR-1’ 142

24.5.2 HR-2’ 145

24.5.3 HR-3’ 148

24.6 Protokoll III 150

142

24.6.1 Protokoll IIIA

150

24.6.2 Protokoll IIIB

151

24.7 DNX-FLA

153

24.8 Intervalltherapie

154

24.9 Erhaltungstherapie

156

24.10 ZNS-Therapie

159

25 Indikationen zur allogenen Stammzelltransplantation

160

26 Toxizität

160

26.1 Überwachung der Toxizität 160

160

26.1.1 Toxizität unter Therapie, allgemeine Empfehlungen

26.1.2 Monitoring der Toxizität in den randomisierten Therapieelementen 161

26.1.3 Nachsorge, Diagnostik von Spätfolgen 162

26.2 Dosismodifikationen in bestimmten Patientengruppen 163

26.3 Therapiemodifikationen bei Toxizität

163

26.3.1 PEG-L-Asparaginase 163

26.3.2 Cyclophosphamid

166

26.3.3 Cytarabin

166

26.3.4 Daunorubicin, Doxorubicin 166

26.3.5 Etoposid 167

26.3.6 Ifosfamid

26.3.7 Methotrexat 168

26.3.8 6-Mercaptopurin und Thioguanin (Intensive Therapiephase)

26.3.9 6-Mercaptopurin und Methotrexat p.o. (Erhaltungstherapie, Intervalltherapie)

172

26.3.10 Steroide (Dexamethason und Prednison) 174

167

171

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26.3.11

Vincristin

174

27

Supportivtherapie, Supportivmaßnahmen

175

27.1

Akutes Tumorlyse-Syndrom

175

27.1.1 Pathophysiologie

175

27.1.2 Prävention des TLS

175

27.1.3 Therapie von Elektrolytstörungen

177

27.1.4 Nierenversagen, Hämodialyse 178

27.2 Substitution von Blutprodukten 179

179

27.4 Mukositis, Mundsoor 180

27.3

Gastritis

27.5 Antiemetische Behandlung 180

27.6 Hyponatriämie und SIADH

181

27.7 Infektionen

181

27.7.1 Allgemeine präventive Maßnahmen

181

27.7.2 Erfassung der Keimbesiedlung und des Immunitätsstatus 182

27.7.3 Medikamentöse Infektionsprophylaxe

182

27.7.4 Fieber bei Neutropenie

185

27.7.5 Pneumocystis carinii (jirovecii) Pneumonie

186

27.7.6 Invasive/systemische Pilzinfektionen 186

27.7.7 Varizellen und Herpes zoster 187

188

28 Notfallsituationen und schwerwiegende Komplikationen 189

27.8 Nebennierenrindeninsuffizienz

28.1

Hyperleukozytose (Leukozyten > 100 000/µl)

189

28.1.1

Indikation zur Austauschtransfusion oder Leukapharese

189

28.2 Mediastinaltumor mit Trachealkompression und oberer Einflussstauung

189

28.3 Paravasat von Vincristin, Anthrazyklinen und Etoposid 190

29

Diagnostik und Materialversand

191

29.1

Initiale Diagnostik

191

29.1.1

TPMT-Diagnostik

192

29.2 Diagnostik im Verlauf 192

192

29.2.2 Logistik der PCR-MRD-Diagnostik bei allen Patienten (MRD-ZP 1 und -ZP 2)

192

29.2.3 Logistik der PCR-MRD-Diagnostik unter HR-Therapie 192

29.2.1 Logistik der FCM-MRD-Diagnostik bei allen Patienten (Tag 15)

29.3

Materialversand

194

29.3.1 Studienbegleitende Diagnostik

194

29.3.2 Begleitforschung

197

29.4 Übersichtspläne studienbegleitende Labordiagnostik und Begleitforschung 198

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30 Versandscheine 201

31 Informationsmaterial für Patienten und Eltern/Sorgeberechtigte, Einwilligungserklärungen 209

31.1 Informationsmaterial und Einwilligungen zur Studienteilnahme

211

31.1.1 Patienteninformation für Eltern und Sorgeberechtigte 213

31.1.2 Patienteninformation für Patienten älter als 15 Jahre 225

31.1.3 Patienteninformation für Patienten im Alter von 12 bis 15 Jahren 237

31.1.4 Patienteninformation für Patienten im Alter von 8 bis 11 Jahren 243

31.1.5 Patienteninformation für Patienten jünger als 8 Jahre 249

31.1.6 Einwilligungserklärung zur Studienteilnahme

31.1.7 Protokoll über das Aufklärungsgespräch zur Studientherapie 253

255

31.2.1 Patienteninformation zur Datenweitergabe 257

31.2.2 Einwilligungserklärung zur Datenweitergabe 262

263

31.3.1 Patienteninformation zur Teilnahme an Begleitforschungsprojekten mit diagnostischem Restmaterial (Sorgeberechtigte) 265

31.3.2 Patienteninformation zur Teilnahme an Begleitforschungsprojekten mit diagnostischem Restmaterial für Patienten älter als 15 Jahre 268

31.3.3 Patienteninformation zur Teilnahme an Begleitforschungsprojekten mit diagnostischem Restmaterial für Patienten im Alter von 12 bis 15 Jahren 271

31.3.4 Patienteninformation zur Teilnahme an Begleitforschungsprojekten mit diagnostischem Restmaterial für Patienten im Alter von 8 bis 11 Jahren 272

31.3.5 Einwilligung zur Teilnahme an Begleitforschungsprojekten mit diagnostischem Restmaterial 273

31.3.6 Patienteninformation zur Teilnahme am Forschungsprojekt „MRD in späten Therapiephasen“ (Sorgeberechtigte) 274

31.3.7 Patienteninformation zur Teilnahme am Forschungsprojekt „MRD in späten Therapiephasen“ für Patienten älter als 15 Jahre 276

31.3.8 Patienteninformation zur Teilnahme am Forschungsprojekt „MRD in späten Therapiephasen“ für Patienten im Alter von 12 bis 15 Jahren 278

31.3.9 Patienteninformation zur Teilnahme am Forschungsprojekt „MRD in späten Therapiephasen“ für Patienten im Alter von 8 bis 11 Jahren 279

31.3.10 Einwilligung zur Teilnahme am Forschungsprojekt „MRD in späten Therapiephasen“ 280

252

31.2 Informationsmaterial und Einwilligung zum Datenschutz

31.3 Informationsmaterial und Einwilligung zur Begleitforschung

31.4 Informationsmaterial und Einwilligung Randomisierungen 281

31.4.1 Patienteninformation zur Randomisierung R1 für Sorgeberechtigte 283

31.4.2 Patienteninformation zur Randomisierung R1 für Patienten älter als 15 Jahre

285

31.4.3 Patienteninformation zur Randomisierung R1 für Patienten im Alter von 12 bis

15 Jahren 287

31.4.4 Patienteninformation zur Randomisierung R1 für Patienten im Alter von 8 bis

11 Jahren 289

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31.4.5 Einwilligungserklärung zur Randomisierung R1

31.4.6 Patienteninformation zur Randomisierung R2 für Sorgeberechtigte 292

31.4.7 Patienteninformation zur Randomisierung R2 für Patienten älter als 15 Jahre

295

31.4.8 Patienteninformation zur Randomisierung R2 für Patienten im Alter von 12 bis

15 Jahren 298

31.4.9 Patienteninformation zur Randomisierung R2 für Patienten im Alter von 8 bis

291

11

Jahren

301

31.4.10 Einwilligungserklärung zur Randomisierung R2

304

31.4.11 Patienteninformation zur Randomisierung R HR für Sorgeberechtigte 305

31.4.12 Patienteninformation zur Randomisierung R HR für Patienten älter als 15 Jahre

308

31.4.13 Patienteninformation zur Randomisierung R HR für Patienten im Alter von 12

bis 15 Jahren

311

31.4.14 Patienteninformation zur Randomisierung R HR für Patienten im Alter von 8 bis

11 Jahren 313

31.4.15 Einwilligungserklärung zur Randomisierung R HR

316

31.5

Patienteninformation zu Schädelbestrahlung

317

32 Therapieübersichten (Therapiedokumentationsbögen) und Infusionspläne 319

33 Leukovorin Rescue-Schema (Dokumentationsbogen zur Verwendung auf Station) 354

34 Dokumentationsbögen 355

356

34.1.1 Registrierungsbogen 356

34.1 Hinweise zum Ausfüllen der Dokumentationsbögen

34.1.2 Ersterhebungsbogen

356

34.1.3 Ereignismeldebogen

356

34.1.4 Meldebogen für SAE und AE 357

34.1.5 Dokumentationsbogen über das Auftreten eines SAE/AE 357

34.1.6 Therapiedokumentation

357

34.1.7 Toxizitätsdokumentation

358

34.1.8 Dokumentation von Laborparametern (Leber, Pankreas)

358

34.1.9 Dokumentation über verabreichte Therapieelemente 358

34.2 Meldefax zur Registrierung 359

34.3 Ersterhebung

360

34.4 Ereignismeldung 363

34.5 Meldebogen für SAE/AE 364

34.6 SAE/AE Dokumentation

366

34.7 Dokumentationbogen Therapietoxizität

367

34.8 Dokumentationsbogen für Laborparameter in der Randomisierung R2

368

34.9 Dokumentationsbogen für Laborparameter in der Randomisierung R HR

369

34.10 Dokumentation Erhaltungstherapie für Patienten der Randomisierung R2 370

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34.11 Dokumentation der verabreichten Therapieelemente 371

34.12 Ablauf der Dokumentation

372

34.12.1 Protokoll I, alle Risikogruppen

372

34.12.2 Nach Protokoll I, alle Risikogruppen außer HR

373

34.12.3 Nach Protokoll I, Risikogruppe HR

374

35 Ethische und rechtliche Aspekte 375

35.1 Bewertung durch die Ethikkommissionen 375

35.2 Genehmigung durch die Bundesoberbehörde (BfArM)

375

35.3 Meldepflichten während und zum Abschluss der Studie

375

35.4 Anmeldung bei den lokalen Überwachungsbehörden und den Landesbehörden 375

35.5 Gute klinische Praxis (GCP) 376

35.6 Deklaration von Helsinki

376

35.7 Gesetzliche Grundlagen (Arzneimittelgesetz, nationale Regularien)

376

35.8 Patientenversicherung 376

35.9 Einwilligung zur Studienteilnahme 376

35.10 Verwendung, Speicherung und Weitergabe von Daten 377

379

36.1 Ethikvotum 380

383

36.3 Patientenversicherungspolice 385

37 Literaturverzeichnis 388

38 Empfehlungen für Diagnostik und Therapie von Sinusvenenthrombosen in der Induktionstherapie gemäß ALL-BFM 2000 und EURO-LB 02

39 Abkürzungsverzeichnis 404

397

36 Gesetzliche und administrative Dokumente

36.2 Genehmigung der Bundesoberbehörde

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Introduction and Summary

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1 Introduction and Summary

Progress in the treatment of acute lymphoblastic leukemia in children and adolescents has been made in the last 10 to15 years mainly through refinement of risk stratification and adaptation of chemotherapy. New agents with proven benefit in the frontline therapy of ALL have not been identified, therefore, chemotherapy could only be improved by more effective combination of existing agents (Arico et al., 2002; Conter et al., 2007; Schrappe et al., 2000a). For well-defined high-risk patients, allogeneic hematopoetic stem cell transplantation was also shown to be effective (Balduzzi et al., 2005; Schrauder et al., 2006). The advanced knowledge about genetics of ALL and molecular regulation of treatment response and resistance represents the basis for the design of contemporary treatment protocols. From 2000 to 2006, the AIEOP-BFM ALL Consortium performed the largest international trial (AIEOP-BFM ALL 2000) in which the stratification and treatment adaptation due to early molecular response to therapy was prospectively applied. That study was the "proof-of- principle" trial to confirm the information generated through an international pilot study performed from 1991 to 1995 by members of the International BFM Study Group (van Dongen et al., 1998).

Trial AIEOP-BFM ALL 2000 demonstrated the large-scale feasibility of PCR-based detection of minimal residual disease (MRD) in a multicenter setting (Flohr et al., 2008). The vast majority of patients could be stratified based on the results of the MRD testing but due to very stringent methodological requirements and strict eligibility criteria, 20 % of all patients could not be stratified based on molecular response. Standard risk group (SR) patients (negative for MRD by 5 and 12 weeks after diagnosis) were randomized for moderate treatment reduction, intermediate risk (MR) patients (low level of MRD still present, but < 10 -3 at 12 weeks) were randomized for double delayed intensification, and high-risk (HR) patients were randomized for triple delayed intensification. Patients who could not be stratified by MRD results were assigned to MR or HR according to the remaining risk criteria. Preliminary results reveal, i) that treatment reduction even for well-responding ALL patients is not possible, ii) that modified (double delayed) intensification most likely will not reduce recurrences, and iii) that triple delayed intensification cannot improve outcome of HR patients. The most striking observation was the power of MRD assessment in subdividing essentially all biological and clinical subgroups of ALL by prognosis, respectively. In fact, the new MRD-based stratification clearly demonstrated the limitations of preexisting risk assessment systems mainly based on upfront patient characteristics.

In addition, all patients of trial AIEOP-BFM ALL 2000 were randomized in induction therapy for an alternative corticosteroid preparation (dexamethasone vs. prednisone [control]). According to the latest interim analysis, this intervention yielded a significant reduction of systemic and extramedullary relapses in the majority of ALL patients: when compared with the previous trial ALL-BFM 95 and AIEOP-LLA 95, recurrences were reduced by one third. On the other hand, recent survival analysis demonstrated that the different corticosteroid preparation in induction therapy did not have an impact on survival. This was partly due to the fact that the modified induction therapy was associated with more severe complications and early deaths. This has been recognized by the Data and Safety Monitoring Committee, and was reason to amend the protocol in 10/2004. Since then, children aged 10 years or older have not been randomized for dexamethasone (DEXA). A more recent data analysis with more follow-up revealed, however, that this age group also had a significant reduction of relapses. The only subgroup in which an advantage by using DEXA both in Event Free Survival (EFS) and Survival was seen is that of patients with T-ALL and prednisone good response (PGR). Another significant improvement was demonstrated for HR patients: all HR patients defined by upfront criteria had received induction consolidation with Protocol IB. This element which was omitted in previous trials turned out to effectively reduce the early recurrences.

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One essential aim for the new trial is to extend the MRD-based risk stratification to all patients. This will be achieved through modified methodological requirements for PCR-based MRD analysis (van der Velden et al., 2003; van Dongen et al., 2003) and through the use of MRD testing by flow cytometry at day 15 of Protocol IA (MRD by FCM) (Dworzak et al., 2002; Gaipa et al., 2005; Ratei et al., 2007; Veltroni et al., 2003). This trial will be the largest quality-controlled study on MRD at three different time points with the most advanced state- of-the-art technologies. This approach guarantees long-term impact on optimized patient care.

The first clinical aim of the new trial is to reduce the potential toxicity of Protocol IA. This will be achieved by a controlled (randomized) reduction of daunorubicin (DNR) in the precursor-B ALL (pB-ALL) patients with the lowest risk of relapse: all non-HR pB-ALL patients who are either TEL/AML1 positive or who show a fast reduction of leukemic cells using MRD testing by FCM on day 15 of induction therapy, are eligible for this randomization. For this new early response assessment, the results of a large-scale prospective study of three experienced flow cytometry laboratories (in Padua, Berlin, and Vienna) can be utilized.

For pB-ALL patients with intermediate MRD response, the potential benefit of extended asparagine depletion will be evaluated through a novel randomized approach. Therapy in both arms will be accompanied by a very comprehensive program on pharmacokinetics and pharmacodynamics. This intervention certainly represents a rather significant addition of treatment intensity but despite a rather favorable outcome this large subset of ALL comprises the highest number of recurrences. Moreover, asparaginase is considered to carry little if any long-term toxicity. For reasons of treatment feasibility and in an attempt to avoid allergic reactions, patients will receive the pegylated form of asparaginase.

T-ALL patients with adequate response to the prednisone prephase (non-HR T-ALL) are expected to have a very favorable outcome due to the initial use of dexamethasone. Therefore, it did not appear justified to intensify therapy but to decrease the treatment burden by reducing the use of preventive cranial radiotherapy which is known to cause potentially severe late effects including secondary brain tumors.

For HR patients, an earlier intervention by the controlled (randomized) use of extended PEG- L-asparaginase exposure was chosen to reduce relapses without changing the time course of induction consolidation (Protocol IB) which is relevant for evaluating the MRD response. Patients with T-ALL and prednisone poor response (PPR) will also receive an additional dose of cyclophosphamide in Protocol IA (day 10) with the aim to obtain a faster clearance of leukemic cells. In addition, a new strategy of individualized treatment modification will be applied if continuous MRD measurements indicate a refractory course of the leukemia. Here, innovative alternative treatment elements will be applied. On the other hand, pB-ALL HR patients with delayed but favorable MRD response shown to have a rather positive final outcome will be saved from preventive cranial radiotherapy.

In the attempt to improve the on-site performance, every center might be visited by a group of experienced clinical oncologists if a life-threatening serious adverse event (SAE) has been reported. This team will review the individual case with the aim to overcome local shortcomings, if present, and to prevent such situations. More importantly, the results of the individual case reviews will be communicated to the study group, and utilized in the consultation of other participating centers.

Finally, trial AIEOP-BFM ALL 2009 will offer a unique opportunity to foster basic and applied leukemia research. The trial and its logistics will serve as a well-organized platform to perform extensive biological studies to elucidate the specific disease mechanisms in the various ALL subtypes. Also, genetic germline variants will be thoroughly analyzed which may be responsible for the heterogeneity of treatment response and outcome. To this end, a systematic collection of specimens will be established. Several comprehensive add-on studies will contribute to better understanding of disease mechanisms, to future improvement of diagnostics, to better definition of response assessment as well as to individual risk adaptation of therapy.

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Background

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2

Background

2.1

Important results of previous studies prior to AIEOP-BFM ALL 2000

2.1.1

ALL-AIEOP studies

AIEOP started using BFM-based protocols in the treatment of acute lymphoblastic leukemia in 1988.

AIEOP-LLA 88:

- BFM protocols were found “feasible” in AIEOP centers (Conter et al., 2000).

- Event-free survival (EFS) improved in respect to the previous AIEOP LLA 82 study (Conter et al., 2000).

- A low incidence of isolated central nervous system (CNS) relapses in medium-risk (MR) group was achieved by replacing cranial irradiation with protracted i.th. MTX. as CNS- preventive therapy (Conter et al., 2000).

AIEOP-LLA 91:

- In the standard-risk (SR) group a reduction of therapy (omission of Protocol IB) was associated to inferior results; this disadvantage was however overcome by the administration (randomized study) of protracted high-dose L-asparaginase (HD-L-ASP) (Pession et al., 2005).

- In the MR patients the administration of protracted HD-L-ASP (randomized study) on top of conventional BFM therapy, was not associated with improved outcome; the absence of efficacy of this additional treatment might have been due to suboptimal pharmacokinetics of that therapy since the Erwinase product was used and given weekly at a dose of 25.000 IU/m 2 (Rizzari et al., 2001).

- Dismal results were obtained in T-ALL patients with prednisone good-response and WBC count 100 000/µl not receiving cranial radiotherapy (CRT) as preventive CNS therapy (Conter et al., 1997).

- The modified high-risk (HR) treatment with nine rotational high-dose chemotherapeutic pulses after induction phase achieved unsatisfying results which were worse than in the previous trial (Conter et al., 1998).

AIEOP-LLA 95:

- In the SR group, a reduction of treatment intensity (omission of anthracyclines and IB phase in Protocol I) in a small (9 %) cohort of highly selected patients (on the basis of DNA index, age, WBC count, no HR features) was associated with lower EFS than expected (Arico et al., 2005b).

- In the MR patients the administration of vincristine (VCR) + dexamethasone (DEXA) pulses q10w during maintenance (randomized study) on top of conventional BFM therapy, was not associated with improved outcome; this was a collaborative intergroup prospective randomized study, conducted in the frame of the International BFM Study Group (I-BFM- SG) including also study ALL-BFM 95 (Conter et al., 2007).

- Consolidation/reintensification treatment in HR patients was modified by intensification with three HR blocks and administration of a double delayed intensification (Protocol II given twice) and led to considerable EFS improvement (Arico et al., 2002).

- An additional prospective intergroup study of the I-BFM-SG on the benefit of allogeneic hematopoetic stem cell transplantation (alloHSCT) in very high risk (VHR) ALL comprised HR patients from AIEOP-LLA 95 (see below in 2.1.2) (Balduzzi et al., 2005).

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2.1.2 ALL-BFM studies

The most relevant results of the earlier ALL-BFM studies conducted since 1981 are summarized in the following:

ALL-BFM 81:

- The replacement of preventive cranial irradiation (18 Gy) with intermediate-dose methotrexate at a dose of 500 mg/m 2 /24 h (4 times) in the standard- and medium-risk group resulted in a significant increase of relapses with CNS involvement (Schrappe et al., 1987; Schrappe et al., 1998). Additional intrathecal methotrexate had not been given during maintenance therapy.

ALL-BFM 83:

- The response to the 7-day prednisone prephase plus one intrathecal dose of methotrexate as measured with the absolute blast count in peripheral blood was prospectively evaluated and was identified as important prognostic factor (prednisone response) (Riehm et al.,

1987b).

- Omission of the reinduction element Protocol III in standard-risk patients (BFM risk factor < 0.8) led to a significant increase of the relapse rate (Henze et al., 1990; Riehm et al.,

1987a).

- Shortening of maintenance therapy by 6 months (total treatment duration 18 months instead of 24 months) for patients of all risk groups resulted in a significantly higher event rate (Schrappe et al., 2000b).

- Preventive cranial irradiation with 12 Gy was as effective as 18 Gy in patients with intermediate relapse risk (BFM risk factor 0.8-1.2) (Buhrer et al., 1990; Riehm et al., 1987a; Schrappe et al., 1998).

- Prolongation of Protocol I meant to reduce toxicity may have had an additional unfavorable effect on the overall result in ALL-BFM 83, probably due to partly insufficient dose intensity in induction.

ALL-BFM 86:

- As in the previous trial, standard-risk patients received no reinduction treatment during the initial period of the study, which led to a significant increase of relapses.

- High-dose methotrexate (4 x 5 000 mg/m 2 /24 h) was introduced for all patients and allowed to safely omit the preventive cranial irradiation in all standard-risk patients (Reiter et al.,

1994).

- The prednisone response was introduced as risk stratification criterion. The group of prednisone poor-responders achieved a 6y-EFS of 485 % with an intensified postinduction treatment with Protocol E and Protocol II (Reiter et al., 1994).

ALL-BFM 90:

- Despite reduction of the cumulative anthracycline dose during induction by 25 %, a significant overall improvement with a significantly lower relapse rate in the medium-risk group could be achieved in trial ALL-BFM 90, most likely due to a more condensed application of the induction therapy (Schrappe et al., 2000a).

- The modified HR treatment with nine rotational high-dose chemotherapeutic pulses after induction phase achieved unsatisfying results which were worse than in the previous trial (Schrappe et al., 2000a).

ALL-BFM 95:

- A new stratification strategy based on age and initial white blood cell count was introduced for non-HR patients.

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- Despite further reduction of the cumulative antracycline dose in induction by 50 % for patients of the newly defined standard-risk group, a 6y-pEFS of 90 % could be achieved for this group.

- Omission of preventive cranial irradiation in all non-T-ALL MR patients was possible without relevant loss of EFS despite a small but significant increase of CNS relapses.

- Consolidation/reintensification treatment in HR patients was modified by intensification of the HR blocks and reintroduction of Protocol II as late reintensification element. This led to considerable EFS improvement.

- BFM and AIEOP initiated a prospective intergroup study of the I-BFM-SG to investigate the benefit of allogeneic HSCT from matched family donors (MFD) in very high risk (VHR) ALL. That study demonstrated the efficacy of allogeneic HSCT from MFD for event-free survival (Balduzzi et al., 2005).

- The specific benefit of allogeneic HSCT for HR-T-ALL patients was demonstrated in both ALL-BFM 90 and 95. Despite improvements through chemotherapy in trial ALL-BFM 95, allogeneic HSCT was highly efficacious in preventing relapses even in the small subset of patients transplanted by allografts from matched unrelated donors (Schrauder et al., 2006).

2.2 Interim Results of AIEOP-BFM ALL 2000

For the interim analyses 4826 protocol patients were included who were enrolled in AIEOP- BFM ALL 2000 from 01.07.2000 to 30.06.2006 in BFM and from 01.09.2000 to 31.07.2006 in AIEOP. Since BCR/ABL-positive patients will enter into study EsPhALL, 96 BCR/ABL- positive patients were excluded from the following analyses.

2.2.1 Minimal Residual Disease (MRD)

In the nineties, the prognostic value of minimal residual disease (MRD) was studied in a prospective international collaborative study conducted by the International BFM Study Group (I-BFM SG) (van Dongen et al., 1998). The method used was a PCR-based quantitative analysis of clone-specific T-cell receptor and immunoglobulin gene rearrangements. Based on the results of this study, MRD-based risk stratification was implemented in trial AIEOP-BFM ALL 2000. Stratification into the three MRD risk groups standard risk (MRD-SR), medium risk (MRD-MR) and high risk (MRD-HR) relied on two time points of MRD assessment with time point (TP) 1 at day 33 of induction and TP2 at week 12 after the start of treatment.

MRD risk group criteria were as follows:

MRD-SR: MRD-negative at TP1 and TP2 with at least two markers demonstrating sensitivities of 10 -4 for disease detection.

MRD-MR: MRD-positive at TP1 or TP2, but MRD < 10 -3 at TP2 with at least two markers.

MRD-HR: MRD 10 -3 at TP2 (one marker sufficient).

For stratification into the final risk groups (SR, MR, HR) the traditional clinical/biological high- risk criteria (prednisone poor-response, non-remission on day 33, BCR/ABL (or t(9;22)), MLL/AF4 (or t(4;11)) qualified the patients for being HR independently of the MRD risk group.

In the study AIEOP-BFM ALL 2000, the feasibility of MRD-based risk stratification in the setting of a large multicentric trial could be proven (Flohr et al., 2008). Initial material for MRD analysis was available from 98 % of the patients. Among these patients, MRD risk group classification could be performed in 78 %. In 12 % of the patients with initial material available, potential MRD classification into risk group SR was not feasible as only one marker with a sensitivity of 10 -4 was available. Other reasons for failed MRD classification were missing material at follow-up time points, no markers or no sensitive markers, death before stratification and major treatment modifications.

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Interim outcome analyses of the MRD risk groups confirmed the high prognostic value of MRD resulting in a 5y-pEFS of 921 % for MRD-SR, 791 % for MRD-MR, and 493 % for MRD-HR (median follow up 4.0 years). The prognostic impact of MRD could also be shown within the major biological subgroups (T-ALL, TEL/AML1-positive pB-ALL, TEL/AML1- negative pB-ALL).

Publication of all clinical results also with regard to the randomized questions will be possible between 2009 and 2011 according to the statistical study plan when sufficient follow-up time has been reached, respectively.

2.2.2

Randomized questions (interim analyses)

 

2.2.2.1

Randomization

dexamethasone

versus

prednisone

in

induction

(Protocol IA)

In induction therapy (Protocol IA), the randomized administration of dexamethasone (DEXA, 10 mg/m 2 /day) versus prednisone (PRED, 60 mg/m 2 /day) for 21 days (plus tapering) was investigated in all study patients. Interim analyses indicate that the use of DEXA during induction element Protocol IA reduced the relapses (systemic and extramedullary) significantly, but was also associated with a higher risk of treatment-related serious toxicity. Subgroup analyses showed that patients with prednisone good-response (PGR) had the largest benefit through a significantly lower relapse risk and better pEFS in the DEXA arm, whereas patients with prednisone poor-response (PPR) apparently did not benefit from DEXA treatment.

Patients treated with DEXA in Protocol IA however were at significantly higher risk to experience a life-threatening complication (in Prot. IA 5.9 % vs 2.4 % with PRED) or to die from treatment-associated toxicity (rate of death in induction + death in CCR without SCT related death: 3.7 % vs 2.1 %) (interim analysis). The majority of serious complications occurred at the end of Protocol IA (week 5). In addition to DEXA treatment, age 10 years (and even more pronounced 15 years), slow early response (M3 marrow on day 15), and female gender were identified as significant independent risk factors for life-threatening or fatal toxicity.

Recent interim analyses focusing on the impact of corticosteroid preparation on survival demonstrated however that, to date, in almost all subgroup of AIEOP and BFM patients, there is no difference between the DEXA and PRED arm. Interestingly, also in the randomized DEXA vs PRED studies conducted in UK and COG protocols, the 5y-survival difference was 2-3% only despite a 5y-pEFS difference of 6-9% (Bostrom et al., 2003; Mitchell et al., 2005). The survival data of the AIEOP-BFM ALL 2000 trial, compared with the pEFS data, may be explained partly by the higher toxicity profile of DEXA treatment and partly by the type of relapses prevented; the reduction of relapse rate in the DEXA arm, in fact, is mainly due to the decreased number of late relapses, which have still good chances to be rescued by second line treatments. Due to these two aspects, the reduction of number of deaths after relapse in the DEXA arm compared to PRED arm, is only enough to counterbalance the excess of early deaths observed in the DEXA arm.

2.2.2.2 Randomization during reintensification treatment in the Standard Risk (SR) group

This randomization focused on the question if patients with the most favorable treatment response (no MRD signal detectable at 5 weeks and 12 weeks from diagnosis) may be treated with less intensive reintensification therapy, thus, causing less acute and late toxicities. The interim analysis indicates that treatment with the reduced intensity element Protocol III resulted in a significantly lower EFS (5y-pEFS: 902 % vs. 961 %, p=0.007) in comparison to the control arm with Protocol II (full intensity reintensification): this difference was due to a higher rate of relapses as well as secondary malignancies (mainly AML/MDS).

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Despite significant reduction of cumulative drug doses in Protocol III, toxicity particularly with regard to the treatment-related mortality could not significantly be reduced.

2.2.2.3 Randomization during reintensification treatment in the Medium Risk (MR) group

This randomization investigated the question if the use of two shorter delayed reintensification elements (2 x Protocol III) may be less toxic and more effective than the (previously used) more intensive single reintensification element Protocol II. The interim analysis so far has not shown a difference in the various outcome parameters between the two treatment arms in the overall comparison or within biological risk groups. This appears to be independent of the initial randomization (DEXA vs PRED).

2.2.2.4 Randomization during reintensification treatment in the High Risk (HR) group

The randomized trial in the HR group focused on the question if the highly intensive therapy used so far in AIEOP and BFM (and in the control arms of trial AIEOP-BFM ALL 2000) may be replaced by the less intensive more continuous reintensification element Protocol III given three times. The interim analysis has not yet revealed any difference in outcome parameters between the randomization arms 3 HR blocks + 3 x Protocol III and the control arms with 3 HR blocks + 2 x Protocol II in AIEOP or with 6 HR blocks + 1 x Protocol II in BFM.

2.2.3 Indications for allogeneic hematopoietic stem cell transplantation

In trial AIEOP-BFM ALL 2000, patients with previously known VHR criteria used for indication to allogeneic hematopoietic stem cell transplantation (alloHSCT) (Balduzzi et al., 2005; Schrauder et al., 2006) were complemented by patients selected through high levels of MRD at week 12 (TP2). Early on, interim results from the MRD analyses indicated that among HR patients, subgroups of very different prognosis could be identified. Most strikingly, HR patients (with upfront HR characteristics) with a rather fast clearance of MRD to a load of 10 -4 at week 12 (MRD TP2) showed an excellent 5y-pEFS of 793 %. Therefore in BFM, indications to alloHSCT were restricted over the course of the study exempting all patients with (i) CR on day 33 and MRD load of 10 -4 at TP2 in the absence of MLL/AF4 and BCR/ABL rearrangement and (ii) patients with BCR/ABL rearrangement, PGR, CR d33, and MRD-SR. In the AIEOP group, compared with the BFM group, alloHSCT indications were more restricted since the beginning and were not changed during the course of the study:

Patients with PPR and T-ALL or pro-B ALL or WBC 100, 000/µl and no MRD-HR had indication to alloHSCT only from MSD. All other indications to alloHSCT were based on (i) no CR at day 33 or (ii) translocations (t(9;22) or t(4;11)) or (iii) MRD-HR.

2.2.4 MRD negativity with only one sensitive MRD marker

Patients who were MRD-negative at both MRD time points but had only one MRD marker with the required sensitivity of at least 10 -4 , were not MRD-classifiable by definition and therefore were treated in the MR risk group. Interim analysis of this patient group revealed excellent 5y-EFS of 94 2 % which was well comparable with the outcome of the SR group treated with Protocol II in reintensification.

2.2.5 Prognostic impact of MRD in the High Risk group

The MRD risk group criteria could be shown to also have a high prognostic value within the high-risk group as defined by the final risk group criteria (classical HR criteria and/or MRD- HR). The good prognosis of patients with prednisone poor-response (BCR/ABL-negative, MLL/AF4-negative, CR on day 33) and MRD risk group MRD-SR or MRD-MR led to

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restrictions of the stem cell transplantation (SCT) indications for these patients in the BFM group (see section 2.2.3).

The prospective evaluation of the prognostic impact of the MRD response beyond week 12 in the HR group (add-on study) could show that in patients with high MRD load (10 -3 ) at week 12 the following MRD response to the HR blocks was closely correlated with the outcome. A particularly poor prognosis with 5y-pEFS of less than 20 % could be demonstrated for patients with MRD load of 10 -3 or higher at the beginning of the 3 rd HR block.

2.2.6 MRD by flow cytometry (add-on study)

The prognostic impact of MRD measured by flow cytometry (FCM) was prospectively evaluated in a cohort of AIEOP and BFM patients in Padova (G. Basso), Vienna (M. Dworzak) and Berlin (W.-D. Ludwig, R. Ratei). The interim analysis revealed a prognostic impact of early FCM-based MRD detection (day 15) (Basso et al., 2009).

2.3

Rationale of the study concept of AIEOP-BFM ALL 2009

2.3.1

Stratification

The stratification in AIEOP-BFM ALL 2009 extends the previous attempts to provide individual risk-adapted therapy. The wide range of biological features of the leukemia (immunophenotype, specific chromosomal aberrations) accounts for the different outcome of these subgroups. Consequently, very different requirements regarding treatment intensification and/or reduction need to be met. Precise evaluation of treatment response (prednisone response, response after induction, MRD) is retained for the identification of high-risk patients and for risk stratification (SR, MR) within the biological subgroups. More patients are eligible for response-oriented stratification than in previous trials. The stratification criteria are shown in detail in section 6.3, page 32.

2.3.1.1

PCR-MRD

The detection of clone-specific immunoglobulin (Ig) and T-cell receptor (TCR) gene rearrangements by PCR amplification is a technique widely used for MRD studies in ALL. Through analysis of rearrangements of immunoglobulin (heavy chain, IgH, and light chain, IgK) and T-cell receptors genes it is possible to identify clone-specific sequences corresponding to N-junctional regions of different recombinations. These junctional regions can be regarded as fingerprint-like clone-specific sequences owing to deletion and random insertion of nucleotides. Oligonucleotide primers are designed at opposite sides of the junctional region. To discriminate between the leukemia-derived PCR products and PCR products of normal cells with comparable rearrangements, the amplification products are generally hybridized to an ALL clone-specific junctional region probe. PCR-based MRD detection by clone-specific junctional regions can generally reach sensitivities of 10 -4 to 10 -5 (one leukemic cell in 10 4 to 10 5 cells).

The I-BFM-SG MRD study (see section 2.2.1) showed the best discrimination of risk groups through the combined evaluation of MRD at two different time points during treatment, on day 33 (TP 1) and at week 12 (TP 2). MRD negativity at TP 1 had high specificity in identifying patients with particularly low relapse risk, whereas high MRD load at late time points (in AIEOP-BFM ALL 2000 10 -3 at TP 2) revealed to be more specific for the identification of patients at high risk of relapse. The combined use of these two time points resulted in an excellent discrimination of risk groups in AIEOP-BFM ALL 2000, and, thus, is basically be retained in AIEOP-BFM ALL 2009.

In AIEOP-BFM ALL 2000, MRD negativity at TP 1 and TP 2 with two sensitive MRD markers (sensitivity at least 10 -4 ) was required for stratification into the SR group. As specified in section 2.2.4, outcome of patients with only one sensitive marker available and negative at

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both MRD time points was comparable to the outcome of the SR group. Thus, in AIEOP- BFM ALL 2009 one sensitive marker is considered sufficiently reliable for stratification into SR, if a second marker is not available. However, the establishment of at least two sensitive markers should be still aimed at. With this strategy, it can be expected that about 88 % of patients can be stratified based on MRD analysis by PCR.

In AIEOP-BFM ALL 2000, the MRD risk group “MRD-MR” was defined as being MRD- positive at TP 1 and/or TP 2 but with an MRD load of < 10 -3 at TP 2. Analysis of MRD subgroups revealed an unsatisfactory pEFS of 39.6% (SE 6.7%) in the pB-ALL patients with the slowest response among this heterogeneous “MRD-MR” group (i.e. high MRD load (10 -3 ) at TP 1 and still positivity at TP 2), when the patients were treated with prednisone in induction. Therefore, in AIEOP-BFM ALL 2009 these patients (pB-ALL PCR-MRD-MR Slow Early Responders (SER)) are qualified for treatment in risk group HR. T-ALL with PCR-MRD- MR Slow Early Response have not been included here because they had a pEFS 86.1% (SE 7.4%) when they were treated with dexamethasone in Protocol IA.

2.3.1.2 FCM-MRD

In the AIEOP-BFM ALL 2000 protocol, investigation of flow cytometry-MRD (FCM-MRD) in bone marrow has been performed in more than 1000 patients from AIEOP, BFM-A and BFM-G at three different time points (days 15, 33 and 78). The aim of the study was to evaluate the comparability between PCR-MRD and FCM-MRD analysis at these time points. Concordance between the two different methods was considered adequate (> 90 %) in

samples with the higher tumor load (PCR-MRD 10 -3 ). Using time point day 15 of Protocol I,

a clear separation of risk groups could be achieved. In AIEOP, 42 % of the patients had an

FCM-MRD load of < 0.1 % at this time point with a 5y-pEFS of 89.9% (SE 1.7%). Ten percent of the patients had 10 % residual blasts with a 5y-pEFS of 46.1% (SE 5.9%). The remaining patients (FCM-MRD 0.1 - < 10 % blasts) had a 5y-pEFS of 79.3% (SE 2.3%). The findings of day 15 response by FCM are not fully reflected by the results of PCR-MRD using the later time points day 33 and day 78. For example, in the AIEOP patients, only 44 %

of the patients with FCM-MRD < 0.1 % on day 15 was SR by PCR-MRD.

These data justify the use of the day 15 FCM bone marrow finding to stratify patients lacking the PCR MRD information and to allocate all patients with poor FCM response at day 15 to the HR group (Basso et al., 2009).

2.3.1.3 High risk criteria

The “classical” high-risk criteria prednisone poor-response, non-remission on day 33 and presence of BCR/ABL or MLL/AF4 rearrangement still qualified the patients for treatment in the HR group in the previous trial AIEOP-BFM ALL 2000. Within this “classical” HR group, good MRD response proved to have significant independent prognostic value as such patients achieved excellent results despite the other adverse characteristics. However, these results were obtained under intensive therapy as used for the high-risk group. Therefore, treatment in the high-risk group has been retained for these patients in trial AIEOP-BFM ALL 2009, but a de-escalation of therapy has been realized through the restriction of alloHSCT indications as already implemented during AIEOP-BFM ALL 2000.

Hypodiploidy (modal chromosome number < 45) has been shown to be associated with poor outcome (Harrison et al., 2004; Heerema et al., 1999; Nachman et al., 2007) and has been implemented as high-risk criterion in the treatment protocols of other pediatric ALL trials (Schultz et al., 2007; Vora et al., 2006). Analysis of the patients with hypodiploidy (identified by DNA index of < 0.8) revealed a 5y-EFS of 62 % (n=14, SE 15 %) in trial AIEOP-BFM ALL 2000. Only one of these patients was identified as high risk by other HR criteria. Based on these results and on the experience of other groups, hypodiploidy has been introduced as additional high-risk criterion in AIEOP-BFM ALL 2009.

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2.3.2 Randomized questions

A randomized deintensification of induction therapy in order to diminish treatment-related

toxicity is planned for the large subgroup of non-HR precursor-B ALL (pB-ALL) patients. No

treatment intensification is planned for non-HR patients with T-ALL due to the excellent outcome of these patients in the previous study when treated with dexamethasone in Protocol IA and Protocol II as reintensification element.

Randomized comparisons of treatment intensification are restricted to patients with pB-ALL

in risk group MR and to patients identified as HR before or by day 33 of induction. Both

intensifications will exploit the antileukemic potential of extended asparagine depletion, which

is a unique ALL-specific treatment principle and has the large advantage (for a pediatric ALL

trial) of not having shown any adverse long-term side effects. To optimize this part of ALL therapy, the therapeutic intervention is accompanied by pharmacokinetic and pharmacodynamic studies.

2.3.2.1 Randomization R1: Reduced daunorubicin dose in Protocol IA

The reduction of therapy-related morbidity and mortality in patients with very good prognosis remains a major goal for the childhood ALL front-line protocols. The most delicate treatment

phase in these patients remains the induction element Protocol IA and among drugs used in this phase anthracyclines are considered as the most likely to cause both early and late toxicity. A reduced use of anthracyclines may thus be considered but such reduction must be evaluated in a controlled manner to make sure that deintensification is not associated to inferior outcome. In the randomized trials which have been published so far, no benefit for the use of anthracyclines in addition to a three-drug induction with prednisone, vincristine and L-asparaginase could be proven with respect to EFS (2009; Messinger and Uckun, 1999). However, the treatment schedules in these trials were crucially different from the ALL- BFM 2000 treatment, and EFS of the patients in these early trials was inferior to the results obtained in study AIEOP-BFM ALL 2000, hampering a clear extrapolation from those trials.

In trial ALL-BFM 95, a non-randomized reduction of the daunorubicin dose in induction from

4 doses to 2 doses of 30 mg/m 2 was already performed in the then standard-risk group, which resulted in a 6-year pEFS of 89 % (SE 1 %). This result was similar to the results of trial ALL-BFM 90 (6y-pEFS 88.7%, SE 1.1%), in which the matching patient group had received 4 doses.

With the aim to decrease toxicity during induction treatment, a randomized reduction of the daunorubicin dose in induction by 50 %, i.e. 2 doses daunorubicin vs. 4 doses at 30 mg/m 2 has been implemented in specific subgroups with predictable good prognosis as identifiable by day 15. Patients with pB-ALL and without HR criteria are eligible for this randomization if they are (1) TEL/AML1-positive or (2) TEL/AML1-negative (or TEL/AML1 status not known) with an MRD load in bone marrow on day 15 of < 0.1 % measured by flow cytometry.

2.3.2.2 Randomization R2: Treatment intensification with asparaginase during reintensification and maintenance

Patients with pB-ALL (or unknown immunophenotype) and at medium risk (for definition see section 6.3) are eligible for this randomization. This patient group (as retrospectively defined

in AIEOP-BFM ALL 2000) has a favorable prognosis with an expected 5y-pEFS of 841 %;

however, due to the group size (about 40 % of all patients) this patient subset will comprise an absolute number of relapses which is similar or even more than in the smaller high-risk group. Therefore, more effective treatment without excessive risk to increase serious acute and long-term toxicity is desired for this group. According to the data in the literature, a treatment intensification with asparaginase as scheduled in this trial seems to comply with this requirement.

L-asparaginase (L-ASP) is thought to develop its antileukemic effect through the depletion of circulating asparagine which serves as essential amino acid for most malignant

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lymphoblasts. The antileukemic efficacy of L-ASP could be demonstrated in several trials. Covalent linkage of the synthetic substrate polyethylene glycol (PEG) to native E. coli L-asparaginase results in PEG-L-asparaginase (PEG-L-ASP), which has a lower immunogenicity and a fivefold longer half-life in comparison to native E.coli L-ASP. (Abuchowski et al., 1984; Asselin et al., 1993; Muller et al., 2000; Park et al., 1981).

Recent experiences from several collaborative groups demonstrate that the use of PEG-L- ASP in front-line and second-line treatments for childhood and adult ALL is effective, with a tolerable toxicity profile, similar to that observed with the native product (Abshire et al., 2000; Avramis et al., 2002; Jarrar et al., 2006; Rizzari et al., 2006; Wetzler et al., 2007).

The concept of a long L-ASP phase during reintensification, which at the best leads to a long phase of continuous asparagine depletion, was implemented in a number of other ALL trials, however, with various successes. The additional application of weekly E. coli L-ASP (age- dependent 25 000 or 50 000 IU/m 2 BSA) for three months during the phase of treatment intensification was studied by the Dana-Farber Cancer Institute (DFCI) in a randomized trial

at the end of the seventies and revealed a significant advantage of the asparaginase

treatment arm (Sallan et al., 1983). In a group of standard-risk patients, who were treated in

a collaborative I-BFM study (IDH-ALL 91) the additional weekly administration of

25 000 IU/m 2 BSA Erwinia asparaginase was tested in a randomized manner and as well was superior to the control arm (Pession et al., 2005). In another group of intermediate risk patients, who were treated with another chemotherapy backbone yet with the same randomization in trial AIEOP LLA 91, no advantage of either treatment arm could be proven (Rizzari et al., 2001). In the two latter studies Erwinia asparaginase was used as intramuscular injection in the majority of patients (> 90 %). No analyses of pharmacokinetics were performed in these studies; however, experience from other studies allows the assumption that due to the short half-life of Erwinia asparaginase the schedule probably did not lead to sufficient continuous asparagine depletion. In trial “Protocol 91-01” of the DFCI, asparaginase was given for 30 weeks during the intensification phase. In an analysis of the patients who had been in CCR for at least 40 weeks, i.e. who would potentially have received the complete asparagine treatment, EFS was significantly worse if the L-ASP treatment lasted shorter than 25 weeks (Silverman et al., 2001). This study as well indicates a potential benefit from an intensive post-remission treatment with asparaginase.

An experience by the Pediatric Oncology Group (Abshire et al., 2000), in which an intensified

PEG-L-ASP treatment was administered either weekly or biweekly at dosage of 2500 IU/m 2 i.m. in a randomized manner to relapsed pB-ALL patients, showed that the protracted weekly use of PEG-L-ASP led to a better outcome with a highly significantly different CR rate and with adequate protracted ASN depletion in serum and CSF and tolerable toxicity profile.

In trial AIEOP-BFM ALL 2009, the prognostic impact of a 20-week phase of PEG-L-ASP is compared to the control arm with the standard asparaginase schedule in a randomized study. PEG-L-ASP in the experimental arm is given every other week in a dosage of

2500 IU/m 2 /dose for a total of 10 doses in parallel with the reintensification (Protocol II) and maintenance therapy. The control group receives 1 dose only of PEG-L-ASP in Protocol II. In

a concomitant monitoring program the impact of asparaginase activity and antibody

formation during PEG-L-ASP treatment is evaluated as specified in section 8.3, page 46.

2.3.2.3

Randomization

R HR :

Treatment

intensification

with

Asparaginase

in

Protocol I

For this randomization, all patients are eligible who are identified as high-risk patients by day 33 of Protocol I (MLL/AF4 positive, hypodiploidy, prednisone poor-response, day 15 marrow 10% by FCM, non-remission on day 33).

The first phase of Protocol I (Protocol IA) contains a treatment phase with PEG-L-ASP (2 doses on days 12 and 26). High risk patients receive PEG-L-ASP additionally during high- risk blocks and also reintensification element(s) Protocol III. In study AIEOP-BFM ALL 2000, native E. coli L-ASP was administered intravenously in BFM and intramuscularly in AIEOP.

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In BFM, a high incidence of allergic reactions could be observed over the course of high-risk therapy with a cumulative incidence of > 60 % until the third HR block. After allergic reactions, native E. coli L-ASP usually was replaced by PEG-L-ASP; about 40 % of the patients with first allergic reaction suffered a second allergic reaction to PEG-L-ASP during the further course of HR treatment. It is known, that due to the underlying antibody formation allergic reactions are associated with inactivation of the drug and loss of efficacy (Evans et al., 1982; Killander et al., 1976; Muller et al., 2001). In AIEOP the route of asparaginase administration was intramuscular, and the incidence of apparent allergic reactions was much lower (about 5 %). Yet the rate of silent inactivation, i.e. the faster decrease of enzymatic activity due to antibody formation with lack of clinical symptoms, is unknown in this study.

Thus, one can assume that with the AIEOP-BFM ALL 2000 schedule a relevant proportion of the high-risk patients received no sufficient asparaginase effect during post-induction treatment. The probability of an allergic reaction to asparaginase is related to the number of doses and most notably with the re-exposure after an extended asparaginase-free interval (Muller and Boos, 1998).

For these reasons, the use of the pegylated L-ASP product appears to be reasonable for treatment of HR patients where L-ASP is used extensively and with repeated exposures.

In HR patients, the MRD response in the 2000 study has been associated with a very strong prognostic impact. It may thus be very important to reduce the MRD load at TP2 and in particular during the consolidation phase Protocol IB. L-ASP appears to be very indicated to this purpose and in fact it has been given in parallel with other drugs by groups such as the CCSG and the EORTC-CLCG during this phase.

For these reasons, a randomized study question on the efficacy of an intensive and extended asparaginase exposure during consolidation phase Protocol IB has been implemented in trial AIEOP-BFM ALL 2009. Patients are thus randomized to receive or not 4 weekly doses of PEG-L-ASP during Protocol phase IB (“Protocol IB-ASP+”) (Figure 11). This treatment choice is based on the concept that early and intensive exposure to this drug may prevent allergic reactions or silent drug inactivations and thus be more effective.

During asparaginase treatment, a prospective evaluation of asparaginase activity and antibody formation is conducted as add-on study (see section 16).

2.3.3 PEG-L-asparaginase as first-line L-asparaginase product

Covalent linkage of the synthetic substrate polyethylene glycole (PEG) to native E. coli L-asparaginase results in PEG L-asparaginase (PEG-L-ASP), which has a lower immunogenicity and a fivefold longer half-life in comparison to native E.coli L-ASP (Abuchowski et al., 1984; Asselin et al., 1993; Muller et al., 2000; Park et al., 1981). PEG-L- ASP has been administered for several years in the treatment of ALL. In the former trial AIEOP-BFM ALL 2000, PEG-L-ASP was administered as second-line asparaginase preparation in the case of allergic reaction to native E. coli L-ASP. In this trial, PEG-L-ASP was well tolerated and not associated with unexpected specific side effects.

Recent experiences from several collaborative groups demonstrate that the use of PEG-L- ASP in the front-line treatment for childhood and adult ALL is effective, with a tolerable toxicity profile, similar to that observed with the native product (Abshire et al., 2000; Avramis et al., 2002; Jarrar et al., 2006; Rizzari et al., 2006; Wetzler et al., 2007). A more recent UK experience suggests that the substitution of native E. coli product with pegylated product may reduce the ALL relapse rate, based on a historical control (personal communication from A. Vora and N. Goulden).

Data on effectiveness of PEG-L-ASP on ASN depletion in CSF are not definitely clear, but it seems to depend strictly on the dosage and treatment schedule used. The use of PEG-L- ASP at 1000 IU/m 2 is known to be associated with inadequate ASN depletion in CSF (Appel et al., 2008; Rizzari et al., 2006). On the contrary, a better ASN depletion in CSF is observed when PEG-L-ASP is administered at higher dosage (Vieira Pinheiro et al., 2006). Thus, PEG-

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L-ASP given at the dosage of 2 500 IU/m 2 could offer an adequate ASN depletion in CSF and may thus be effective in preventing CNS relapses. No study has shown yet that inadequate ASN depletion in the CSF when using PEG-L-ASP results in an increase of CNS related relapses.

The pegylated product has been widely introduced in ALL front-line protocols in the U.S. and Europe aiming to obtain optimal L-ASP activity and L-ASN depletion, which should result in better efficacy to prevent ALL systemic relapses too.

In AIEOP-BFM ALL 2009, PEG-L-ASP is used as first-line asparaginase preparation in all patients. It is given at the dose of 2 500 IU/m 2 /d i.v. (2 h) with a maximal absolute dose of 3 750 IU.

The drug is given in Protocol IA on day 12 and 26, in each HR block in one single dose on day 6, and in the reintensification elements Protocol II on day 8 and Protocol III on day 1.

For HR patients randomized to receive additional PEG-L-ASP during Protocol IB see section 9.1.5. For pB-ALL/MR patients randomized (R2) to the experimental arm see section 9.4

2.3.4 Addition of a CPM dose during Protocol IA in T-ALL/PPR patients

Patients with T-ALL and PPR receive an additional dose of cyclophosphamide in Protocol IA (day 10) with the aim to obtain a faster clearance of leukemic cells. This choice is based on the experience of the EORTC trial (personal communication from Y. Benoit and Y. Bertrand) which shows that an intensification of Protocol IA not only with cyclophosphamide (CPM) but also with one dose of high-dose methotrexate (HD-MTX) is feasible with acceptable toxicity and no increased risk of early deaths.

2.3.5 Intensified treatment before SCT in “MRD Non-Responders”

Measurements of MRD during HR treatment can identify a small patient group with inadequate MRD response to the HR courses and a very poor prognosis despite stem cell transplantation. Therefore, a “real-time” MRD monitoring over the HR blocks is implemented in the current trial for patients with MRD load of 10 -3 at week 12. In patients with persistently high MRD load of 10 -3 or higher under the following HR treatment, a better response under continuation of the conventional HR therapy is not to be expected and the prognosis of patients entering stem cell transplantation with high MRD load is very poor. Thus, in AIEOP- BFM ALL 2009, those patients receive an alternative chemotherapy element, DNX-FLA, with the aim to further reduce the MRD load before going into stem cell transplantation. DNX-FLA is an established chemotherapy element which has been frequently administered in the treatment of patients with refractory AML (Clavio et al., 2004).

Since 2006, eight patients with initial ALL and three patients with relapsed ALL with poor morphological or MRD response have been treated according to this concept as curative attempt in the BFM study group. In eight of these patients, the MRD load could be significantly reduced (by one or more log steps) by administration of DNX-FLA. One of these well-responding patients had an early relapse and seven patients underwent alloHSCT. One of them died from toxicity, one patient relapsed and five of them had been in remission for 22, 28, 30, 31 and 35 months since alloHSCT, respectively, as of June 2009. Two of the three patients, who did not respond to DNX-FLA, had a further disease progression; the third patient had been in CCR for 23 months after alloHSCT (as of June 2009). The element was very well tolerated by all patients without serious toxicity.

Other therapeutical elements may substitute DNX-FLA in the future if they were considered worth to be evaluated for this patients group.

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2.3.6 Omission of pCRT in specific subgroups of T-ALL and HR patients and in patients younger than 2 years of age

Patients with T-ALL and high-risk patients were the only ones who still received preventive cranial radiotherapy (pCRT) in AIEOP-BFM ALL 2000. The updated results from the trial ALL-BFM 90 showed a cumulative incidence of brain tumors of 3.41.6 % after 16 years among the patients who had received 12 Gy pCRT. This demonstrates that even with reduced irradiation dose secondary brain tumors are still a major concern of CRT encouraging the omission of CRT in as many patients as possible. In AIEOP-BFM ALL 2000, non-HR T-ALL patients with initial WBC of < 100 000/µl were not irradiated in AIEOP while in BFM these patients received 12 Gy pCRT. There was no significant difference in EFS in these patients comparing AIEOP and BFM. In AIEOP-BFM ALL 2009, non-HR T-ALL patients with initial WBC of < 100 000/µl are no longer irradiated. Furthermore, due to the good prognosis of HR patients with pB-ALL and prednisone-poor response as only HR criterion, this subgroup does also not receive pCRT. Also pB-ALL patients with 10% blasts in day 15 bone marrow by FCM and/or with PCR-MRD MR slow early response (SER, for definition see section 4.5), who were treated in MR and were not irradiated in the 2000 study, although treated as HR in the 2009 study, do not receive pCRT. Thus, patients at HR only for PPR and/or 10% blasts at day 15 bone marrow by FCM and/or PCR-MRD MR SER do not receive pCRT in the 2009 study.

Despite the likewise excellent prognosis of patients with T-ALL with prednisone-poor response as only HR criterion, pCRT has been retained in this patient group because of the generally higher risk of CNS relapses in T-ALL patients. Due to the high rate of potential irradiation-associated late effects in the young age, patients younger than 2 years of age (at start of irradiation) do no longer receive pCRT in AIEOP-BFM ALL 2009. T-ALL or HR patients who are no longer preventively irradiated instead receive intensified intrathecal therapy during maintenance.

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3

Differences to the Previous Study AIEOP-BFM ALL 2000

3.1

Stratification

As in AIEOP-BFM ALL 2000, prednisone response, remission status on day 33, PCR-MRD and presence of MLL/AF4 are still used as stratification criteria in AIEOP-BFM ALL 2009 (BCR/ABL patients are to be treated in the EsPhALL study). In addition, patients are stratified by immunophenotype (T-ALL or pB-ALL), presence of TEL/AML1, hypodiploidy, and according to MRD results on day 15 in bone marrow measured by flow cytometry. Patients with pB-ALL (or unknown immunophenotype) and PCR-MRD load of 10 -3 at TP 1 and any positivity < 10 -3 at TP 2 qualify for treatment in risk group HR (new PCR-MRD MR Slow Early Responder (SER) group). Stratification criteria are specified in section 6.3 (page 32).

3.2 MRD risk group classification criteria

In the case of non-availability of at least two sensitive MRD markers (sensitivity at least 10 -4 ), MRD risk group stratification can also be based on only one sensitive marker. However, the identification and use of at least two sensitive markers is still to be attempted.

3.3 Treatment

Differences to the former trial which arise from the randomized treatment questions are specified in the sections 2.2.2 and 2.3.2.

3.3.1 Choice of steroid preparation in Protocol IA

After prednisone prephase, only T-ALL PGR patients receive dexamethasone; all other patients continue steroid treatment in Protocol IA with prednisone.

3.3.2 Choice of PEG-L-asparaginase as first-line L-asparaginase product

PEG-L-ASP is used as first-line asparaginase preparation in all patients. It is given at the dose of 2 500 IU/m 2 /single dose i.v. (2 h) with a maximal absolute single dose of 3 750 IU.

The drug is given in Protocol IA on day 12 and 26, in each HR block in one single dose on day 6, and in the reintensification elements Protocol II on day 8 and Protocol III on day 1.

For HR patients randomized to receive additional PEG-L-ASP during Protocol IB see section 9.1.5. For pB-ALL/MR patients randomized (R2) to the experimental arm see section 9.4

3.3.3 Addition of a cyclophosphamide dose during Protocol IA in T-ALL/PPR patients

Patients with T-ALL and PPR receive an additional dose of cyclophosphamide in Protocol IA (day 10).

3.3.4 Reintensification therapy in SR and MR

All SR and MR patients receive Protocol II as reintensification.

3.3.5 Intensified consolidation (HR blocks) and reintensification in HR

The new HR group corresponds to the former HR group supplemented by patients with hypodiploidy or slow response in bone marrow at day 15 (FCM-MRD 10% blasts) or pB- ALL with slow response on day 33 (PCR-MRD < 10 -3 at TP2 and 10 -3 at TP1). After Protocol I HR patients receive 3 HR blocks (HR-1’, HR-2’, HR’3) followed by Protocol III given three times as reintensification treatment.

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3.3.6 Intrathecal drugs in HR blocks

Intrathecal therapy has not changed for AIEOP patients (methotrexate i.th.). BFM patients also receive only methotrexate intrathecally during HR blocks instead of triple therapy, which was given in ALL-BFM 2000. In block HR-3’, i. th. dose is now scheduled on day 1 (formerly day 5) and can therefore be performed at the same time as the bone marrow puncture.

3.3.7 Length of dexamethasone phase in Protocol IIIA

In Protocol IIIA, dexamethasone is now given for 14 days plus tapering (in ALL-BFM 2000 formerly 15 days, only new in BFM).

3.3.8 Dosage of Erwinia asparaginase

Erwinia asparaginase is available as second-line preparation after allergy to the PEG-L-ASP and is recommended at the dosage of 20 000 IU/m 2 /dose i.v. over 1 h or i.m. every second day for the whole period planned for asparaginase therapy, i.e. up to a total duration of exposure of 28 days in Protocol IA, 14 days in Protocol II or Protocol III and 14 days after each HR block (beginning on day 6 for a total of 7 doses). In case of allergic reaction to PEG-L-ASP during experimental arms (R 2 , R HR ), substitution with Erwinia asparaginase is not recommended except for allergy to the first dose in Protocol II in R 2 experimental as well as control arm. For specific recommendations see section 26.3.1 in the national protocol part.

3.3.9 Timing of i.th. methotrexate during high-dose methotrexate

Intrathecal methotrexate is now allowed to be given at any time during the 24 h high-dose methotrexate i.v. infusion.

3.3.10 Cranial radiotherapy

Preventive cranial radiotherapy (pCRT) is omitted in certain subgroups, which receive additional intrathecal methotrexate in maintenance therapy (see section 9.10)

3.3.11 Retinal involvement

Isolated retinal involvement is no longer a criterion of CNS involvement (only new in BFM), i.e. it does not qualify for additional intrathecal therapy and therapeutic cranial irradiation.

3.4

Initial diagnostics:

X-ray of the lumbar vertebral column at initial diagnosis is no longer recommended (only new in BFM).

Since hypodiploidy qualifies for high-risk treatment in the study AIEOP-BFM ALL 2009, cytogenetics or DNA index or SNPs arrays are mandatory for all patients.

Follow-up diagnostics:

MRD on day 15 (by PCR and by flow cytometry) is prospectively analyzed for all patients and MRD by flow cytometry (FCM) on day 15 is used for stratification as specified in section 6.3.

Bone marrow punctures for MRD diagnostics before each HR element are mandatory in all HR patients, especially patients with poor MRD response by TP2 (MRD TP2 10 -3 ) since the subsequent MRD response in these patients has implication for further treatment.

Bone marrow punctures at week 52 and 104 (one year after diagnosis and at the end of maintenance) are no longer required.

Diagnostics

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Definitions of Response and Remission Status

4.1

Prednisone response

The prednisone response is evaluated at the end of the cytoreductive prephase with 7 days prednisone and one dose intrathecal methotrexate. The absolute blast count in the peripheral blood on day 8 is decisive for categorization.

- Prednisone Good Response (PGR): absolute blast count in peripheral blood < 1 000/µl

- Prednisone Poor Response (PGR): absolute blast count in peripheral blood 1 000/µl

4.2 Complete remission

Complete remission can per definitionem not be stated before day 33 of Protocol I.

Complete remission (CR) has been achieved when the following criteria are fulfilled:

- < 5 % blast cells (M1) in representative bone marrow with sufficient cellularity and signs of regeneration of normal myelopoiesis

- 5 nucleated cells/µl in CSF, or > 5 nucleated cells/µl and no evidence of blasts in cytospin

- no evidence of leukemic infiltrates as evaluated clinically and by imaging; a preexisting mediastinal mass must have decreased at least to 1/3 of the initial tumor volume

Identification of residual blast cells by PCR or flow cytometry is not decisive for assessment

of complete remission.

4.3 Late-Response

A patient, who is not in CR on day 33 but achieves CR in the regenerating bone marrow with

Protocol IB or any of the three HR blocks, is classified as having Late-Response.

4.4 Morphological Non-Response (resistance to protocol)

A

patient, who has not achieved CR in the regenerating bone marrow after the 3 rd HR block,

is

classified as having morphological Non-Response (resistance to protocol).

4.5 Response by PCR-MRD and resulting PCR-MRD risk groups

Risk stratification by PCR-MRD uses the MRD load in bone marrow on day 33 (TP1) and at week 12 (before Protocol M or 1 st HR block, TP2).

According to PCR-MRD analysis, it is possible to define three risk groups:

- PCR-MRD-SR: MRD negative at TP1 and TP2 with at least one, if possible two markers with a sensitivity of at least 10 -4 .

- PCR-MRD-MR: MRD positive at TP1 and/or TP2, and MRD load < 10 -3 at TP2.

o PCR-MRD MR Slow Early Responders (SER): MRD 10 -3 at TP1 and MRD positive at a level of < 10 -3 at TP2. (Note: PCR-MRD MR SER patients with pB-ALL (or unknown immunophenotype) have to be treated in the HR arm)

- PCR-MRD-HR: MRD 10 -3 at TP2.

For integration of PCR-MRD results in the final risk group assignment see section 6.3.3, page 32.

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4.6 Response by FCM-MRD

The following MRD levels in bone marrow on day 15 measured by flow cytometry (FCM- MRD) are relevant for treatment and risk group assignment:

- FCM-MRD on day 15 < 0.1 % lymphoblasts in bone marrow

- FCM-MRD on day 15 0.1 % and < 10 % lymphoblasts in bone marrow

- FCM-MRD on day 15 10 % lymphoblasts in bone marrow

FCM-MRD is used for eligibility for randomization R1 (see section 6.4.1). For final risk group assignment, FCM-MRD becomes relevant, if PCR-based MRD classification is ambiguous or not feasible (see section 6.3.3, page 32) and, regardless of PCR-MRD status, in case of FCM-MRD on day 15 10% (patient allocated to HR; see 6.3.2, page 32).

4.7 Relapse

The diagnosis of a relapse can only be made if complete remission has been achieved before.

Definitions:

Isolated bone marrow relapse:

- 25 % lymphoblasts in bone marrow without extramedullary involvement.

Combined bone marrow relapse:

- 5 % lymphoblasts in bone marrow and at least one extramedullary site localization

CNS relapse:

- > 5/µl nucleated cells in CSF and morphologically unequivocal evidence of lymphoblasts

- If an intracranial mass is detected by imaging without evidence of blasts in CSF and this tumor is the only site of the suspected relapse, a biopsy is required.

Testicular relapse:

- unilateral or bilateral painless hard testicular tumor

- If the testis is the only site of the suspected relapse, a biopsy of the tumor is mandatory.

Other extramedullary relapse:

- Diagnosis needs imaging and/or biopsy.

Identification of blast cells by PCR or flow cytometry but morphological remission is not sufficient for diagnosis of relapse.

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Study Objectives

5.1

Primary objectives

The primary aims of the AIEOP-BFM ALL 2009 study are to answer the following questions:

- Non-HR pB-ALL patients with TEL/AML1-negative ALL or unknown TEL/AML1 status and FCM-MRD in bone marrow on day 15 < 0.1 % or with TEL/AML1-positive ALL (randomized study question): can the daunorubicin dose in Protocol IA be safely reduced by 50 % with a non-inferior EFS and a reduction of toxicity (treatment-related mortality and AE/SAE in Protocol I)?

- Patients with precursor-B ALL and risk group MR (randomized study question): can the clinical outcome be improved by protracted asparagine depletion achieved through application of intensified pegylated L-asparaginase during reintensification and early maintenance?

- High Risk patients (as identified by day 33 - randomized study question): can the clinical outcome be improved by protracted exposure to PEG-L-asparaginase during Protocol IB?

5.2 Secondary objectives

The secondary goals of the AIEOP-BFM ALL 2009 study are to answer the following questions:

- Standard risk patients identified by at least one sensitive marker: Is the clinical outcome comparable to that obtained in SR patients (identified with two sensitive markers) in AIEOP-BFM ALL 2000, or can the outcome even be improved with the use of PEG-L- asparaginase instead of native E. coli L-asparaginase?

- T-ALL non-HR patients: Can the high level of outcome (pEFS) which was obtained for these patients in study AIEOP-BFM ALL 2000 be preserved or even improved with the use of PEG-L-ASP instead of native E.coli L-ASP?

- HR patients with persistingly high MRD levels despite the use of the HR blocks in the reintensification phase, “MRD Non-Responders”: Is it possible to improve the outcome and to achieve a further reduction of leukemic cell burden by administration of an innovative treatment schedule (DNX-FLA)? NOTE: if new drugs or therapeutic options become available, the experimental treatment planned in this patient group may change during the course of the study.

- Patients participating in the randomized asparaginase studies (pB-ALL/MR, HR): Are asparaginase activity and asparaginase antibodies associated with development of allergic reactions, and do they have an effect on the outcome of the patients?

- What is the relative value of different methods of MRD monitoring in the definition of alternative stratification systems within the BFM-oriented protocol?

5.3 Add-on studies

(for details see section 17, page 100)

Microarray analysis-based studies

o

Early diagnosis of very high-risk (refractory) childhood acute lymphoblastic leukemia (BFM)

o

Integration of genotyping, gene and microRNA expression in MRD-based subgroups of B-cell precursor patients (AIEOP)

o

Comprehensive genetic characterization of the different response to treatment in T-ALL (AIEOP)

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o Integration of genotyping, gene expression and miRNA expression in BCP- ALL 'others' patients (AIEOP)

Comprehensive characterization of extramedullary disease

o

Flow-cytometric study on cerebrospinal fluid (AIEOP)

o

PCR-based detection of leukemia-specific immunoglobulin and T-cell receptor rearrangements in cerebrospinal fluid in comparison to cytomorphological analysis (BFM)

o

Prospective assessment of the diagnostic qualities of leukemic expression of a gene set including IL-15 for an improved characterization of leukemic involvement of the CNS and other extramedullary sites (AIEOP, BFM)

o

Modeling pathomechanisms of extramedullary leukemia (INS)

Prospective evaluation of genetic aberrations and genetic variants of currently unknown prognostic value (AIEOP, BFM)