BFM- 95 (German Protocol)
Regimen
For Medium and High Risk Patients
Standard risk patients are, by definition, paediatric patients and are not included in the protocol as it appears here (See Risk Groups Below)
Induction therapy Phase 1 - part 1
Methotrexate 12 mg (12 mg) IT INTRATHECAL Day 1 , 12, (18, 27 CNS DISEASE AT DIAGNOSIS ONLY), 33 Prednisolone 60 mg/m² orally daily days 1 to day 29 Vincristine 1.5 mg/m² IVI Days 8,15,22,29 Daunorubicin 30 mg/m² IVI Days 8,15,22,29 L-asparaginase 5000 units/m² IVI over 60 minutes (ensure test dose has been given) given) Days 12,15,18,21,24,27,30,33
Induction therapy, Phase 1 - part 2
6-Mercaptopurine 60 mg/m² orally daily from day 36 to day 63 (28 days total) Cyclophosphamide 1000 mg/m² by IV infusion Day 36, 64 Mesna 400 mg/m² by IV infusion hours 0, 4 and 8 post cyclophosphamide Cytarabine 75 mg/m² by IV infusion daily days 38 to 41, 45 to 48, 52 to 55, 59 to 62 Methotrexate 12 mg IT INTRATHECAL Days 45, 59
MCA Consolidation
Commence this cycle 2 weeks post the completion of Part 1, phase 2
Requirements for commencing consolidation include good general condition, no severe infections, normal creatinine clearance, ALT and AST <5x upper limit of normal, bilirubin <3x upper limit of normal and adequate neutrophil/platelet recovery (WBC >1.5, neutrophils > 0.5 and platelets > 50).
Do not administer methotrexate in the absence of normal creatinine and creatinine clearance.
6-Mercaptopurine is to be temporarily ceased if cytarabine if postponed and further doses to be given at the end of the cycle.
6-Mercaptopurine 25 mg/m² orally days 1 to 56 Methotrexate 500 mg/m² IVI over 30 minutes days 8, 22, 36, 50 Methotrexate 4500 mg/m² by IV infusion over 23.5 hours days 8, 22, 36, 50 Methotrexate 12 mg IT INTRATHECAL days 8, 22, 36, 50 Leucovorin (Calcium folinate) 15 mg/m² IVI at hour 42 post commencement of MTX infusion; continue Q6H until MTX level <0.25micromol/L days 9, 23, 37, 51 Cytarabine 200 mg/m² as a continuous IV infusion over 24 hours (commence as soon as MTX has completed) Days 9, 23, 37, 51
Protocol 2, part 1
Begin this cycle 2 weeks after completing BFM MCA consolidation and WBC >2.5 x 109/L, ANC >1.0 x 109/L and platelets >100 x 109/L
Vincristine is capped at 2mg
Dexamethasone 10 mg/m² orally days 1 to 21 Methotrexate 12 mg (12 mg) IT ONLY FOR PATIENTS WITH CNS DOSEASE AT DIAGNOSIS days 1, 18 Vincristine 1.5 mg/m² IVI Days 8,15,22,29 Doxorubicin 30 mg/m² IVI Days 8,15,22,29 L-asparaginase 10000 units/m² IVI over 1 to 2 hours Days 8,11,15,18
Protocol 2, part 2
Commence when WBC >2.0 x 109/L neutrophils >0.5 x 109/L and platelets >50 x 109/L and creatinine is normal
Cytarabine blocks should commence when WBC > 0.5 x 109/L and platelets > 30 x 109/L
6-Thioguanine (6-TG) is to be temporarily ceased if cytarabine if postponed and further doses to be given at the end of the cycle to total dose of 840mg/m2
Cranial irradiation usually commences day 38. Doses as follows:
o 18Gy if CNS involvement or o 12Gy as prophylactic therapy for T cell ALL, high risk patients and planned allogeneic stem cell transplant
Thioguanine 60 mg/m² orally daily from day 36 to 49 (14 days total) Cyclophosphamide 1000 mg/m² by IV infusion over 1 hour Days 36 Mesna 400 mg/m² by IV infusion hour 0, 4 and 8 of cyclophosphamide infusion Methotrexate 12 mg (12 mg) IT INTRATHECAL Day 38, 45 Cytarabine 75 mg/m² by IV infusion days 38 to 41, 45 to 48 (over 30 to 60 minutes each day)
Standard maintenance therapy
PCP prophylaxis must be given throughout this consolidation treatment
Usually commences 2 weeks after conclusion of Protocol II depending on WBC and patient’s condition
6-Mercaptopurine 50 mg/m² orally day 1 to day 70 Methotrexate 20 mg/m² orally weekly for a total of ten doses No of cycles: 6 cycles with a 1 week break between cycles - i.e. 104 weeks in total
Risk Groups
Standard risk group
* Leukaemic cells < 1000micromol/L in the peripheral blood on day 8 after 7 day prednisone pre-phase * WBC <20 000 micromol/L and age >1 <6 years * A complete remission on day 33 (M1-marrow) * No translocation t(9;22) or BCR/ABL recombination * No translocation t(4;11) or MLL/AF4 recombination * No T-immunology * All six criteria must be met
Medium risk group
* Leukaemic cells < 1000micromol/L in the peripheral blood on day 8 after 7 day prednisone pre-phase * Complete remission on day 33 (M1-marrow) * No translocation t(9;22) or BCR/ABL recombination * No translocation t(4;11) or MLL/AF4 recombination * All 4 criteria must be met as well as at least one of the following * Leukocytes > 20000 micromol/L * Age < 1 year * Age > 6 years
High risk group
* 1000micromol/L leukaemic cells in the peripheral blood on day 8 * No complete remission on day 33 * Translocation t(9;22) or BCR/ABL recombination * Translocation t(4;11) or MLL/AF4 recombination * Each criterion alone qualifies as high risk regardless of age and WBC
Dose Modifications
Hepatic dysfunction
Daunorubicin & Doxorubicin Bilirubin 20-50 micromols/L dose at 50% Bilirubin > 50 micromol/L dose at 25% of total dose.
L-asparaginase - use caution
Vincristine Bilirubin > 50micromol/L dose at 50%
Renal impairment
Cyclophosphamide GFR (mL/min) Dose (% of total dose to be given) > 50 100 <50 omit
Do not administer methotrexate if CrCl <50ml/min
Peripheral neuropathy
Omit vincristine if grade 2 or above neuropathy