SUPPLEMENTARY FILE GRAALL and GRAALL PROTOCOLS

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1 SUPPLEMENTARY FILE GRAALL and GRAALL PROTOCOLS INTRODUCTION 1 FIGURE 1. GRAALL AND GRAALL OVERALL SURVIVAL 2 GRAALL PROTOCOL 3 1. GENERAL STUDY DESIGN 3 2. INCLUSION AND NON- INCLUSION CRITERIA 5 3. TREATMENT PROTOCOL 5 4. PATIENTS FOLLOW- UP STATISTICAL PLAN 15 GRAALL PROTOCOL AMENDMENTS 16 FIRST AMENDMENT (APPROVED ON NOVEMBER 13, 2003) 16 SECOND AMENDMENT (APPROVED ON FEBRUARY 5, 2004) 16 THIRD AMENDMENT (APPROVED ON MAY 6, 2004) 16 GRAALL PROTOCOL GENERAL STUDY DESIGN INCLUSION AND NON- INCLUSION CRITERIA GENERAL RULES GRAALL 2005 STUDY GRAALL R STUDY PATIENTS WITH CNS INVOLVEMENT AT DIAGNOSIS PATIENTS FOLLOW- UP STATISTICAL PLAN 32 GRAALL PROTOCOL AMENDMENTS 35 FIRST AMENDMENT (APPROVED ON MARCH 29, 2006) 35 SECOND AMENDMENT (APPROVED ON APRIL 26, 2006) 35 THIRD AMENDMENT (APPROVED ON FEBRUARY 14, 2007) 35 FOURTH AMENDMENT (APPROVED ON MAY 23, 2007) 35 FIFTH AMENDMENT (APPROVED ON JULY 16, 2007) 35 SIXTH AMENDMENT (APPROVED ON MAY 28, 2008) 35 SEVENTH AMENDMENT (APPROVED ON APRIL 22, 2009) 35 EIGHTH AMENDMENT (APPROVED ON FEBRUARY 18, 2011) 35 NINTH AMENDMENT (APPROVED ON DECEMBER 21, 2012) 36 APPENDIX 37 APPENDIX 1. EARLY RESPONSE CRITERIA 37 APPENDIX 2. MYELOID RECOVERY BETWEEN CHEMOTHERAPY COURSES 37 APPENDIX 3. ADMINISTRATION OF HIGH- DOSE METHOTREXATE 37 APPENDIX 4. FOLLOW- UP RULES DURING MAINTENANCE 38 APPENDIX 5. L- ASPARAGINASE ADMINISTRATION 39 APPENDIX 6. RULES FOR THE PRESCRIPTION OF RITUXIMAB 43 REFERENCES 46

2 1 INTRODUCTION The present study entitled A New Risk Model for Adult Acute Lymphoblastic Leukemia is a prognostic meta- analysis of two consecutive multicenter prospective trials conducted between 2003 and 2011 by the French- Swiss- Belgian Group for Research on Adult Acute Lymphoblastic Leukemia (GRAALL) in adult patients aged 15 to 59 years old with newly- diagnosed acute lymphoblastic leukaemia (ALL). The first GRAALL study (ClinicalTrial.gov, NCT ), which enrolled 225 patients, was a Pilot Phase 2 study aiming to evaluate the feasibility of a new pediatric- inspired comprehensive treatment strategy. Results of the GRAALL study have been already reported (Huguet et al. J Clin Oncol. 2009;27:911-8). The second GRAALL trial (ClinicalTrial.gov, NCT ), which enrolled 730 evaluable patients between 2006 and 2011, was a randomized Phase 3 study including two randomizations aiming to evaluate: 1) intensified sequential cyclophosphamide administration during induction and late intensification; and 2) addition of rituximab during induction, consolidation, late intensification and maintenance in CD20- positive Ph- negative B- cell precursor (BCP) ALL. As indicated in this Supplementary File, treatment schedules of the two protocols were very similar, allowing the present meta- analysis of conventional and new risk factors. Cumulative incidence of relapse, relapse- free survival and overall survival curves were very similar between the two protocols, as shown on the Figure 1 for overall survival). Therefore, the present prognostic meta- analysis does not deal with the primary endpoints of these two trials and does not use the statistical analysis study plans. Original versions are only available in French. This Supplementary File provides the two final versions of the GRAALL and GRAALL protocols, translated in English, with a summary of all amendments (indicated in red font in the final versions provided here). Of note, both protocols also included specific sections for the treatment of patients with Philadelphia chromosome- positive ALL (namely the GRAAPH and GRAAPH protocols). As not considered for the present prognostic meta- analysis, these sections are not provided here. Informed consent was obtained from all patients. Both trials were conducted in accordance with the Declaration of Helsinki and approved by local and multicenter research ethical committees.

3 Figure 1. GRAALL and GRAALL overall survival 2

4 3 GRAALL PROTOCOL 1. General study design In the GRAALL trial, there was no randomization, but conventional risk factors were used to stratify the two following treatment decisions: 1) intensified sequential cyclophosphamide administration at day 15 of induction course; and) allogeneic stem cell transplantation (SCT) in first complete remission (CR) Intensified induction at day 15 Early response criteria only, namely resistance to steroid prephase evaluated at day 1 and/or poor early bone marrow (BM) blast clearance evaluated at day 8 (see APPENDIX 1), can lead to induction course intensification. Other conventional risk factors are not involved in the decision Therefore, all patients are treated similarly during the first 3 weeks, including the prophase week. At day 15, corresponding to day 15 to 18 of prephase initiation, patients may enter two different treatment groups: 1. Standard induction if no resistance to steroid prephase AND good early BM blast clearance. 2. Intensified induction if resistance to steroid prephase AND/OR poor early BM blast clearance Allogeneic SCT in CR1 Candidates for allogeneic SCT in first CR are defined as patients presenting at least one of the following high- risk factors: Initial WBC 30 G/L if BCP- ALL Initial involvement of the CNS, clinical symptoms and/or cytological CSF analysis t(4;11) and/or MLL- AF4+ or other MLL gene rearrangement t(1;19) and/or E2A- PBX1+ Low hypodiploidy or near triploidy o Low hypodiploidy was defined by a modal number of 30 to 39 chromosomes or a DNA index <0.85. o Near triploidy was defined by a modal number of 60 to 78 chromosomes or a DNA index of 1.30 to Resistance to steroid prephase at day 1 (APPENDIX 1) Poor early BM blast clearance at day 8 (APPENDIX 1) No hematological CR after the first induction course

5 4 Ig/TCR minimal residual disease 10-2 after the first induction course (MRD- 1, evaluated at week 6) 1.3. Types of allogeneic SCT Indications for allogeneic SCT types in CR1 depend on the high- risk factor(s) identified, patient's age and the type of identified hematopoietic stem cell donor source. Schematically, we define four SCT levels, of potential increasing toxicity: 1. LEVEL 1: Geno- identical transplant* (45 years old and under). 2. LEVEL 2: Geno- identical transplant 55 years old and under* (or according to physiological age). Registry phenotype identical (10/10) (45 years old and under). 3. LEVEL 3: Geno- identical transplant 55 years old and under* (and beyond as physiological age). Registry phenotype identical (10/10) 55 years old and under (or according to physiological age). In all cases, a geno- identical donor (including one mismatch A) should be preferred to a pheno- identical donor (10/10). The indication for allogeneic SCT follows the following levels, according to the most severe risk factor identified: LEVEL 1 t(1;19) and/or E2A- PBX1+ Uninformative for residual disease (MRD) LEVEL 1 or 2 Initial WBC 30 G/L if BCP- ALL Initial involvement of the CNS, clinical symptoms and/or cytological CSF analysis t(4;11) and/or MLL- AF4+ or other MLL gene rearrangement Low hypodiploidy or near triploidy Resistance to steroid prephase at day 1 (APPENDIX 1) Poor early BM blast clearance at day 8 (APPENDIX 1) No haematological CR after the first induction course Ig/TCR minimal residual disease 10-2 after the first induction course (MRD- 1, evaluated at week 6)

6 5 LEVELS 1, 2 or 3 Ig/TCR minimal residual disease 10-2 after the first consolidation course (MRD- 2, evaluated at week 12) 2. Inclusion and non- inclusion criteria 2.1. Inclusion criteria 1. Patients aged years old with newly- diagnosed non previously treated ALL according to WHO 2008 definition. 2. With or without central nervous system (CNS) involvement. 3. Without other evolving cancer or its treatment should be finished at least since 6 months. 4. Signed written informed consent. 5. With health insurance coverage 6. Normal cardiac function (as determined by scintigraphy or echography) 2.2. Non- inclusion criteria 1. Patients with lymphoblastic lymphoma with bone marrow blasts<20% 2. Patients with a Burkitt- type ALL 3. Patients with a history of chronic myeloid leukemia (CML) or other myeloproliferative disease 4. Infection with human immunodeficiency virus (HIV) or chronic infection with hepatitis B virus (HBsAg positive) or hepatitis C virus (anti- HCV positive) 5. Pregnant or nursing women 6. Heart failure NYHA grade III/IV, LEVF < 50% and or RF < 30%, myocardial infarction within the past 6 months prior to study 7. Regular follow- up not possible 3. Treatment protocol General considerations: 1. Central venous access 2. Take into account the desire of paternity or maternity at a later date 3. No Bactrim prophylaxis during the induction courses and/or the courses of late induction/intensification (increases the risk of thrombosis related to L- asparaginase) 4. Capping the- dose chemotherapy according to the body surface to 2 m²

7 Prephase (D- 7 to D- 1) PREDNISONE 60 mg/m²/d (PO): D- 7 to D- 1 (may be prolonged for a total of 10 days maximum) METHOTREXATE 15 mg (IT): between D- 7 and D Induction (first part, D1 to D14) After assessment of corticosteroid sensitivity at D1 (APPENDIX 1) VINCRISTINE 2 mg/d (IV bolus) : D1, D8, PREDNISONE 60 mg/m²/d (PO) : D1-14 DAUNORUBICIN 50 mg/m²/d (IV) : D1, D2, D3 L- ASPARAGINASE 6,000 UI/m²/d (IVL 1h) : D8, D10, D12, CYCLOPHOSPHAMIDE 750 mg/m²/d (IV 3h): D1 IT (n 1, 2): MTX 15 mg+ Ara- C 40mg + DEPOMEDROL 40mg: D1, D8 This phase must follow directly the prephase, regardless of the hematologic parameters. (D1 follows the D- 1; D0 does not exist). Assessment of BM blast clearance is performed at D8, on peripheral blood (PB) and BM examination (APPENDIX 1) Induction (second part) Applicable to all patients with ALL sensitive to steroid prophase and good early BM blast clearance (APPENDIX 1), regardless of whether these patients have other conventional high- risk factor or not. This phase must follow directly the first part of the induction, regardless of the hematologic parameters. VINCRISTINE 2 mg/d (IV bolus) : D15, D22 DAUNORUBICIN 30 mg/m²/d (IV) : D15, D16 L- ASPARAGINASE 6,000 UI/m²/d (IVL 1h) D20, D22, D24, D26, D28 CYCLOPHOSPHAMIDE 750 mg/m²/d (IV 3h): D15 LENOGRASTIM G- CSF 150 µg/m²/d (SC or IV): D17 to neutrophil recovery (first day with ANC >1 G/L) 3.4. Intensified induction (second part) Applicable to all patients with ALL resistant to steroid prophase and/or poor early BM blast clearance (APPENDIX 1). This phase must be chained directly to the first part of the induction, whatever the situation VINCRISTINE 2 mg/d (IV bolus) : D15, D22

8 7 DAUNORUBICIN 30 mg/m²/d (IV 1h) : D15, D16 L- ASPARAGINASE 6,000 UI/m²/d (IVL 1h) D20, D22, D24, D26, D28 CYCLOPHOSPHAMIDE 500 mg/m²/12h (IV3h): D15, D16 (four perfusions) LENOGRASTIM G- CSF 150 µg/m²/d (SC or IV): D17 to neutrophil recovery (first day with ANC >1 G/L) 3.5. Response assessment According to pediatric protocols, it is very important to start the first block of consolidation as soon as possible after myeloid recovery following induction and as soon as CR1 is identified. PB and BM response assessment should be done at least 48 hours after the last injection of G- CSF when the ANC reaches 1 G/L and the platelet count reaches 100 G/L. MRD evaluation must be done at that time, on both PB and BM samples, before starting the first block of consolidation Second salvage Induction Applicable to all patients who have not obtained hematologic CR after standard or intensified induction. MRD evaluation is not requested here before starting the salvage course. This phase can begin as soon as the bone marrow assessment is available after the induction course. IDARUBICIN 12 mg/m²/d (IV 1h): D1, D2, D3 ARACYTINE 2,000 mg/m²/12h (IV 3h): D1-4 (eight perfusions) LENOGRASTIM G- CSF 150 µg/m²/d (SC or IV): D9 to neutrophil recovery (first day with ANC >1 G/L) 3.7. Consolidation The consolidation phase comprises two identical sets, each consisting of three consecutive blocks of chemotherapy (ARA- C, METHOTREXATE and CYCLOPHOSPHAMIDE), in combination with other cytotoxic agents. The first 3- block set must begin on the same day as hematologic CR, if: ALT <2.5 x N Creatinine clearance 60 ml/min Albumin 25 g/l. For each 3- block set, specified intervals must be strictly two weeks, regardless of blood counts. However, do not start the second 3- block set (Block 4, Block 5 and Block 6), until haematological recovery (ANC> 1G/L and platelets> 100 G/L) and ensure that: ALT <2.5 x N

9 8 Creatinine clearance 60 ml/min Albumin 25 g/l. MRD evaluation must be done on PB and BM samples just before starting the second 3- block set. For patients eligible for allogeneic SCT in CR1, the SCT procedure must be delayed after the administration of the entire first 3- block consolidation set. If the donor is not identified after the first part, the patient should receive the second 3- block set before SCT. If the donor is identified, but the SCT should be delayed, an interphase chemotherapy can be administered before SCT (see 3.8). Block ARA- C (Blocks 1 & 4) ARACYTINE mg/m² /12h (IV 3h): D1, D2 (four infusions) DEXAMETHASONE 10 mg/12h (PO ): D1, D2 L- ASPARAGINASE UI/m²/d (IVL 1h)* : D3 LENOGRASTIM G- CSF 150 µg/m²/d (SC): D7-13 *: see APPENDIX 5 Block METHOTREXATE (Blocks 2 & 5) METHOTREXATE 3,000 mg/m²/d (CIV 24h)**: D15 VINCRISTINE 2 mg/d (IVD): D15 L- ASPARAGINASE UI/m²/d (IVL 1h)*: D16 6- MERCAPTOPURINE 60 mg/m²/d (PO): D15-21 LENOGRASTIM G- CSF 150 µg/m²/d (SC): D22-27 *: see APPENDIX 5 **: followed by folinic acid rescue, see APPENDIX 3 Block CYCLOPHOSPHAMIDE (Blocks 3 & 6) CYCLOPHOSPHAMIDE 500 mg/m²/d (IV 3h): D29, D30 VP mg/m²/d (IV 1h): D29, D30 METHOTREXATE 25 mg/m²/d (IV): D29 LENOGRASTIM G- CSF 150 µg/m²/d (SC): D31 to neutrophil recovery IT (n 3,4): MTX 15 mg + Ara- C 40 mg + DEPOMEDROL 40 mg: D29 Blocks 4, 5 and 6 should begin 24 to 48 hours after discontinuation of the GCSF administration.

10 Interphase This phase is relevant for patients eligible for SCT in CR1 with an identified donor, but in whom transplantation is postponed for logistical reasons. This interphase, intended not to be administered or to be as short as possible, is provided between the end of the first or second series of blocks of consolidation and SCT. It comprises one or two cycles at maximum (two weeks apart) METHOTREXATE 1,500 mg/m²/d (IV 30 min) D1** L- ASPARAGINASE UI/m²/d (IVL 1h)* : D2 G- CSF is NOT administered during this (these) interphase *: see APPENDIX 5 **: followed by folinic acid rescue, see APPENDIX Late intensification No need of second salvage induction to reach CR1 Applicable to all patients who did not need a second salvage induction to reach first CR and who are not eligible for allogeneic SCT in first CR. It begins one week after myeloid recovery following the consolidation Block 6 (ANC > 1G/L and Platelet > 100 G/L; APPENDIX 2), provided that ALT is <2.5 x N, creatinine clearance 60 ml/min, and serum albumin 25 g/l. MRD assessment should be made on PB and BM samples before starting late intensification and, but does not affect treatment decision. VINCRISTINE 2 mg/d (IV bolus): D1, D8, D15, PREDNISONE 60 mg/m²/d (PO): D1-14 DAUNORUBICIN 30 mg/m²/d (IV 1h): D1, D2, D3 L- ASPARAGINASE 6,000 UI/m²/d (IVL 1h): D8, D10, D12, D18, D20, D22,* CYCLOPHOSPHAMIDE 500 mg/m²/12h (IV 3h): D15 (two perfusions) LENOGRASTIM G- CSF 150 µg/m²/d (SC): if ANC < 0,5 G/L to neutrophil recovery IT (n 5): MTX 15 mg + Ara- C 40 mg + DEPOMEDROL 40 mg : D1 *: see APPENDIX 5 The second part of the late intensification consists of the three ARA- C, CYCLOPHOSPHAMIDE and METHOTREXATE blocks, as used in the consolidation phase. This part must start after myeloid recovery following the first part (ANC> 1G/L and Platelets > 100 G/L) (see APPENDIX 2) or alternatively at D30 of the first part if no cytopenias was observed after first part

11 10 administration. However, ALT must be <2.5 x N, creatinine clearance 60 ml/min, and serum albumin 25 g/l. The three blocks are administered at 2- week intervals, regardless blood counts. Block ARA- C Ara- C mg/m²/12h (IV 3h): D1, D2 (four infusions) DEXAMETHASONE 10 mg /12h (PO): D1, D2 L- ASPARAGINASE UI/m²/d (IVL 1h)*: D3 LENOGRASTIM G- CSF 150 µg/m²/d (SC): D7-13 *: see APPENDIX 5 Block METHOTREXATE METHOTREXATE 3,000 mg/m²/d (CIV 24h)**: D15 VINCRISTINE 2 mg/d (IVD): D15 L- ASPARAGINASE UI/m²/d (IVL 1h)*: D16 6- MERCAPTOPURINE 60 mg/m²/d (PO): D15-21 LENOGRASTIM G- CSF 150 µg/m²/d (SC): D22-27 *: see APPENDIX 5 **: followed by folinic acid rescue, see APPENDIX 3 Block CYCLOPHOSPHAMIDE CYCLOPHOSPHAMIDE 500 mg/m²/d (IV 3h): D29, D30 VP mg/m²/d (IV 1h): D29, D30 METHOTREXATE 25 mg/m²/d (IV): D29 LENOGRASTIM G- CSF 150 µg/m²/d (SC): D31 to neutrophil recovery ANC > 1 G/L IT (n 6): MTX 15 mg + Ara- C 40 mg + DEPOMEDROL 40 mg: D Need of second salvage induction to reach CR1 Patients who achieved first CR only after an idarubicin / cytarabine second salvage induction will receive another idarubicin / cytarabine course as first part of late intensification: IDARUBICIN 9 mg/m²/d (IV 1h): D1, D2, D3 ARACYTINE 2,000 mg/m²/12h (IV 3h): D1-4 (eight perfusions) LENOGRASTIM G- CSF 150 µg/m²/d (SC): D9 to neutrophil recovery (first day with ANC >1G/L) IT (n 5, 6): MTX 15 mg + Ara- C 40 mg + DEPOMEDROL 40 mg: D8 & D15

12 CNS Irradiation CNS prophylaxis includes to the 6 triple PL + 1 single PL already administered, as well as cranial irradiation. Prophylactic CNS irradiation occurs between the end of late intensification and initiation of maintenance therapy. For the non- SCT patients, its modalities are different from those of the curative irradiation of patients with initial CNS involvement (see 3.13). It includes two lateral fields encompassing the skull, skull base, and the first two cervical vertebrae. The dose reaches 18 Gy to the midplane in 10 sessions (5 sessions per week for 2 weeks). It is accompanied by daily 6- MERCAPTOPURINE 60 mg/m²/day, PO, with dose adjustment according to blood cell counts (APPENDIX 4). There is no G- CSF administration during this treatment phase Maintenance therapy The total duration of maintenance therapy is 24 months. Maintenance treatment starts one week after myeloid recovery following CNS irradiation if hematological toxicity of CNS irradiation phase is observed (ANC > 1G/L and Platelets> 100 G/L; APPENDIX 2). Otherwise, it starts 1-2 weeks after the end of this irradiation phase. MRD evaluation should be done before starting maintenance therapy, without affecting affect treatment decisions. This is a standard maintenance therapy, based on a combination of 6- Mercaptopurine and Methotrexate with re- inductions using Vincristine and Prednisone monthly for the first year. No G- CSF administration is allowed during this phase Maintenance (2 years) 6- MERCAPTOPURINE 60 mg/m²/d, PO maintained during the re- induction phases METHOTREXATE 25 mg/m²/wk, PO Dose adjustments should be strictly observed (APPENDIX 4) Monthly reinductions (only during the first year) VINCRISTINE 2 mg, IV, D1 PREDNISONE 40 mg/m²/d, PO D1-7 These re- inductions are done every 4 weeks. They can be delayed or adapted according to the toxicity criteria (APPENDIX 4).

13 Allogeneic BMT in CR1 Indications for allogeneic transplantation in CR1 are described in Chapter 1.2. Conditioning regimen typically includes: ICT: 10 Gy single dose with lung protection beyond 8 Gy or12 Gy in 6 fractions with lung protection beyond 8 or 10 Gy. Cyclophosphamide: 60 mg/kg on two consecutive days. GVHD prophylaxis comprises cyclosporine A and methotrexate at D1, D3, D8 +/- D11. To accelerate hematologic recovery after transplantation, the use of G- CSF 150 µg/m²/day IV or SC is allowed. For patients in poor condition or elderly, the terms of ICT can be changed. Transplants with non- myeloablative conditioning are possible if a geno- identical donor is available. In such cases the conditioning regimen and prophylaxis of GVHD proposed by the SFGM- TC (French Society for Bone Marrow Transplantation en Cell Therapy) are recommended Patients with CNS involvement at diagnosis Patients with initial CNS involvement clinical and/or cytological (CSF) will have - Increased number and frequency of triple IT (methotrexate, Ara- C, Depo) - Indication for SCT in CR1 (up to indication level 3), - CNS irradiation, prior to SCT if SCT Curative triple ITs Two triple ITs per week between D- 7 (D- 10) and D21 induction (i.e. 8 ITs within 4 weeks) then one triple IT per week up to a total of 12 triple ITs. The (or the 2) other triple IT programmed during CYCLOPHOSPHAMIDE blocks of the consolidation phase will be performed (leading to a total of 13 or 14 triple ITs before SCT for SCTpatients) CNS irradiation PATIENTS receiving allogeneic SCT: CNS irradiation is performed in these patients between the end of the first or eventually second set of consolidation blocks, as follows: It includes two lateral fields encompassing the skull, facial (eye protection), the base of the skull, and the first two cervical vertebrae. The dosage is 15 Gy to the midplane in 10 sessions (5 sessions per week for 2 weeks). It is associated with 6- MERCAPTOPURINE 60 mg/m²/day PO monitored according to the CBC (APPENDIX 4).

14 13 PATIENTS not receiving allogeneic SCT: CNS irradiation occurs in these patients between the end of the delayed intensification and the start of maintenance treatment. It includes two lateral fields encompassing the skull, facial (eye protection), the base of the skull, and the first two cervical vertebrae. The dosage is 24 Gy to the midplane in 10 sessions (5 sessions per week for 2 weeks). It is associated with 6- MERCAPTOPURINE 60 mg/m²/day PO monitored according to the CBC (APPENDIX 4). 4. Patients Follow- up 4.1. Baseline evaluation The following assessment must be completed prior to the start of first induction course: Medical history, physical examination including height and weight, vital signs, ECOG performance status Previous hematological abnormalities, type and date Standard hematological evaluation Peripheral blood and bone marrow evaluation Classification of ALL according to FAB and WHO classifications Immunophenotype of leukemic blasts, based on panel recommandations Assessment of ploidy of leukemic blasts (DNA index) Cell cycle evaluation (amendment N 2) Cytogenetic analysis +/- FISH evaluation, Molecular biology including BCR/ABL, MLL/AF4, E2A/PBX1, NUP/ABL, SIL/TAL, CALM/AF10, as well a research of clonal rearrangement of Ig- TCR Serum biochemistry (Na, Ca, PO4, HCO3-, uric acid, glucose, total protein, creatinine, total bilirubin, AST, ALT, alkaline phosphatase) two times per week. PT, ACT, fibrinogen once a week Evaluation of thrombotic risk factor (optional), including: determination of antithrombin III, protein C, protein S, factor V G1691A mutation, the prothrombin G20210 mutation or mutation C677T of the MTHFR gene ECG and chest X- ray Echocardiogram prior to chemotherapy administration in induction Pregnancy testing (β- HCG) HLA phenotyping (10 antigens)

15 14 HLA typing will be performed if possible at baseline, otherwise after the achievement of hematologic CR. Search for a sibling or unrelated donor is conditioned by age, risk factors and the existence of a sibling donor. Biological tests, and diagnostic imaging during treatment, especially during phases of chemotherapy- induced cytopenias, are typically conducted in each participating centers without specific recommendations. Their type and frequency will be adapted to any intercurrent events. Note, however, the need to repeat hemostasis tests every two days during the phases of treatment including L- asparaginase Enrolment procedure All patients must be registered before or during the prephase by Véronique LHERITIER (GRAALL coordination office), Monday through Friday from 9:00 to 5:00 pm (Telephone only: ) Assessment of response The assessment of response is standardized as follows: Evaluation of steroid sensitivity at D1, on PB sample Evaluation of early BM blast clearance at D8, on PB and BM samples Evaluation of hematologic CR after myeloid recovery following induction +/- salvage, on PB and BM samples performed 48 hours after injection of growth factors MRD evaluation on PB and BM samples after induction (MRD1), after the first 3- block consolidation set (MRD2), pre- transplant or pre- late intensification, and at D100 post- transplant or post- late intensification Off- study criteria Patients participation in the study will be discontinued for any of the following reasons: If, in the investigator s medical judgment, further participation would be injurious to the health and well- being of the patient, or is not in the best interest of the patient. Patient wishes to withdraw from the study. Administrative reasons, such as subject non- compliance or a major protocol violation.

16 15 5. Statistical plan 5.1. Primary objective The primary objective is to evaluate the feasibility to offer patients a treatment stratified on numerous individual risk factors in a multicentre setting. Initial response to therapy and early MRD evaluation represent the most crucial factors, since governing induction chemotherapy intensification and indications for allogeneic SCT. 1. Initial response to therapy, as assessed by evaluation of BM blast clearance at D8. Assessment of the steroid sensitivity at D0 is much simpler and thus not taken into account here. 2. Ig/TCR MRD1 level evaluation. The main objective is to collect these two prognostic factors in real time in 80% of eligible patients (still alive at the end of induction), with the following constraints: 1. BM blast clearance at D8: decisional result available within 7 days. 2. MRD1 level: decisional result (<10-2 / 10-2 /uninformative) available within 21 days Secondary objectives To test the whole treatment tolerance, including consolidation, late intensification and allogeneic SCT. The tolerance will be mainly evaluated on hematological toxicity (Grade and duration of neutropenia and thrombocytopenia) and on the rate of death in complete remission. To assess the results of a strategy including levels of allogeneic BMT of potentially increasing toxicity adjusted on prognostic factors of the disease Statistical Analysis A simple experimental plan was chosen. The goal is to determine whether the collection of the two response- related risk factors mentioned above can be performed in 80% of eligible patients with a confidence interval between 72% and 88%. To answer this question, it is necessary to collect information in 96 evaluable patients. Taking into account a maximal 10% early mortality rate before MRD1 assessment, the number of patients needed can be estimated to be 107. This study is planned for 120 patients, which in view of the anticipated recruitment rate should be 12 to 18 months from the date of activation of the trial scheduled for May 1, 2003.

17 16 GRAALL PROTOCOL AMENDMENTS First amendment (approved on November 13, 2003) Updated list of investigators. Second amendment (approved on February 5, 2004) Updated participating centers and list of investigators. Introduction of cell cycle evaluation at baseline; no impact on treatment decision. Early introduction of imatinib in patients with Ph- positive ALL and poor early response (changed the GRAAPH trial, not the GRAALL trial). Third amendment (approved on May 6, 2004) Given the higher than expected enrolment rate, the decision to increase the number of patients up to 200 was taken, without increasing the study duration initially planned. Updated participating centers and list of investigators.

18 17 GRAALL PROTOCOL 1. General study design The GRAALL trial is a randomized Phase 3 study including two randomizations aiming to evaluate: 1) intensified sequential cyclophosphamide administration during induction and late intensification (GRAALL study); and 2) addition of rituximab during induction, consolidation, late intensification and maintenance in CD20- positive Ph- negative B- cell precursor (BCP) ALL (GRAALL R study) Intensified induction at day 15 (GRAALL study) All patients with Ph- negative ALL included in the trial (BCP- ALL and T- ALL patients) are randomized after the first 1- week prophase to receive either standard doses or intensified sequential doses of cyclophosphamide during the first induction course and the late intensification Addition of rituximab (GRAALL R study) Patients with CD20- positive BCP- ALL, defined by the standard 20% expression threshold, are eligible for rituximab versus no- rituximab randomization. Patients randomized in the rituximab arm will received a total 16 to 18 standard- dose rituximab infusion during the induction, consolidation, late intensification and maintenance treatment phases Allogeneic SCT in CR1 Candidates for allogeneic SCT in first CR are defined as patients presenting at least one of the following high- risk factors: Initial WBC 30 G/L if BCP- ALL Initial involvement of the CNS, clinical symptoms and/or cytological CSF analysis CD10- negative immature ALL t(4;11) and/or MLL- AF4+ or other MLL gene rearrangement t(1;19) and/or E2A- PBX1+ Complex karyotype (5 abnormalities or more), in the absence of recurrent cytogenetic abnormality (amendment N 3)

19 18 Low hypodiploidy or near triploidy o Low hypodiploidy was defined by a modal number of 30 to 39 chromosomes or a DNA index <0.85. o Near triploidy was defined by a modal number of 60 to 78 chromosomes or a DNA index of 1.30 to o Does not include hyperdiploidy or tetraploidy (amendment N 3). Resistance to steroid prephase at day 1 (APPENDIX 1) Poor early BM blast clearance at day 8 (APPENDIX 1) No hematological CR after the first induction course 1.4. Types of allogeneic SCT Indications for allogeneic SCT types in CR1 depend on the high- risk factor(s) identified and the type of identified hematopoietic stem cell donor source. All patients aged 55 years old or less with high- risk ALL (defined as the presence of at least one of conventional risk factors listed above) are eligible for allogeneic SCT if either an HLA- identical sibling donor or a 10/10 HLA fully matched unrelated donor, unless too poor status or contra- indications to SCT procedure. In all cases, a geno- identical donor (including one mismatch A) should be preferred to a pheno- identical donor (10/10). In case of: 1) t(4;11) and/or MLL- AF4+ or other MLL gene rearrangement; 2) low hypodiploidy or near triploidy; or 3) no hematological CR after the first induction course, a 9/10 HLA matched unrelated donor was acceptable (one HLA mismatch). 2. Inclusion and non- inclusion criteria 2.1. Inclusion criteria Patients aged years old with newly- diagnosed non previously treated ALL according to the WHO definition. With a percentage of marrow blasts 20%. With or without testicular or CNS involvement. With a minimum immunophenotypic study allowing B- or T- lineage assignement Without other evolving cancer or its treatment should be finished at least since 6 months (amendment N 7). Signed written informed consent. With health insurance coverage. Normal cardiac function (as determined by scintigraphy or echography). Offering effective contraception for women of reproductive age.

20 19 Therapy- related ALL (history of chemotherapy and/or radiotherapy) may be included Non- inclusion criteria Patients with lymphoblastic lymphoma with bone marrow blasts<20%. Patients with a Burkitt- type ALL. Patients with a history of chronic myeloid leukemia (CML) or other myeloproliferative disease. Not able to receive anthracycline, as well as any other general intensive treatment (amendment N 7). Cardiomyopathy (NYHA grade 3 or 4). Thrombophilic disease diagnosed before inclusion (amendment N 7). Presence of severe comorbidity precluding intensive treatment. Serum creatinine > 2 times the upper normal limit (UNL) of the laboratory, total bilirubin> 2.5 UNL unless related to ALL, AST or ALT > 5 UNL, unless related to ALL Progressive severe infection or seropositivity for HIV or HTLV- 1, active HBC or HBC hepatitis. Intolerance to treatment with monoclonal antibody. Positive pregnancy test (β- HCG) for women of childbearing age. Inability to comply with regular monitoring. 3. General rules Central venous access is required in all patients. Consider the desire for paternity or maternity at a later date. Cap chemotherapy dose to body surface area of 2 m². Pneumocystis prophylaxis is provided by either oral Bactrim or monthly Pentacarinat. For patients not receiving an allograft as part of first line therapy, blood products should be irradiated from the start of maintenance. In case of neuropathy associated with repeated administration of vincristine, use vindesine (4 mg/injection) or VP16 (50 mg/m²/injection) Prophylactic broad spectrum antibiotics (according to local guidelines) should be used during the first three weeks of steroid treatment, once the neutrophil count falls to 0.5 G/L. During L- asparaginase administration, contraceptive treatment should be replaced by progesterone only.

21 20 In the case of anaphylactic shock, please measure serum tryptase as soon as possible after the event (amendment N 2), and declare the event as a SAE. Prophylactic heparin therapy is recommended: assess the ATIII levels and use ATIII concentrates (not FFP) for replacement therapy according to rules of APPENDIX 5. In case of CNS involvement at diagnosis, do not administer the first 3 L- asparaginase injections (D8, D10, D12 of induction course). Zelitrex (1g x 3) should be prescribed during treatment with rituximab. If WBC >30 G/L on day 1, split first rituximab injection over 3 days. All patients will receive a common 7- to 10- day prophase as follows: PREDNISONE 60 mg/m²/d (PO): D- 7 to D- 1 (may be prolonged for a total of 10 days maximum) METHOTREXATE 15 mg (IT): between D- 7 and D GRAALL 2005 Study 4.1. Criteria for randomization Randomization occurs no later than day 1 of induction chemotherapy. This randomization governs the second part of the first induction course (starting at day 15), as well as late intensification for patients not eligible for allogeneic SCT in first CR. Patients will be randomized between the standard (Arm A) and the HyperC (Arm B) arms Induction (D1 to D14) After randomization and assessment of corticosteroid sensitivity at D1 (APPENDIX 1) VINCRISTINE 2 mg/d (IV bolus) : D1, D8, PREDNISONE 60 mg/m²/d (PO) : D1-14 DAUNORUBICIN 50 mg/m²/d (IV) : D1, D2, D3 L- ASPARAGINASE 6,000 UI/m²/d (IVL 1h) : D8, D10, D12, CYCLOPHOSPHAMIDE 750 mg/m²/d (IV 3h): D1 IT (n 1, 2): MTX 15 mg+ Ara- C 40mg + DEPOMEDROL 40mg: D1, D8 This phase must follow directly the prephase, regardless of the hematologic parameters. (D1 follows the D- 1; D0 does not exist). Assessment of BM blast clearance is performed at D8, on peripheral blood (PB) and BM examination (APPENDIX 1). The 3- days of L- asparaginase should be deferred in patients with initial CNS involvement.

22 Induction (second Part), standard arm (Arm A) This phase follow the first part of the induction directly, regardless of the hematological parameters. VINCRISTINE 2 mg/d (IV bolus) : D15, D22 DAUNORUBICIN 30 mg/m²/d (IV) : D15, D16 L- ASPARAGINASE 6,000 UI/m²/d (IVL 1h) D20, D22, D24, D26, D28 CYCLOPHOSPHAMIDE 750 mg/m²/d (IV 3h): D15 LENOGRASTIM G- CSF 263 µg/d (SC or IV): D18 to neutrophil recovery (first day with ANC >1 G/L) 4.4. Induction (second part), HyperC arm (Arm B) This phase must follow the first part of the induction directly, regardless of the haematological parameters. VINCRISTINE 2 mg/d (IV bolus) : D15, D22 DAUNORUBICIN 30 mg/m²/d (IV 1h) : D15, D16 L- ASPARAGINASE 6,000 UI/m²/d (IVL 1h) D20, D22, D24, D26, D28 CYCLOPHOSPHAMIDE 300 mg/m²/12h (IV 3h): D15, D16, D17 (six infusions) LENOGRASTIM G- CSF 263 µg/d (SC or IV): D18 to neutrophil recovery (first day with WBC >1 G/L) 4.5. Response Assessment According to pediatric protocols, it is very important to start the first block of consolidation as soon as possible after myeloid recovery following induction and as soon as CR1 is identified. PB and BM response assessment should be done at least 48 hours after the last injection of G- CSF when the ANC reaches 1 G/L and the platelet count reaches 100 G/L. MRD evaluation (MRD1) must be done at that time, on both PB and BM samples, before starting the first block of consolidation. MRD1 levels have no impact on treatment decision Second salvage induction Applicable to all patients who have not obtained hematologic CR after standard or intensified induction. MRD evaluation is not requested here before starting the salvage course. This phase can begin as soon as the bone marrow assessment is available after the induction course (either arm A or arm B). IDARUBICIN 12 mg/m²/d (IV 1h): D1, D2, D3 ARACYTINE 2,000 mg/m²/12h (IV 3h): D1-4 (eight perfusions)

23 22 LENOGRASTIM G- CSF 263 µg/d (SC or IV): D9 to neutrophil recovery (first day with ANC >1 G/L) 4.7. Consolidation 1 and 2 The consolidation phase comprises two identical sets, each consisting of three consecutive blocks of chemotherapy (ARA- C, METHOTREXATE and CYCLOPHOSPHAMIDE), in combination with other cytotoxic agents. The first 3- block set must begin on the same day as hematologic CR, if: ALT <2.5 x N Creatinine clearance 60 ml/min For each 3- block set, specified intervals must be strictly two weeks, regardless of blood counts. However, do not start the second 3- block set (Block 4, Block 5 and Block 6), until haematological recovery (ANC> 1 G/L and platelets> 100 G/L) and ensure that: ALT <2.5 x N Creatinine clearance 60 ml/min Any delay > 30 days in administration of a block for reasons of toxicity is a reason for exclusion of the patient from the trial. MRD evaluation must be done on PB and BM samples just before starting the second 3- block set. For patients eligible for allogeneic SCT in CR1, the SCT procedure must be delayed after the administration of the entire first 3- block consolidation set. If the donor is not identified after the first part, the patient should receive the second 3- block set before SCT. If the donor is identified, but the SCT should be delayed, an interphase chemotherapy can be administered before SCT (see 4.9). Block ARA- C (Blocks 1 & 4) ARACYTINE mg/m² /12h (IV 3h): D1, D2 (four infusions) DEXAMETHASONE 10 mg/12h (PO ): D1, D2 L- ASPARAGINASE UI/m²/d (IVL 1h)* : D3 LENOGRASTIM G- CSF 263 µg/d (SC): D9-13 *: see APPENDIX 5 Block METHOTREXATE (Blocks 2 & 5) METHOTREXATE 3,000 mg/m²/d (CIV 24h)**: D15

24 23 VINCRISTINE 2 mg/d (IVD): D15 L- ASPARAGINASE UI/m²/d (IVL 1h)*: D16 6- MERCAPTOPURINE 60 mg/m²/d (PO): D15-21 LENOGRASTIM G- CSF 263 µg/d (SC): D23-27 *: see APPENDIX 5 **: followed by folinic acid rescue, see APPENDIX 3 Block CYCLOPHOSPHAMIDE (Blocks 3 & 6) CYCLOPHOSPHAMIDE 500 mg/m²/d (IV 3h): D29, D30 VP mg/m²/d (IV 1h): D29, D30 METHOTREXATE 25 mg/m²/d (IV): D29 LENOGRASTIM G- CSF 263 µg/d (SC): D31 to neutrophil recovery IT (n 3,4): MTX 15 mg + Ara- C 40 mg + DEPOMEDROL 40 mg: D29 Blocks 4, 5 and 6 should begin 24 to 48 hours after discontinuation of the GCSF administration Adaptation Adaptation of the administration of the consolidation blocks after the induction phase (with or without a salvage course) may be required. For example, the persistence of non- hematological toxicity, or a deterioration of the general condition of the patient may not allow a rapid administration of the first consolidation block. In such a case, please use these following guidelines: Patients with liver toxicity In cases of liver toxicity leading to a predictable delay of block 1 (Ara- C based) over 2 weeks, block 3 (cyclophosphamide based) will be administered first. In these patients the sequence of the three consolidation blocks (sequence 1) will therefore be 3, 1, 2 and not 1, 2, 3. For the second consolidation, resume the order cycle 1, 2, 3. No other change is allowed by the protocol Patients with impaired general condition. For patients with significant impairment of general condition (at the discretion of investigator) with or without liver toxicity, the administration of consolidation blocks will be delayed. In the meanwhile, these patients receive a combination of vincristine + prednisone, according to the following scheme: VINCRISTINE 2 mg IV total dose: D1, +/- D8, +/- D15, +/- D22 DEXAMETHASONE 40 mg PO total dose: D1, +/- D8, +/- D15, +/- D22

25 Interphase This phase is relevant for patients eligible for SCT in CR1 with an identified donor, but in whom transplantation is postponed for logistical reasons. This interphase, intended not to be administered or to be as short as possible, is provided between the end of the first or second series of blocks of consolidation and SCT. It comprises one or two cycles at maximum (two weeks apart) METHOTREXATE 1,500 mg/m²/d (IV 30 min) D1** L- ASPARAGINASE UI/m²/d (IVL 1h)* : D2 G- CSF is NOT administered during this (these) interphase *: see APPENDIX 5 **: followed by folinic acid rescue, see APPENDIX Late intensification Applicable to all patients who are not eligible for allogeneic SCT in first CR. It begins one week after myeloid recovery following the consolidation Block 6 (ANC > 1G/L and Platelet > 100 G/L; APPENDIX 4), provided that ALT is <2.5 x N and creatinine clearance 60 ml/min. MRD assessment should be made on PB and BM samples before starting late intensification and, but does not affect treatment decision. During late intensification, cyclophosphamide doses are adjusted on the randomization arm. Patients randomized in the standard arm A receive standard doses of cyclophosphamide. Patients randomized in the HyperC arm B will receive intensified sequential cyclophosphamide (HyperC). Arm A: VINCRISTINE 2 mg/d (IV bolus): D1, D8, D15, D22 PREDNISONE 60 mg/m²/d (PO): D1-14* DAUNORUBICIN 30 mg/m²/d (IV 1h): D1, D2, D3, D15, D16 L- ASPARAGINASE 6,000 UI/m²/d (IVL 1h): D8, D10, D12, D18, D20, D22, D26, D28 * CYCLOPHOSPHAMIDE 750 mg/m² (IV 3h): D1 and D15 (two perfusions) LENOGRASTIM G- CSF 263 µg/d (SC): D18 to neutrophil recovery IT (n 5,6): MTX 15 mg + Ara- C 40 mg + DEPOMEDROL 40 mg : D1, D8 *: see APPENDIX 5

26 25 Arm B: VINCRISTINE 2 mg/d (IV bolus): D1, D8, D15, D22 PREDNISONE 60 mg/m²/d (PO): D1-14* DAUNORUBICIN 30 mg/m²/d (IV 1h): D1, D2, D3, D15, D16 L- ASPARAGINASE 6,000 UI/m²/d (IVL 1h): D8, D10, D12, D18, D20, D22, D26, D28 * CYCLOPHOSPHAMIDE 750 mg/m²/12h (IV 3h): D15, D16, D17 CYCLOPHOSPHAMIDE 300 mg/m² (IV 3h): D1 LENOGRASTIM G- CSF 263 µg/d (SC): D18 to neutrophil recovery IT (n 5,6): MTX 15 mg + Ara- C 40 mg + DEPOMEDROL 40 mg : D1, D8 *: see APPENDIX 5 Patients who needed a second salvage course to reach CR1 Patients who achieved first CR only after an idarubicin / cytarabine second salvage induction will receive another idarubicin / cytarabine course as first part of late intensification: IDARUBICIN 9 mg/m²/d (IV 1h): D1, D2, D3 ARACYTINE 2,000 mg/m²/12h (IV 3h): D1-4 (eight perfusions) LENOGRASTIM G- CSF 263 µg/d (SC): D9 to neutrophil recovery (first day with ANC >1G/L) IT (n 5, 6): MTX 15 mg + Ara- C 40 mg + DEPOMEDROL 40 mg: D8, D Consolidation N 3 Late intensification is followed by consolidation 3, which is basically a repetition of the three ARA- C, CYCLOPHOSPHAMIDE and METHOTREXATE blocks used in consolidation 1 and 2, except for IT during the cyclophosphamide block. This part must start after myeloid recovery following the first part (ANC >1G/L and Platelets >100 G/L) (see APPENDIX 2) or alternatively at D30 of the first part if no cytopenias was observed after first part administration. However, ALT must be <2.5 x N and creatinine clearance 60 ml/min. The three blocks are administered at 2- week intervals, regardless blood counts. Block ARA- C Ara- C mg/m²/12h (IV 3h): D1, D2 (four infusions) DEXAMETHASONE 10 mg /12h (PO): D1, D2 L- ASPARAGINASE UI/m²/d (IVL 1h)*: D3 LENOGRASTIM G- CSF 263 µg/d (SC): D9-13 *: see APPENDIX 5

27 26 Block METHOTREXATE METHOTREXATE 3,000 mg/m²/d (CIV 24h)**: D15 VINCRISTINE 2 mg/d (IVD): D15 L- ASPARAGINASE UI/m²/d (IVL 1h)*: D16 6- MERCAPTOPURINE 60 mg/m²/d (PO): D15-21 LENOGRASTIM G- CSF 263 µg/d (SC): D23-27 *: see APPENDIX 5 **: followed by folinic acid rescue, see APPENDIX 3 Block CYCLOPHOSPHAMIDE CYCLOPHOSPHAMIDE 500 mg/m²/d (IV 3h): D29, D30 VP mg/m²/d (IV 1h): D29, D30 METHOTREXATE 25 mg/m²/d (IV): D29 LENOGRASTIM G- CSF 263 µg/d (SC): D31 to D35 WARNING: no IT during this block CNS irradiation CNS prophylaxis includes to the 6 triple PL + 1 single PL already administered, as well as cranial irradiation. Prophylactic CNS irradiation occurs between the end of consolidation 3 and initiation of maintenance therapy. For the non- SCT patients, its modalities are different from those of the curative irradiation of patients with initial CNS involvement (see chapter 6). It includes two lateral fields encompassing the skull, skull base, and the first two cervical vertebrae. The dose reaches 18 Gy to the midplane in 10 sessions (5 sessions per week for 2 weeks). It is accompanied by daily 6- MERCAPTOPURINE 60 mg/m²/day, PO, with dose adjustment according to blood cell counts (APPENDIX 4). There is no G- CSF administration during this treatment phase Maintenance therapy The total duration of maintenance therapy is 24 months. Maintenance treatment starts one week after myeloid recovery following CNS irradiation if hematological toxicity of CNS irradiation phase is observed (ANC > 1G/L and Platelets> 100 G/L; APPENDIX 2). Otherwise, it starts 1-2 weeks after the end of this irradiation phase. MRD evaluation should be done before starting maintenance therapy, without affecting affect treatment decisions. This is a standard maintenance therapy, based on a combination of 6- Mercaptopurine and Methotrexate with re-

28 27 inductions using Vincristine and Prednisone monthly for the first year. No G- CSF administration is allowed during this phase Maintenance (2 years) 6- MERCAPTOPURINE 60 mg/m²/d, PO maintained during the re- induction phases METHOTREXATE 25 mg/m²/wk, PO Dose adjustments should be strictly observed (APPENDIX 4) Monthly reinductions (only during the first year) VINCRISTINE 2 mg, IV, D1 PREDNISONE 40 mg/m²/d, PO D1-7 These re- inductions are done every 4 weeks. They can be delayed or adapted according to the toxicity criteria (APPENDIX 4). The prophylactic use of Bactrim or monthly Pentacarinat is strongly recommended during the maintenance period Allogeneic BMT in CR1 Indications for allogeneic transplantation in CR1 are described in Chapter 1.3. Conditioning regimen typically includes: ICT: 10 Gy single dose with lung protection beyond 8 Gy or12 Gy in 6 fractions with lung protection beyond 8 or 10 Gy. Cyclophosphamide: 60 mg/kg on two consecutive days. GVHD prophylaxis comprises cyclosporine A and methotrexate at D1, D3, D8 +/- D11. To accelerate hematologic recovery after transplantation, the use of G- CSF 150 µg/m²/day IV or SC is allowed. Indications for allogeneic and search for a related or unrelated donor (until age 55) are summarized in Chapter 1.4. Note that in case of: 1) t(4;11) and/or MLL- AF4+ or other MLL gene rearrangement; 2) low hypodiploidy or near triploidy; or 3) no hematological CR after the first induction course, a 9/10 HLA matched unrelated donor was acceptable (one HLA mismatch). MRD evaluation should be done on PB and BM samples at D100 post- SCT, but has no impact on treatment decisions. 5. GRAALL R Study 5.1. Eligibility Randomization occurs no later than day 1 of induction chemotherapy. Only patients randomized with Ph- negative BCP- ALL expressing the CD20 antigen at the usual 20% threshold may be

29 28 randomized in the GRAALL R study. For these patients, the first randomization between the standard arm A and the HyperC arm B will be part of the GRAALL study. This first randomization will be followed by a second randomization (GRAALL R) between the arms "rituximab" (arm 1) versus "no rituximab" (arm 0), leading to 4 treatment arms for this subgroup of patients: A0 or A1, B0 or B1. If there is any concern about CD20 positivity for a given patient, the histogram should be faxed to the MC Bene at (33) (0) Administration of rituximab (Arm 1) All patients randomized into the GRAALL R study will receive all treatments described in the GRAALL study, according to the standard arm A or to the HyperC arm B in which they are randomized. Patients randomized in the rituximab arm 1 will receive additional rituximab infusions, at the dose of 375 mg/m² per infusion, according to the following schedule: Day 1 and 7 of the induction course; rituximab injections will be administered after steroids planned for these days. Day 1 and 7 of the salvage cycle, if applicable. Day 1 and 29 of consolidation 1 and 2. If the order of the blocks is changed according to protocol, the two injections of rituximab planned for blocks 1 and 3 remain assigned to these blocks. Day 1 and 7 of the late intensification cycle, rituximab injections will be administered after the corticosteroids planned for these days. Day 1 and 29 of consolidation 3. Day 1 of reinductions 1, 3, 5, 7, 9 and 11 of the maintenance phase (rituximab injection will be administered after the corticosteroids planned these days). In patients with initial WBC > 30 G/L on day 1 after the steroid prophase, first rituximab administration should be fractionated as follows: 100 mg/m² on day 1 and day 2 and 175 mg/m² on day 3. The administration of Rituximab is detailed in APPENDIX 6. The key points are: Rituximab is administered IV before chemotherapy and after hydration. Premedication with Paracetamol and Polaramine IV or PO (2 tablets of paracetamol and one tablet Polaramine Retard ) is administered minutes before starting the infusion of rituximab. Corticosteroids are used as premedication when they are included in the chemotherapy regimen (including early induction for the first doses of rituximab). They are then administered minutes before starting the infusion of rituximab. If corticosteroids