T-cell acute lymphoblastic leukemia, pediatric

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 Wayne H. Liang, MD, MS, FAMIA
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This page contains studies that were specific to pediatric populations. For the more general T-cell acute lymphoblastic leukemia page, follow this link.

16 regimens on this page
17 variants on this page


Guidelines

"How I Treat"

NCCN

Upfront induction therapy

Daunorubicin, Pegaspargase, Vincristine, Dexamethasone

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Regimen, modified ABFM

Study Evidence
Vora et al. 2013 (UKALL 2003) Non-randomized portion of RCT

Chemotherapy

CNS prophylaxis

  • Cytarabine (Ara-C) as follows:
    • Ages 1 to 1.99: 30 mg IT once on day 1
    • Ages 2 to 2.99: 50 mg IT once on day 1
    • Age 3 and older: 70 mg IT once on day 1
  • Methotrexate (MTX) as follows:
    • Ages 1 to 1.99: 8 mg IT once per day on days 8 & 29
    • Ages 2 to 2.99: 10 mg IT once per day on days 8 & 29
    • Ages 3 to 8.99: 12 mg IT once per day on days 8 & 29
    • Age 9 and older: 15 mg IT once per day on days 8 & 29

4-week course

Subsequent treatment

References

  1. UKALL 2003: Vora A, Goulden N, Wade R, Mitchell C, Hancock J, Hough R, Rowntree C, Richards S. Treatment reduction for children and young adults with low-risk acute lymphoblastic leukaemia defined by minimal residual disease (UKALL 2003): a randomised controlled trial. Lancet Oncol. 2013 Mar;14(3):199-209. link to original article PubMed ISRCTN07355119

Daunorubicin, Pegaspargase, Vincristine, Prednisone

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Regimen

Study Evidence
Winter et al. 2015 (COG AALL0434) Non-randomized portion of RCT

Chemotherapy

4-week course

Subsequent treatment

References

  1. COG AALL0434: Winter SS, Dunsmore KP, Devidas M, Eisenberg N, Asselin BL, Wood BL, Leonard Rn MS, Murphy J, Gastier-Foster JM, Carroll AJ, Heerema NA, Loh ML, Raetz EA, Winick NJ, Carroll WL, Hunger SP. Safe integration of nelarabine into intensive chemotherapy in newly diagnosed T-cell acute lymphoblastic leukemia: Children's Oncology Group Study AALL0434. Pediatr Blood Cancer. 2015 Jul;62(7):1176-83. Epub 2015 Mar 8. link to original article link to PMC article contains verified protocol PubMed NCT00408005

DOLP

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DOLP: Daunorubicin, Oncovin (Vincristine), L-Asparaginase, Prednisone
DVPA: Daunorubicin, Vincristine, Prednisone, Asparaginase

Regimen (BFM 76/79 Phase I)

Study Years of enrollment Evidence Comparator Comparative Efficacy
Gaynon et al. 1988 (CCG-106) 1983-1984 Phase III (E-esc) 1. Control regimen Seems to have superior EFS36
2. New York regimen Did not meet primary endpoint of EFS36
Steinherz et al. 1998 (CCG-123) 1983-1985 Phase III (C) 1. LSA2-L2 & WBRT
2. LSA-L2
3. New York regimen 		Did not meet primary endpoint of EFS

Note: the specific days of L-asparaginase are not specified; the schedule here is similar to those of other similar protocols.

Chemotherapy

CNS therapy

6-week course

Subsequent treatment

  • BFM 76/79 Phase II

References

  1. CCG-106: Gaynon PS, Steinherz PG, Bleyer WA, Ablin AR, Albo VC, Finklestein JZ, Grossman NJ, Littman PS, Novak LT, Pyesmany AF, Sather HN, Hammond GD. Intensive therapy for children with acute lymphoblastic leukaemia and unfavourable presenting features: early conclusions of study CCG-106 by the Childrens Cancer Study Group. Lancet. 1988 Oct 22;2(8617):921-4. link to original article PubMed
  2. CCG-123: Steinherz PG, Gaynon PS, Breneman JC, Cherlow JM, Grossman NJ, Kersey JH, Johnstone HS, Sather HN, Trigg ME, Uckun FM, Bleyer WA. Treatment of patients with acute lymphoblastic leukemia with bulky extramedullary disease and T-cell phenotype or other poor prognostic features: randomized controlled trial from the Children's Cancer Group. Cancer. 1998 Feb 1;82(3):600-12. link to original article contains verified protocol PubMed

Consolidation after upfront therapy

Cyclophosphamide, Cytarabine, Mercaptopurine, Nelarabine, Pegaspargase, Vincristine

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Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy Comparative Toxicity
Winter et al. 2015 (COG AALL0434) 2007-2010 Phase III (E-esc) Cyclophosphamide, Cytarabine, Mercaptopurine, Pegaspargase, Vincristine Not reported Similar toxicity

Note: although the induction doses of vincristine are capped at 2 mg, capping is not mentioned in the subsequent phases of treatment.

Preceding treatment

Chemotherapy

CNS prophylaxis

71-day course

Subsequent treatment

  • Interim maintenance; see paper for details

References

  1. COG AALL0434: Winter SS, Dunsmore KP, Devidas M, Eisenberg N, Asselin BL, Wood BL, Leonard Rn MS, Murphy J, Gastier-Foster JM, Carroll AJ, Heerema NA, Loh ML, Raetz EA, Winick NJ, Carroll WL, Hunger SP. Safe integration of nelarabine into intensive chemotherapy in newly diagnosed T-cell acute lymphoblastic leukemia: Children's Oncology Group Study AALL0434. Pediatr Blood Cancer. 2015 Jul;62(7):1176-83. Epub 2015 Mar 8. link to original article link to PMC article contains verified protocol PubMed NCT00408005

Cyclophosphamide, Cytarabine, Mercaptopurine, Pegaspargase, Vincristine

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Regimen variant #1

Study Years of enrollment Evidence Comparator Comparative Efficacy Comparative Toxicity
Winter et al. 2015 (COG AALL0434) 2007-2010 Phase III (C) Cyclophosphamide, Cytarabine, Mercaptopurine, Nelarabine, Pegaspargase, Vincristine Not reported Similar toxicity

Note: although the induction doses of vincristine are capped at 2 mg, capping is not mentioned in the subsequent phases of treatment.

Preceding treatment

Chemotherapy

CNS prophylaxis

71-day course

Subsequent treatment

  • Interim maintenance; see paper for details

Regimen variant #2

Study Evidence
Children's Oncology Group (COG AALL1231) Non-randomized portion of RCT

Note: this regimen is available as a COG protocol but no manuscript has been published yet, to our knowledge. Per the protocol, it is intended only for patients greater than 1 and less than 31 years of age.

Preceding treatment

Chemotherapy

Supportive medications

  • Mesna (Mesnex) "is not required for this dose of cyclophosphamide, but may be administered at institutional discretion."

CNS prophylaxis

  • Methotrexate (MTX) as follows, for CNS3:
    • Ages 1 to 1.99: 8 mg IT once per day on days 1 & 8
    • Ages 2 to 2.99: 10 mg IT once per day on days 1 & 8
    • Ages 3 to 8.99: 12 mg IT once per day on days 1 & 8
    • Age 9 and older: 15 mg IT once per day on days 1 & 8

50-day course

Subsequent treatment

  • See protocol for details of treatment beyond consolidation, which is guided by MRD status obtained at the end of induction.

References

  1. COG AALL0434: Winter SS, Dunsmore KP, Devidas M, Eisenberg N, Asselin BL, Wood BL, Leonard Rn MS, Murphy J, Gastier-Foster JM, Carroll AJ, Heerema NA, Loh ML, Raetz EA, Winick NJ, Carroll WL, Hunger SP. Safe integration of nelarabine into intensive chemotherapy in newly diagnosed T-cell acute lymphoblastic leukemia: Children's Oncology Group Study AALL0434. Pediatr Blood Cancer. 2015 Jul;62(7):1176-83. Epub 2015 Mar 8. link to original article link to PMC article contains verified protocol PubMed NCT00408005
  2. COG AALL1231: NCT02112916

Doxorubicin, L-asparaginase, Mercaptopurine, Vincristine, Prednisone

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Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Asselin et al. 2011 (POG 9404) 1996-2001 Phase III (C) Doxorubicin, L-asparaginase, Mercaptopurine, Methotrexate, Vincristine, Prednisone Seems to have inferior EFS

Chemotherapy

References

  1. POG 9404: Asselin BL, Devidas M, Wang C, Pullen J, Borowitz MJ, Hutchison R, Lipshultz SE, Camitta BM. Effectiveness of high-dose methotrexate in T-cell lymphoblastic leukemia and advanced-stage lymphoblastic lymphoma: a randomized study by the Children's Oncology Group (POG 9404). Blood. 2011 Jul 28;118(4):874-83. Epub 2011 Apr 7. link to original article link to PMC article PubMed

Doxorubicin, L-asparaginase, Mercaptopurine, Methotrexate, Vincristine, Prednisone

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Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Asselin et al. 2011 (POG 9404) 1996-2001 Phase III (E-esc) Doxorubicin, L-asparaginase, Mercaptopurine, Vincristine, Prednisone Seems to have superior EFS

Chemotherapy

References

  1. POG 9404: Asselin BL, Devidas M, Wang C, Pullen J, Borowitz MJ, Hutchison R, Lipshultz SE, Camitta BM. Effectiveness of high-dose methotrexate in T-cell lymphoblastic leukemia and advanced-stage lymphoblastic lymphoma: a randomized study by the Children's Oncology Group (POG 9404). Blood. 2011 Jul 28;118(4):874-83. Epub 2011 Apr 7. link to original article link to PMC article PubMed

Etoposide & TBI, then allo HSCT

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Regimen

Study Evidence
Peters et al. 2015 (ALL-SCT-BFM 2003) Non-randomized

Chemotherapy

Radiotherapy

Immunotherapy

One course

Immunotherapy

Stem cells transfused on day 0

References

  1. ALL-BFM 90: Schrappe M, Reiter A, Ludwig WD, Harbott J, Zimmermann M, Hiddemann W, Niemeyer C, Henze G, Feldges A, Zintl F, Kornhuber B, Ritter J, Welte K, Gadner H, Riehm H; German-Austrian-Swiss ALL-BFM Study Group. Improved outcome in childhood acute lymphoblastic leukemia despite reduced use of anthracyclines and cranial radiotherapy: results of trial ALL-BFM 90. Blood. 2000 Jun 1;95(11):3310-22. link to original article contains verified protocol PubMed
    1. Subgroup analysis: Schrauder A, Reiter A, Gadner H, Niethammer D, Klingebiel T, Kremens B, Peters C, Ebell W, Zimmermann M, Niggli F, Ludwig WD, Riehm H, Welte K, Schrappe M. Superiority of allogeneic hematopoietic stem-cell transplantation compared with chemotherapy alone in high-risk childhood T-cell acute lymphoblastic leukemia: results from ALL-BFM 90 and 95. J Clin Oncol. 2006 Dec 20;24(36):5742-9. link to original article PubMed
  2. ALL-BFM 95: Möricke A, Reiter A, Zimmermann M, Gadner H, Stanulla M, Dördelmann M, Löning L, Beier R, Ludwig WD, Ratei R, Harbott J, Boos J, Mann G, Niggli F, Feldges A, Henze G, Welte K, Beck JD, Klingebiel T, Niemeyer C, Zintl F, Bode U, Urban C, Wehinger H, Niethammer D, Riehm H, Schrappe M; German-Austrian-Swiss ALL-BFM Study Group. Risk-adjusted therapy of acute lymphoblastic leukemia can decrease treatment burden and improve survival: treatment results of 2169 unselected pediatric and adolescent patients enrolled in the trial ALL-BFM 95. Blood. 2008 May 1;111(9):4477-89. Epub 2008 Feb 19. Erratum in: Blood. 2009 Apr 30;113(18):4478. Dosage error in article text. link to original article contains verified protocol PubMed
    1. Subgroup analysis: Schrauder A, Reiter A, Gadner H, Niethammer D, Klingebiel T, Kremens B, Peters C, Ebell W, Zimmermann M, Niggli F, Ludwig WD, Riehm H, Welte K, Schrappe M. Superiority of allogeneic hematopoietic stem-cell transplantation compared with chemotherapy alone in high-risk childhood T-cell acute lymphoblastic leukemia: results from ALL-BFM 90 and 95. J Clin Oncol. 2006 Dec 20;24(36):5742-9. link to original article PubMed
  3. ALL-SCT-BFM-2003: Peters C, Schrappe M, von Stackelberg A, Schrauder A, Bader P, Ebell W, Lang P, Sykora KW, Schrum J, Kremens B, Ehlert K, Albert MH, Meisel R, Matthes-Martin S, Gungor T, Holter W, Strahm B, Gruhn B, Schulz A, Woessmann W, Poetschger U, Zimmermann M, Klingebiel T. Stem-cell transplantation in children with acute lymphoblastic leukemia: a prospective international multicenter trial comparing sibling donors with matched unrelated donors-the ALL-SCT-BFM-2003 trial. J Clin Oncol. 2015 Apr 10;33(11):1265-74. Epub 2015 Mar 9. link to original article PubMed

L-asparaginase monotherapy

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Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Amylon et al. 1999 (POG 8704) 1987-1992 Phase III (E-esc) No L-asp Superior CRR

Chemotherapy

28-day cycle for 5 cycles

References

  1. POG 8704: Amylon MD, Shuster J, Pullen J, Berard C, Link MP, Wharam M, Katz J, Yu A, Laver J, Ravindranath Y, Kurtzberg J, Desai S, Camitta B, Murphy SB. Intensive high-dose asparaginase consolidation improves survival for pediatric patients with T cell acute lymphoblastic leukemia and advanced stage lymphoblastic lymphoma: a Pediatric Oncology Group study. Leukemia. 1999 Mar;13(3):335-42. link to original article contains protocol PubMed

Interim maintenance

Mercaptopurine, Methotrexate, Vincristine

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BFM HDMTX: Berlin Frankfurt Muenster High-Dose MTX (Methotrexate) regimen

Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Winter et al. 2015 (COG AALL0434) 2007-2010 Phase III (C) COG C-MTX Seems to have inferior OS1

1Reported efficacy is based on the 2018 update.
Details to be completed

Preceding treatment

Chemotherapy

8-week course

Subsequent treatment

  • Delayed intensification

References

  1. COG AALL0434: Winter SS, Dunsmore KP, Devidas M, Eisenberg N, Asselin BL, Wood BL, Leonard Rn MS, Murphy J, Gastier-Foster JM, Carroll AJ, Heerema NA, Loh ML, Raetz EA, Winick NJ, Carroll WL, Hunger SP. Safe integration of nelarabine into intensive chemotherapy in newly diagnosed T-cell acute lymphoblastic leukemia: Children's Oncology Group Study AALL0434. Pediatr Blood Cancer. 2015 Jul;62(7):1176-83. Epub 2015 Mar 8. link to original article link to PMC article contains verified protocol PubMed NCT00408005
    1. Update: Winter SS, Dunsmore KP, Devidas M, Wood BL, Esiashvili N, Chen Z, Eisenberg N, Briegel N, Hayashi RJ, Gastier-Foster JM, Carroll AJ, Heerema NA, Asselin BL, Gaynon PS, Borowitz MJ, Loh ML, Rabin KR, Raetz EA, Zweidler-Mckay PA, Winick NJ, Carroll WL, Hunger SP. Improved survival for children and young adults with T-lineage acute lymphoblastic leukemia: results from the Children's Oncology Group AALL0434 methotrexate randomization. J Clin Oncol. 2018 Oct 10;36(29):2926-2934. Epub 2018 Aug 23. link to original article PubMed

Methotrexate, Pegaspargase, Vincristine

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COG C-MTX: Children's Oncology Group Capizzi-style MTX (Methotrexate) regimen

Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Winter et al. 2015 (COG AALL0434) 2007-2010 Phase III (C) BFM HDMTX Seems to have superior OS

Details to be completed; reported efficacy is based on the 2018 update.

Preceding treatment

Chemotherapy

8-week course

Subsequent treatment

  • Delayed intensification

References

  1. COG AALL0434: Winter SS, Dunsmore KP, Devidas M, Eisenberg N, Asselin BL, Wood BL, Leonard Rn MS, Murphy J, Gastier-Foster JM, Carroll AJ, Heerema NA, Loh ML, Raetz EA, Winick NJ, Carroll WL, Hunger SP. Safe integration of nelarabine into intensive chemotherapy in newly diagnosed T-cell acute lymphoblastic leukemia: Children's Oncology Group Study AALL0434. Pediatr Blood Cancer. 2015 Jul;62(7):1176-83. Epub 2015 Mar 8. link to original article link to PMC article contains verified protocol PubMed NCT00408005
    1. Update: Winter SS, Dunsmore KP, Devidas M, Wood BL, Esiashvili N, Chen Z, Eisenberg N, Briegel N, Hayashi RJ, Gastier-Foster JM, Carroll AJ, Heerema NA, Asselin BL, Gaynon PS, Borowitz MJ, Loh ML, Rabin KR, Raetz EA, Zweidler-Mckay PA, Winick NJ, Carroll WL, Hunger SP. Improved survival for children and young adults with T-lineage acute lymphoblastic leukemia: results from the Children's Oncology Group AALL0434 methotrexate randomization. J Clin Oncol. 2018 Oct 10;36(29):2926-2934. Epub 2018 Aug 23. link to original article PubMed

Relapsed or refractory

Mitoxantrone, Asparaginase Erwinia chrysanthemi, Vincristine, Dexamethasone

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Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Parker et al. 2010 (CCLG ALL R3) 2003-NR Phase III, <20 pts in this subgroup (E-switch-ic) Idarubicin, Asparaginase Erwinia chrysanthemi, Vincristine, Dexamethasone Did not meet primary endpoint of PFS

Note: per the protocol, this regimen is intended only for patients 18 and younger and for patients allergic to pegaspargase. This is the same regimen used in relapsed B-ALL, but this subgroup did not have a statistically significant difference between the regimens.

Chemotherapy

CNS prophylaxis

  • Methotrexate (MTX) as follows:
    • Age less than 2: 8 mg IT once per day on days 1 & 8
    • Age 2: 10 mg IT once per day on days 1 & 8
    • Age older than 2: 12 mg IT once per day on days 1 & 8

4-week course

Subsequent treatment

  • See paper for details of treatment beyond induction

References

  1. CCLG ALL R3: Parker C, Waters R, Leighton C, Hancock J, Sutton R, Moorman AV, Ancliff P, Morgan M, Masurekar A, Goulden N, Green N, Révész T, Darbyshire P, Love S, Saha V. Effect of mitoxantrone on outcome of children with first relapse of acute lymphoblastic leukaemia (ALL R3): an open-label randomised trial. Lancet. 2010 Dec 11;376(9757):2009-17. Epub 2010 Dec 3. link to original article contains verified protocol link to PMC article PubMed ISCRTN45724312

Mitoxantrone, Pegaspargase, Vincristine, Dexamethasone

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Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Parker et al. 2010 (CCLG ALL R3) 2003-NR Phase III, <20 pts in this subgroup (E-switch-ic) Idarubicin, Pegaspargase, Vincristine, Dexamethasone Did not meet primary endpoint of PFS

Note: per the protocol, this regimen is intended only for patients 18 and younger. This is the same regimen used in relapsed B-ALL, but this subgroup did not have a statistically significant difference between the regimens.

Chemotherapy

CNS prophylaxis

  • Methotrexate (MTX) as follows:
    • Age less than 2: 8 mg IT once per day on days 1 & 8
    • Age 2: 10 mg IT once per day on days 1 & 8
    • Age older than 2: 12 mg IT once per day on days 1 & 8

4-week course

Subsequent treatment

  • See paper for details of treatment beyond induction

References

  1. CCLG ALL R3: Parker C, Waters R, Leighton C, Hancock J, Sutton R, Moorman AV, Ancliff P, Morgan M, Masurekar A, Goulden N, Green N, Révész T, Darbyshire P, Love S, Saha V. Effect of mitoxantrone on outcome of children with first relapse of acute lymphoblastic leukaemia (ALL R3): an open-label randomised trial. Lancet. 2010 Dec 11;376(9757):2009-17. Epub 2010 Dec 3. link to original article contains verified protocol link to PMC article PubMed ISCRTN45724312

Nelarabine monotherapy

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Regimen

Study Years of enrollment Evidence Efficacy
Berg et al. 2005 1997-2002 Phase II (RT) ORR: 14-55%
Zwaan et al. 2017 (GSK 111081) 2009-2014 Phase IV ORR: 39%

Chemotherapy

21-day cycles

References

  1. Berg SL, Blaney SM, Devidas M, Lampkin TA, Murgo A, Bernstein M, Billett A, Kurtzberg J, Reaman G, Gaynon P, Whitlock J, Krailo M, Harris MB; Children's Oncology Group. Phase II study of nelarabine (compound 506U78) in children and young adults with refractory T-cell malignancies: a report from the Children's Oncology Group. J Clin Oncol. 2005 May 20;23(15):3376-82. link to original article contains protocol PubMed
  2. GSK 111081: Zwaan CM, Kowalczyk J, Schmitt C, Bielorai B, Russo MW, Woessner M, Ranganathan S, Leverger G. Safety and efficacy of nelarabine in children and young adults with relapsed or refractory T-lineage acute lymphoblastic leukaemia or T-lineage lymphoblastic lymphoma: results of a phase 4 study. Br J Haematol. 2017 Oct;179(2):284-293. Epub 2017 Aug 2. link to original article contains verified protocol PubMed
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