7–11 minutes
NCCN Chemotemplate
Indication: T-ALL or B-ALL (Philadelphia negative): Frontline and Relapsed/Refractory
Induction → Extended Induction (if needed) → Consolidation → Interim Maintenance → Delayed Intensification → Maintenance
Induction (DAUNOrubicin/Pegaspargase/VinCRIStine/PredniSONE)
29-day cycle for 1 cycle
| Medication | Day 1 | Day 4 | Day 8 | Day 15 | Day 22 | Day 29 |
|---|---|---|---|---|---|---|
| Daunorubicin Q1wk | 25 mg/m² IV push | 25 mg/m² IV push | 25 mg/m² IV push | 25 mg/m² IV push | ||
| Vincristine Q1wk | 1.5 mg/m² IV over 5–10 min (max 2 mg) | 1.5 mg/m² IV over 5–10 min | 1.5 mg/m² IV over 5–10 min | 1.5 mg/m² IV over 5–10 min | ||
| Pegaspargase (≤21 years) | 2,500 units/m² IV over 2 h (max 3,750units ~1vial) | |||||
| OR Pegaspargase (>21 years) | 2,000 units/m² IV over 2 h (max 3,750units ~1vial) | |||||
| Prednisone daily 60 mg/m²/day PO divided BID | colspan Days 1–28 | colspan Days 1–28 | colspan Days 1–28 | colspan Days 1–28 | colspan Days 1–28 | |
| Cytarabine (IT) PF only | 70 mg IT | |||||
| Methotrexate (IT) standard CNS ppx | 15 mg IT | 15 mg IT | ||||
| OR Methotrexate IT (CNS-3 at diagnosis) Intensified CNS-directed therapy | 15 mg IT | 15 mg IT | 15 mg IT | 15 mg IT |
Pegaspargase Premedications (30–60 min prior): Acetaminophen 650–1000 mg PO + Diphenhydramine (or equivalent H1 blocker) 12.5–50 mg IV/PO + Famotidine (or equivalent H2 blocker) 20 mg IV/PO +/- Corticosteroid Per institutional protocol
Primary febrile neutropenia prophylaxiss (high risk): G-CSF is recommended per NCCN hematopoietic growth factor guidance.
Intrathecal medications must use preservative-free formulations only, and should be administered in one syringe to minimize handling/errors.
Extended Induction (if needed; DAUNOrubicin/Pegaspargase/VinCRIStine/PredniSONE)
29-day cycle for 1 cycle (for patients without M0 or M1 marrow after initial induction)
| Medication | Day 1 | Day 4 | Day 8 | Days 1–14 |
|---|---|---|---|---|
| Daunorubicin | 25 mg/m² IV push | |||
| Vincristine | 1.5 mg/m² IV over 5–10 min (max 2 mg) | 1.5 mg/m² IV over 5–10 min (max 2 mg) | ||
| Pegaspargase (≤21 years) | 2,500 units/m² IV over 2 h | |||
| OR Pegaspargase (>21 years) | 2,000 units/m² IV over 2 h (max 3,750units ~1vial) | |||
| Prednisone 60 mg/m²/day PO divided BID | Days 1–14 | Continued | Continued |
Pegaspargase Premedications (30–60 min prior): Acetaminophen 650–1000 mg PO + Diphenhydramine (or equivalent H1 blocker) 12.5–50 mg IV/PO + Famotidine (or equivalent H2 blocker) 20 mg IV/PO +/- Corticosteroid Per institutional protocol
Primary febrile neutropenia prophylaxis (high risk): G-CSF risk ecommended per NCCN hematopoietic growth factor guidance.
Intrathecal Therapy: Use preservative-free formulations only; administer IT therapy in one syringe whenever applicable to minimize handling/errors.
Consolidation (CycloPHOSphamide/Cytarabine/Mercaptopurine/ Pegaspargase/VinCRIStine)
56-day cycle for 1 cycle
| Medication | D1 | D4 | D8 | D11 | D15 | D22 | D29 | D32 | D36 | D39 | D43 | D50 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Cyclophosphamide IV over 30min | 1000 mg/m² IV | 1000 mg/m² IV | ||||||||||
| Cytarabine IV over 1-3h or SC | 75 mg/m² daily (D1–4) | ✓ | 75 mg/m² daily (D8–11) | ✓ | 75 mg/m² daily (D29–32) | ✓ | 75 mg/m² daily (D36–39) | ✓ | ||||
| Mercaptopurine 60 mg/m² PO daily | Daily (D1–14) | → | → | → | End D14 | Daily (D29–42) | → | → | → | End D42 | ||
| Vincristine IV over 5-10 min | 1.5 mg/m² IV (max 2 mg) | 1.5 mg/m² IV (max 2 mg) | 1.5 mg/m² IV (max 2 mg) | 1.5 mg/m² IV (max 2 mg) | ||||||||
| Pegaspargase ≤21 yr IV over 2 h | 2500 units/m² IV | 2500 units/m² IV | ||||||||||
| OR Pegaspargase >21 yr | 2000 units/m² IV (max 3,750units ~1vial) | 2000 units/m² IV (max 3,750units ~1vial) | ||||||||||
| Methotrexate IT | 15 mg IT | 15 mg IT | 15 mg IT* | 15 mg IT* |
Pegaspargase Premedications (30–60 min prior): Acetaminophen 650–1000 mg PO + Diphenhydramine (or equivalent H1 blocker) 12.5–50 mg IV/PO + Famotidine (or equivalent H2 blocker) 20 mg IV/PO +/- Corticosteroid Per institutional protocol
Primary febrile neutropenia prophylaxis (high risk): G-CSF risk ecommended per NCCN hematopoietic growth factor guidance.
Intrathecal Therapy: Use preservative-free formulations only; administer IT therapy in one syringe whenever applicable to minimize handling/errors.
Hydration with Cyclophosphamide: Target combined oral + IV hydration of 2–3 L/day on cyclophosphamide days (D1 and D29). Oral hydration strongly encouraged.
Interim Maintenance (Methotrexate/Pegaspargase/VinCRIStine)
42-day cycle for 1 cycle
| Medication | Day 1 | Day 2 | Day 11 | Day 21 | Day 22 | Day 31 | Day 41 |
|---|---|---|---|---|---|---|---|
| Vincristine IV over 5–10 min | 1.5 mg/m² IV (max 2 mg) | 1.5 mg/m² IV (max 2 mg) | 1.5 mg/m² IV (max 2 mg) | 1.5 mg/m² IV (max 2 mg) | 1.5 mg/m² IV (max 2 mg) | ||
| Methotrexate (Systemic) | 100 mg/m² IV push* | 150 mg/m² IV push* | 200 mg/m² IV push* | 250 mg/m² IV push* | 300 mg/m² IV over 30 min | ||
| Pegaspargase ≤21 years | 2,500 units/m² IV over 2 h | 2,500 units/m² IV over 2 h | |||||
| OR Pegaspargase >21 years | 2,000 units/m² IV over 2 h (max 3,750units ~1vial) | 2,000 units/m² IV over 2 h (max 3,750units ~1vial) | |||||
| Methotrexate (Intrathecal) | 15 mg IT | 15 mg IT |
Pegaspargase Premedications (30–60 min prior): Acetaminophen 650–1000 mg PO + Diphenhydramine (or equivalent H1 blocker) 12.5–50 mg IV/PO + Famotidine (or equivalent H2 blocker) 20 mg IV/PO +/- Corticosteroid Per institutional protocol
Intrathecal Therapy: Use preservative-free formulations only; administer IT therapy in one syringe whenever applicable to minimize handling/errors.
Delayed Intensification (CycloPHOSphamide/Cytarabine/DOXOrubicin/Pegaspargase/Thioguanine/VinCRIStine/DexAMETHasone)
56-day cycle for 1 cycle
| Medication | D1 | D4/5/6* | D8 | D15 | D21 | D29 | D32 | D36 | D39 | D43 | D50 |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Vincristine IV over 5–10 min | 1.5 mg/m² IV (max 2 mg) | 1.5 mg/m² IV | 1.5 mg/m² IV | 1.5 mg/m² IV | 1.5 mg/m² IV | ||||||
| Doxorubicin Slow IV push | 25 mg/m² IV push | 25 mg/m² IV push | 25 mg/m² IV push | ||||||||
| Pegaspargase ≤21 years | 2,500 units/m² IV | 2,500 units/m² IV | |||||||||
| OR Pegaspargase >21 years | 2,000 units/m² IV (max 3,750units ~1vial) | 2,000 units/m² IV (max 3,750units ~1vial) | |||||||||
| Cyclophosphamide IV over 30 min | 1,000 mg/m² IV | ||||||||||
| Cytarabine IV over 1–3 h or SC | 75 mg/m² daily (D29–32) | ✓ | 75 mg/m² daily (D36–39) | ✓ | |||||||
| Thioguanine 60 mg/m² PO daily | Daily D29–42 | → | → | → | End D42 | ||||||
| Dexamethasone 10 mg/m²/day PO/IV divided BID | Days 1–7 | → | Days 15–21 | End D21 | |||||||
| Methotrexate (IT) | 15 mg IT | 15 mg IT | 15 mg IT | ||||||||
| Medication | D1 | D4/5/6* | D8 | D15 | D21 | D29 | D32 | D36 | D39 | D43 | D50 |
Pegaspargase Premedications (30–60 min prior): Acetaminophen 650–1000 mg PO + Diphenhydramine (or equivalent H1 blocker) 12.5–50 mg IV/PO + Famotidine (or equivalent H2 blocker) 20 mg IV/PO +/- Corticosteroid Per institutional protocol
Primary febrile neutropenia prophylaxis (high risk): G-CSF risk ecommended per NCCN hematopoietic growth factor guidance.
Intrathecal Therapy: Use preservative-free formulations only; administer IT therapy in one syringe whenever applicable to minimize handling/errors.
Hydration with Cyclophosphamide: Target combined oral + IV hydration of 2–3 L/day on cyclophosphamide days (D29). Oral hydration strongly encouraged.
| Medication | D1 | D4/5/6* | D8 | D15 | D21 |
|---|---|---|---|---|---|
| Vincristine IV over 5–10 min | 1.5 mg/m² IV (max 2 mg) | 1.5 mg/m² IV | 1.5 mg/m² IV | ||
| Doxorubicin Slow IV push | 25 mg/m² IV push | 25 mg/m² IV push | 25 mg/m² IV push | ||
| Pegaspargase ≤21 years | 2,500 units/m² IV | ||||
| OR Pegaspargase >21 years | 2,000 units/m² IV (max 3,750units ~1vial) | ||||
| Cyclophosphamide IV over 30 min | |||||
| Cytarabine IV over 1–3 h or SC | |||||
| Thioguanine 60 mg/m² PO daily | |||||
| Dexamethasone 10 mg/m²/day PO/IV divided BID | Days 1–7 | → | Days 15–21 | End D21 | |
| Methotrexate (IT) | 15 mg IT | ||||
| Medication | D1 | D4/5/6* | D8 | D15 | D21 |
Pegaspargase Premedications (30–60 min prior): Acetaminophen 650–1000 mg PO + Diphenhydramine (or equivalent H1 blocker) 12.5–50 mg IV/PO + Famotidine (or equivalent H2 blocker) 20 mg IV/PO +/- Corticosteroid Per institutional protocol
Primary febrile neutropenia prophylaxis (high risk): G-CSF risk ecommended per NCCN hematopoietic growth factor guidance.
Intrathecal Therapy: Use preservative-free formulations only; administer IT therapy in one syringe whenever applicable to minimize handling/errors.
Hydration with Cyclophosphamide: Target combined oral + IV hydration of 2–3 L/day on cyclophosphamide days (D29). Oral hydration strongly encouraged.
| Medication | D29 | D36 | D43 | D50 |
|---|---|---|---|---|
| Vincristine IV over 5–10 min | 1.5 mg/m² IV | 1.5 mg/m² IV | ||
| Doxorubicin Slow IV push | ||||
| Pegaspargase ≤21 years | 2,500 units/m² IV | |||
| OR Pegaspargase >21 years | 2,000 units/m² IV (max 3,750units ~1vial) | |||
| Cyclophosphamide IV over 30 min | 1,000 mg/m² IV | |||
| Cytarabine IV over 1–3 h or SC | 75 mg/m² daily (D29–32) | 75 mg/m² daily (D36–39) | ||
| Thioguanine 60 mg/m² PO daily | Daily D29–42 | → | End D42 | |
| Dexamethasone 10 mg/m²/day PO/IV divided BID | ||||
| Methotrexate (IT) | 15 mg IT | 15 mg IT | ||
| Medication | D29 | D36 | D43 | D50 |
Pegaspargase Premedications (30–60 min prior): Acetaminophen 650–1000 mg PO + Diphenhydramine (or equivalent H1 blocker) 12.5–50 mg IV/PO + Famotidine (or equivalent H2 blocker) 20 mg IV/PO +/- Corticosteroid Per institutional protocol
Primary febrile neutropenia prophylaxis (high risk): G-CSF risk ecommended per NCCN hematopoietic growth factor guidance.
Intrathecal Therapy: Use preservative-free formulations only; administer IT therapy in one syringe whenever applicable to minimize handling/errors.
Hydration with Cyclophosphamide: Target combined oral + IV hydration of 2–3 L/day on cyclophosphamide days (D29). Oral hydration strongly encouraged.
Maintenance (Mercaptopurine/Methotrexate/VinCRIStine/DexAMETHasone)
12-week cycle until the total duration of therapy, beginning with the first interim maintenance period, reaches 2 years for females and 3 years for males
- People diagnosed with T-ALL received 24Gy prophylactic cranial irradiation during the first cycle of maintenance therapy.
- People diagnosed with CNS involvement at diagnosis received 18Gy cranial irradiation during the first cycle of maintenance therapy.
- Mercaptopurine (6MP): Must be taken on an empty stomach, at least one hour before or two hours after eating.
- Methotrexate (MTX): Taken orally once a week. Taken on an empty stomach like the 6-MP
| C1–4 | D1 | D8 | D15 | D22 |
|---|---|---|---|---|
| Mercaptopurine 75 mg/m² PO daily | Daily D1–84 | → | → | → |
| Methotrexate (PO) | 20 mg/m² | 20 mg/m² | 20 mg/m² | |
| Dexamethasone 6 mg/m²/day PO/IV divided BID x5d | Days 1–5 | |||
| Vincristine IV over 5–10 min | 1.5 mg/m² IV (max 2 mg) | |||
| Methotrexate (IT) | 15 mg IT |
Methotrexate tablets available: 2.5 mg, 5 mg, 7.5 mg, 10 mg, and 15 mg; oral solution 2mg/mL
Intrathecal Therapy: Use preservative-free formulations only; administer IT therapy in one syringe whenever applicable to minimize handling/errors.
| C1–4 | D29 | D36 | D43 | D50 |
|---|---|---|---|---|
| Mercaptopurine 75 mg/m² PO daily | → | → | → | → |
| Methotrexate (PO) | 20 mg/m² | 20 mg/m² | 20 mg/m² | |
| Dexamethasone 6 mg/m²/day PO/IV divided BID x5d | Days 29–33 | |||
| Vincristine IV over 5–10 min | 1.5 mg/m² IV | |||
| Methotrexate (IT) | 15 mg IT |
Methotrexate tablets available: 2.5 mg, 5 mg, 7.5 mg, 10 mg, and 15 mg; oral solution 2mg/mL
Intrathecal Therapy: Use preservative-free formulations only; administer IT therapy in one syringe whenever applicable to minimize handling/errors.
| C1–4 | D57 | D64 | D71 | D78 |
|---|---|---|---|---|
| Mercaptopurine 75 mg/m² PO daily | → | → | → | → |
| Methotrexate (PO) | 20 mg/m² | 20 mg/m² | 20 mg/m² | 20 mg/m² |
| Dexamethasone 6 mg/m²/day PO/IV divided BID x5d | Days 57–61 | |||
| Vincristine IV over 5–10 min | 1.5 mg/m² IV | |||
| Methotrexate (IT) |
Methotrexate tablets available: 2.5 mg, 5 mg, 7.5 mg, 10 mg, and 15 mg; oral solution 2mg/mL
Intrathecal Therapy: Use preservative-free formulations only; administer IT therapy in one syringe whenever applicable to minimize handling/errors.
| C5+ | D1 | D8 | D15 | D22 |
|---|---|---|---|---|
| Mercaptopurine 75 mg/m² PO daily | Daily D1–84 | → | → | → |
| Methotrexate (PO) | 20 mg/m² | 20 mg/m² | 20 mg/m² | |
| Dexamethasone 6 mg/m²/day PO/IV divided BID x5d | Days 1–5 | |||
| Vincristine IV over 5–10 min | 1.5 mg/m² IV (max 2 mg) | |||
| Methotrexate (IT) | 15 mg IT |
Methotrexate tablets available: 2.5 mg, 5 mg, 7.5 mg, 10 mg, and 15 mg; oral solution 2mg/mL
Intrathecal Therapy: Use preservative-free formulations only; administer IT therapy in one syringe whenever applicable to minimize handling/errors.
| C5+ | D29 | D36 | D43 | D50 |
|---|---|---|---|---|
| Mercaptopurine 75 mg/m² PO daily | → | → | → | → |
| Methotrexate (PO) | 20 mg/m² | 20 mg/m² | 20 mg/m² | 20 mg/m² |
| Dexamethasone 6 mg/m²/day PO/IV divided BID x5d | Days 29–33 | |||
| Vincristine IV over 5–10 min | 1.5 mg/m² IV | |||
| Methotrexate (IT) |
Methotrexate tablets available: 2.5 mg, 5 mg, 7.5 mg, 10 mg, and 15 mg; oral solution 2mg/mL
Intrathecal Therapy: Use preservative-free formulations only; administer IT therapy in one syringe whenever applicable to minimize handling/errors.
| C5+ | D57 | D64 | D71 | D78 |
|---|---|---|---|---|
| Mercaptopurine 75 mg/m² PO daily | → | → | → | → |
| Methotrexate (PO) | 20 mg/m² | 20 mg/m² | 20 mg/m² | 20 mg/m² |
| Dexamethasone 6 mg/m²/day PO/IV divided BID x5d | Days 57–61 | |||
| Vincristine IV over 5–10 min | 1.5 mg/m² IV | |||
| Methotrexate (IT) |
Methotrexate tablets available: 2.5 mg, 5 mg, 7.5 mg, 10 mg, and 15 mg; oral solution 2mg/mL
Intrathecal Therapy: Use preservative-free formulations only; administer IT therapy in one syringe whenever applicable to minimize handling/errors.