Testing the Addition of Daratumumab to Chemotherapy for Treating Patients With Newly-Diagnosed T-Cell Lymphoblastic Leukemia (T-ALL) and T-Cell Lymphoblastic Lymphoma (T-LL)

Last updated: July 29, 2026
Sponsor: Children's Oncology Group
Overall Status: Active - Not Recruiting

Phase

2/3

Condition

Lymphoma

Leukemia

Treatment

Nelarabine

Biopsy Procedure

Calaspargase Pegol

Clinical Study ID

NCT07072585
AALL2331
AALL2331
U10CA180886
NCI-2025-02230
  • Ages 365-21
  • All Genders

Study Summary

This phase II/III trial tests the addition of daratumumab to chemotherapy for treating patients with newly-diagnosed T-ALL and T-LL. Daratumumab is in a class of medications called monoclonal antibodies. It binds to a protein called CD38, which is found on some types of immune cells and cancer cells. Daratumumab may block CD38 and help the immune system kill cancer cells. Chemotherapy drugs work in different ways to stop the growth of cancer cells, either by killing the cells, by stopping them from dividing, or by stopping them from spreading. Giving chemotherapy with daratumumab may kill more cancer cells.

Eligibility Criteria

Inclusion

Inclusion Criteria:

  • All patients must be enrolled on APEC14B1 and consented to eligibility screening (part A) prior to treatment and enrolled on AALL2331.

  • Patients must be > 365 days and < 21 years of age at the time of diagnosis.

    • Newly diagnosed T-cell acute lymphoblastic leukemia (T-ALL) or T-lineagelymphoblastic lymphoma (T-LL) stages II-IV.

  • Note: A diagnosis of T-ALL is established when leukemic blasts lackmyeloperoxidase or evidence of B-lineage derivation (CD19/CD22/CD20), andexpress either surface or cytoplasmic CD3 or two or more of the antigens CD8,CD7, CD5, CD4, CD2 or CD1a, and are present either in peripheral blood or > 25%in the bone marrow. If surface CD3 is expressed on all leukemic cells,additional markers of immaturity, including TdT, CD34 or CD99 will be assessedfor expression. Cases with uncertain expression will receive additional reviewwithin the appropriate Children's Oncology Group (COG) reference laboratory.

  • For T-LL patients with tissue available for flow cytometry, the criterion fordiagnosis should be analogous to T-ALL. For tissue processed by other means (i.e. paraffin blocks), the methodology and criteria for immunophenotypicanalysis to establish the diagnosis of T-LL defined by the submittinginstitution will be accepted.

Exclusion

Exclusion Criteria:

  • Diagnosis of Down syndrome (trisomy 21).

  • Patients with known Charcot-Marie-Tooth disease.

    • Patients must not have received any cytotoxic chemotherapy for either the currentdiagnosis of T-ALL, T-LL or for any cancer diagnosis prior to the initiation ofprotocol therapy on AALL2331 with the exception of:

  • Steroid pretreatment: Prednisone or methylprednisolone for ≤ 120 hours (5 days)in the 7 days prior to initiating induction chemotherapy or for ≤ 336 hours (14days) in the 28 days prior to initiation of protocol therapy does not affecteligibility.

  • Intrathecal cytarabine; or

  • Pretreatment with hydroxyurea; or

  • 600 cGy of chest irradiation, if medically necessary.

  • Pre-treatment with dexamethasone in the 28 days prior to initiation of protocoltherapy is not allowed with the exception of a single dose of dexamethasoneused during sedation to prevent or treat airway edema. Patients who receive asingle dose of dexamethasone to prevent or treat airway edema in the 28 dayspreceding diagnosis are eligible for this study.

    • Female patients who are pregnant since fetal toxicities and teratogenic effectshave been noted for several of the study drugs. A pregnancy test is required forfemale patients of childbearing potential.

  • Lactating females who plan to breastfeed their infants.

  • Sexually active patients of reproductive potential who have not agreed to use aneffective contraceptive method for the duration of their study participation.

  • Known severe persistent asthma anytime in the previous two years or uncontrolledasthma of any classification.

  • Peripheral neurotoxicity: Pre-existing ≥ grade 2 sensory or motor peripheralneurotoxicity.

  • Seizure disorder: Patients must not have an uncontrolled seizure disorder. Patientswith a seizure history or a controlled seizure disorder are eligible. A controlledseizure disorder is defined as having stable or decreasing symptoms over the past 3months without anti-epileptic medications or is on a stable or decreasing dose ofanti-epileptic medication.

    • Patients who are previously known to be seropositive for HIV except forHIV-infected patients on effective anti-retroviral therapy with undetectable viralload within 6 months of enrollment on this trial.

  • Patients with evidence of chronic hepatitis B (HBV) infection, except forpatients who have an HBV viral load that is undetectable on suppressivetherapy.

  • Patients with a history of hepatitis C virus (HCV) infection, except for thosepatients who have been treated and cured, or patients who are currently on HCVtreatment who have an undetectable HCV viral load.

  • Patients with significant hepatic dysfunction defined as those with an alanineaminotransferase (ALT) (serum glutamic pyruvic transaminase [SGPT]) > 10x upperlimit of normal (ULN) or direct bilirubin > 2x ULN unless the patient has knownGilbert's syndrome or has hepatic involvement from leukemic or lymphomatousinfiltration.

  • All patients and/or their parents or legal guardians must sign a written informedconsent.

  • All institutional, Food and Drug Administration (FDA), and National Cancer Institute (NCI) requirements for human studies must be met.

Study Design

Total Participants: 1708
Treatment Group(s): 31
Primary Treatment: Nelarabine
Phase: 2/3
Study Start date:
August 28, 2026
Estimated Completion Date:
September 01, 2035

Study Description

PRIMARY OBJECTIVES:

I. To compare the event-free survival (EFS) from the end of induction (EOI) in patients with newly diagnosed T-ALL who are randomized to either receive a modified augmented Berlin-Frankfurt-Münster (aBFM) chemotherapy backbone or a modified aBFM backbone with the addition of daratumumab.

II. To compare the EFS from the EOI in patients with newly diagnosed T-LL who are randomized to a modified aBFM chemotherapy backbone with bortezomib or to a modified aBFM backbone with bortezomib and the addition of daratumumab.

SECONDARY OBJECTIVES:

I. To compare health-related quality of life (HRQoL) and therapy-related toxicity and tolerability between patients with T-ALL or T-LL randomized to a modified aBFM backbone or to a modified aBFM backbone with the addition of daratumumab.

II. To compare overall survival (OS) from date of randomization in patients with newly diagnosed T-ALL who are randomized to either receive a modified aBFM chemotherapy backbone or a modified aBFM backbone with the addition of daratumumab.

III. To compare OS from date of randomization in patients with newly diagnosed T-LL who are randomized to a modified aBFM chemotherapy backbone with bortezomib or to a modified aBFM backbone with bortezomib and the addition of daratumumab.

EXPLORATORY OBJECTIVES:

I. In patients with newly diagnosed T-LL, to determine if minimal residual disease (MRD) testing at EOI can predict EFS and/or OS.

II. In T-ALL patients, to describe changes in the immunophenotype (specifically CD38 surface expression on T-ALL/T-LL blasts) and for the development of anti-daratumumab antibodies over the course of treatment and correlate changes with clinical outcomes and demographic variables.

III. To explore the associations between family-reported social determinants of health and both clinical outcomes (including incidence of treatment-related toxicities, EFS, OS), and leukemia/lymphoma and host biology.

IV. To describe outcome differences (EFS and OS) in patients with T-LL who differ in degrees of positron emission tomography (PET)-imaging avid disease at the EOI.

V. To explore potential imaging findings and biomarkers of significant/severe nelarabine-induced central nervous system toxicities by central review of magnetic resonance imaging (MRI) and to investigate possible clinical features in patients experiencing such toxicities.

VI. To bank peripheral blood specimens for future correlative studies in patients with T-LL.

VII. To compare EFS and OS from the EOI in patients with newly diagnosed T-ALL who are MRD positive (≥ 0.01%) at the EOI to those who are MRD negative at the EOI.

OUTLINE: This is a phase II study, followed by a phase III study. Patients are assigned to 1 of 2 groups.

GROUP I T-ALL:

INDUCTION: Patients receive cytarabine intrathecally (IT) once at the time of lumbar puncture, or day 1, daunorubicin intravenously (IV) over 1 - 15 minutes on days 1, 8, 15 and 22, dexamethasone orally (PO) or IV twice a day (BID) on days 1 - 28, vincristine IV on days 1, 8, 15 and 22, pegaspargase IV over 1 - 2 hours or intramuscularly (IM) once on day 4 or calaspargase pegol-mknl IV over 1 - 2 hours once on day 4, and methotrexate IT on days 8 and 29 (patients with central nervous system [CNS]1 or CNS2) or methotrexate IT, hydrocortisone IT and cytarabine IT on days 8, 15, 22 and 29 (patients with CNS3). Induction treatment continues over 35 days in the absence of disease progression or unacceptable toxicity.

EOI: Patients are randomized to 1 of 2 arms.

ARM A:

CONSOLIDATION: Patients receive nelarabine IV over 60 minutes QD on days 1 - 5 and 36 - 40, cyclophosphamide IV over 30 - 60 minutes on days 8 and 43, cytarabine IV over 1 - 30 minutes or subcutaneously (SC) QD on days 8 - 11, 15 - 18, 43 - 46 and 50 - 53, mercaptopurine PO QD on days 8 - 21 and 43 - 56, methotrexate IT on days 15, 22, 50 and 57 (patients with CNS1 or CNS2) or methotrexate IT, hydrocortisone IT and cytarabine IT on days 15, 22, 50 and 57 (patients with CNS3), pegaspargase IV over 1 - 2 hours or IM on days 22 and 57 or calaspargase pegol-mknl IV over 1 - 2 hours on days 22 and 57, and vincristine IV on days 22, 29, 57 and 64. Patients with persistent testicular disease undergo radiation therapy QD for 12 fractions within the first two weeks of consolidation. Consolidation treatment continues over 77 days in the absence of disease progression or unacceptable toxicity. Patients with MRD < 1% following consolidation proceed to interim maintenance.

INTERIM MAINTENANCE: Patients receive methotrexate IT on days 1 and 31 (patients with CNS1 or CNS2) or methotrexate IT, hydrocortisone IT and cytarabine IT on days 1 and 31 (patients with CNS3), methotrexate IV over 2 - 15 minutes on days 1, 11, 21, 31 and 41, pegaspargase IV over 1 - 2 hours or IM on days 2 and 22 or calaspargase pegol-mknl IV over 1 - 2 hours on days 2 and 23, and vincristine IV on days 1, 11, 21, 31 and 41. Interim maintenance treatment continues over 56 days in the absence of disease progression or unacceptable toxicity. Patients with MRD < 0.1% following interim maintenance proceed to delayed intensification.

DELAYED INTENSIFICATION:

PART 1: Patients receive dexamethasone PO or IV BID on days 1 - 7 and 15 - 21, doxorubicin IV over 3 - 15 minutes on days 1, 8 and 15, methotrexate IT once on day 1 (patients with CNS1 or CNS2) or methotrexate IT, hydrocortisone IT and cytarabine IT once on day 1 (patients with CNS3), pegaspargase IV over 1 - 2 hours or IM once on day 4 or calaspargase pegol-mknl IV over 1 - 2 hours once on day 4, and vincristine IV on days 1, 8 and 15. Delayed intensification part 1 treatment continues over 28 days in the absence of disease progression or unacceptable toxicity.

PART 2: Patients receive nelarabine IV over 60 minutes QD on days 29 - 33, cyclophosphamide IV over 30 - 60 minutes once on day 36, cytarabine IV over 1 - 30 minutes or SC QD on days 36 - 39 and 43 - 46, thioguanine PO QD on days 36 - 49, methotrexate IT on days 36 and 43 (patients with CNS1 or CNS2) or methotrexate IT, hydrocortisone IT and cytarabine IT on days 36 and 43 (patients with CNS3), pegaspargase IV over 1 - 2 hours or IM once on day 50 or calaspargase pegol-mknl IV over 1 - 2 hours once on day 50, and vincristine IV on days 50 and 57. Delayed intensification part 2 treatment continues over 35 days in the absence of disease progression or unacceptable toxicity.

MAINTENANCE:

CYCLES 1 - 3: Patients receive methotrexate IT once on day 1 (patients with CNS1 or CNS2) or methotrexate IT, hydrocortisone IT and cytarabine IT once on day 1 (patients with CNS3), mercaptopurine PO QD on days 1 - 28 and 36 - 84, prednisone PO or IV BID on days 1

  • 5 and 57 - 61 or prednisolone PO or IV BID on days 1 - 5 and 57 - 61 or methylprednisolone IV BID on days 1 - 5 and 57 - 61, vincristine IV on days 1 and 57, methotrexate PO on days 8, 15, 22, 36, 43, 50, 57, 64, 71 and 78, and nelarabine IV over 60 minutes QD on days 29 - 33. Cycles repeat every 84 days for up to 3 cycles in the absence of disease progression or unacceptable toxicity.

CYCLES 4 +: Patients receive methotrexate IT once on day 1 (patients with CNS1 or CNS2) or methotrexate IT, hydrocortisone IT and cytarabine IT once on day 1 (patients with CNS3), prednisone PO or IV BID on days 1 - 5, 29 - 33 and 57 - 61 or prednisolone PO or IV BID on days 1 - 5, 29 - 33 and 57 - 61, mercaptopurine PO QD on days 1 - 84, vincristine IV on days 1, 29 and 57, and methotrexate PO on days 8, 15, 22, 29, 36, 43, 50, 57, 64, 71 and 78. Cycles repeat every 84 days until 2 years from the start of interim maintenance in the absence of disease progression or unacceptable toxicity.

ARM B:

CONSOLIDATION: Patients receive daratumumab IV on days 8, 15, 22, 29, 43, 50, 57 and 64, nelarabine IV over 60 minutes QD on days 1 - 5 and 36 - 41, cyclophosphamide IV over 30 - 60 minutes on days 8 and 43, cytarabine IV over 1 - 30 minutes or SC QD on days 8 - 11, 15 - 18, 43 - 46 and 50 - 53, mercaptopurine PO QD on days 8 - 21 and 43 - 56, methotrexate IT on days 15, 22, 50 and 57 (patients with CNS1 or CNS2) or methotrexate IT, hydrocortisone IT and cytarabine IT on days 15, 22, 50 and 57 (patients with CNS3), pegaspargase IV over 1 - 2 hours or IM on days 23 and 58 or calaspargase pegol-mknl IV over 1 - 2 hours on days 23 and 58, and vincristine IV on days 22, 29, 57 and 64. Patients with persistent testicular disease undergo radiation therapy QD for 12 fractions within the first two weeks of consolidation. Consolidation treatment continues over 77 days in the absence of disease progression or unacceptable toxicity. Patients with MRD < 1% following consolidation proceed to interim maintenance.

INTERIM MAINTENANCE: Patients receive daratumumab IV on days 1, 21 and 41, methotrexate IT on days 1 and 31 (patients with CNS1 or CNS2) or methotrexate IT, hydrocortisone IT and cytarabine IT on days 1 and 31 (patients with CNS3), methotrexate IV over 2 - 15 minutes on days 1, 11, 21, 31 and 41, pegaspargase IV over 1 - 2 hours or IM on days 2 and 22 or calaspargase pegol-mknl IV over 1 - 2 hours on days 2 and 23, and vincristine IV on days 1, 11, 21, 31 and 41. Interim maintenance treatment continues over 56 days in the absence of disease progression or unacceptable toxicity. Patients with MRD < 0.1% following interim maintenance proceed to delayed intensification.

DELAYED INTENSIFICATION:

PART 1: Patients receive daratumumab IV on days 1 and 15, dexamethasone PO or IV BID on days 1 - 7 and 15 - 21, doxorubicin IV over 3 - 15 minutes on days 1, 8 and 15, methotrexate IT once on day 1 (patients with CNS1 or CNS2) or methotrexate IT, hydrocortisone IT and cytarabine IT once on day 1 (patients with CNS3), vincristine IV on days 1, 8 and 15, and pegaspargase IV over 1 - 2 hours or IM once on day 4 or calaspargase pegol-mknl IV over 1 - 2 hours once on day 4. Delayed intensification part 1 treatment continues over 28 days in the absence of disease progression or unacceptable toxicity.

PART 2: Patients receive nelarabine IV over 60 minutes QD on days 29 - 33, daratumumab IV on days 36 and 50, cyclophosphamide IV over 30 - 60 minutes once on day 36, cytarabine IV over 1 - 30 minutes or SC QD on days 36 - 39 and 43 - 46, thioguanine PO QD on days 36 - 49, methotrexate IT on days 36 and 43 (patients with CNS1 or CNS2) or methotrexate IT, hydrocortisone IT and cytarabine IT on days 36 and 43 (patients with CNS3), pegaspargase IV over 1 - 2 hours or IM once on day 51 or calaspargase pegol-mknl IV over 1 - 2 hours once on day 51, and vincristine IV on days 50 and 57. Delayed intensification part 2 treatment continues over 35 days in the absence of disease progression or unacceptable toxicity.

MAINTENANCE:

CYCLES 1 - 3: Patients receive methotrexate IT once on day 1 (patients with CNS1 or CNS2) or methotrexate IT, hydrocortisone IT and cytarabine IT once on day 1 (patients with CNS3), mercaptopurine PO QD on days 1 - 28 and 36 - 84, prednisone PO or IV BID on days 1

  • 5 and 57 - 61 or prednisolone PO or IV BID on days 1 - 5 and 57 - 61 or methylprednisolone IV BID on days 1 - 5 and 57 - 61, vincristine IV on days 1 and 57, methotrexate PO on days 8, 15, 22, 36, 43, 50, 57, 64, 71 and 78, and nelarabine IV over 60 minutes QD on days 29 - 33. Cycles repeat every 84 days for up to 3 cycles in the absence of disease progression or unacceptable toxicity.

CYCLES 4 +: Patients receive methotrexate IT once on day 1 (patients with CNS1 or CNS2) or methotrexate IT, hydrocortisone IT and cytarabine IT once on day 1 (patients with CNS3), prednisone PO or IV BID on days 1 - 5, 29 - 33 and 57 - 61 or prednisolone PO or IV BID on days 1 - 5, 29 - 33 and 57 - 61, mercaptopurine PO QD on days 1 - 84, vincristine IV on days 1, 29 and 57, and methotrexate PO on days 8, 15, 22, 29, 36, 43, 50, 57, 64, 71 and 78. Cycles repeat every 84 days until 2 years from the start of interim maintenance in the absence of disease progression or unacceptable toxicity.

Additionally, patients undergo echocardiography (ECHO) during screening and bone marrow biopsy and aspiration as well as lumbar puncture throughout the study. Patients may undergo MRI, ultrasound and biopsy on study as well as may undergo blood sample collection throughout the study.

GROUP II T-LL:

INDUCTION: Patients receive bortezomib IV over 3 - 5 seconds or SC on days 1, 4, 8 and 11, cytarabine IT once at the time of lumbar puncture, or day 1, daunorubicin IV over 1 - 15 minutes on days 1, 8, 15 and 22, prednisone PO or IV BID on days 1 - 28 or prednisolone PO or IV BID on days 1 - 28 or methylprednisolone IV BID on days 1 - 28, methotrexate IT on days 8 and 29 (patients with CNS1 or CNS2) or methotrexate IT, hydrocortisone IT and cytarabine IT on days 8, 15, 22 and 29 (patients with CNS3), pegaspargase IV over 1 - 2 hours or IM once on day 4 or calaspargase pegol-mknl IV over 1

  • 2 hours once on day 4, and vincristine IV on days 1, 8, 15 and 22. Induction treatment continues over 35 days in the absence of disease progression or unacceptable toxicity.

EOI: Patients are randomized to 1 of 2 arms.

ARM C:

CONSOLIDATION: Patients receive cyclophosphamide IV over 30 - 60 minutes on days 1 and 29, cytarabine IV over 1 - 30 minutes or SC QD on days 1 - 4, 8 - 11, 29 - 32 and 36 - 39, mercaptopurine PO QD on days 1 - 14 and 29 - 42, methotrexate IT on days 1, 8, 15 and 22 (patients with CNS1 or CNS2) or methotrexate IT, hydrocortisone IT and cytarabine IT on days 1, 8, 15 and 22 (patients with CNS3), pegaspargase IV over 1 - 2 hours or IM on days 15 and 43 or calaspargase pegol-mknl IV over 1 - 2 hours on days 15 and 43, and vincristine IV on days 15, 22, 43 and 50. Patients with persistent testicular disease undergo radiation therapy QD for 12 fractions within the first two weeks of consolidation. Consolidation treatment continues over 63 days in the absence of disease progression or unacceptable toxicity. Patients with a complete response (CR) following consolidation proceed to interim maintenance.

INTERIM MAINTENANCE: Patients receive methotrexate IT on days 1 and 31 (patients with CNS1 or CNS2) or methotrexate IT, hydrocortisone IT and cytarabine IT on days 1 and 31 (patients with CNS3), methotrexate IV over 2 - 15 minutes on days 1, 11, 21, 31 and 41, pegaspargase IV over 1 - 2 hours or IM on days 2 and 22 or calaspargase pegol-mknl IV over 1 - 2 hours on days 2 and 23, and vincristine IV on days 1, 11, 21, 31 and 41. Interim maintenance treatment continues over 56 days in the absence of disease progression or unacceptable toxicity.

DELAYED INTENSIFICATION:

PART 1: Patients receive bortezomib IV over 3 - 5 seconds or SC on days 1, 4, 15 and 18, dexamethasone PO or IV BID on days 1 - 7 and 15 - 21, doxorubicin IV over 3 - 15 minutes on days 1, 8 and 15, methotrexate IT once on day 1 (patients with CNS1 or CNS2) or methotrexate IT, hydrocortisone IT and cytarabine IT once on day 1 (patients with CNS3), vincristine IV on days 1, 8 and 15, and pegaspargase IV over 1 - 2 hours or IM once on day 4 or calaspargase pegol-mknl IV over 1 - 2 hours once on day 4. Delayed intensification part 1 treatment continues over 28 days in the absence of disease progression or unacceptable toxicity.

PART 2: Patients receive cyclophosphamide IV over 30 - 60 minutes once on day 29, cytarabine IV over 1 - 30 minutes or SC QD on days 29 - 32 and 36 - 39, thioguanine PO QD on days 29 - 42, methotrexate IT on days 29 and 36 (patients with CNS1 or CNS2) or methotrexate IT, hydrocortisone IT and cytarabine IT on days 29 and 36 (patients with CNS3), pegaspargase IV over 1 - 2 hours or IM once on day 43 or calaspargase pegol-mknl IV over 1 - 2 hours once on day 43, and vincristine IV on days 43 and 50. Delayed intensification part 2 treatment continues over 28 days in the absence of disease progression or unacceptable toxicity.

MAINTENANCE: Patients receive methotrexate IT once on day 1 (patients with CNS1 or CNS2) or methotrexate IT, hydrocortisone IT and cytarabine IT once on day 1 (patients with CNS3), mercaptopurine PO QD on days 1 - 84, prednisone PO or IV BID on days 1 - 5, 29 - 33 and 57 - 61 or prednisolone PO or IV BID on days 1 - 5, 29 - 33 and 57 - 61 or methylprednisolone IV BID on days 1 - 5, 29 - 33 and 57 - 61, vincristine IV on days 1, 29 and 57, and methotrexate PO on days 8, 15, 22, 29, 36, 43, 50, 57, 64, 71 and 78. Cycles repeat every 84 days for 2 years from the start of interim maintenance in the absence of disease progression or unacceptable toxicity.

ARM D:

CONSOLIDATION: Patients receive daratumumab IV on days 1, 8, 15, 22, 29, 36, 43 and 50, cyclophosphamide IV over 30 - 60 minutes on days 1 and 29, cytarabine IV over 1 - 30 minutes or SC QD on days 1 - 4, 8 - 11, 29 - 32 and 36 - 39, mercaptopurine PO QD on days 1 - 14 and 29 - 42, methotrexate IT on days 1, 8, 15 and 22 (patients with CNS1 or CNS2) or methotrexate IT, hydrocortisone IT and cytarabine IT on days 1, 8, 15 and 22 (patients with CNS3), pegaspargase IV over 1 - 2 hours or IM on days 16 and 44 or calaspargase pegol-mknl IV over 1 - 2 hours on days 16 and 44, and vincristine IV on days 15, 22, 43 and 50. Patients with persistent testicular disease undergo radiation therapy QD for 12 fractions within the first two weeks of consolidation. Consolidation treatment continues over 63 days in the absence of disease progression or unacceptable toxicity. Patients with a CR following consolidation proceed to interim maintenance.

INTERIM MAINTENANCE: Patients receive daratumumab IV on days 1, 21 and 41, methotrexate IT on days 1 and 31 (patients with CNS1 or CNS2) or methotrexate IT, hydrocortisone IT and cytarabine IT on days 1 and 31 (patients with CNS3), methotrexate IV over 2 - 15 minutes on days 1, 11, 21, 31 and 41, pegaspargase IV over 1 - 2 hours or IM on days 2 and 22 or calaspargase pegol-mknl IV over 1 - 2 hours on days 2 and 23, and vincristine IV on days 1, 11, 21, 31 and 41. Interim maintenance treatment continues over 56 days in the absence of disease progression or unacceptable toxicity.

DELAYED INTENSIFICATION:

PART 1: Patients receive daratumumab IV on days 1 and 15, bortezomib IV over 3 - 5 seconds or SC on days 1, 4, 15 and 18, dexamethasone PO or IV BID on days 1 - 7 and 15 - 21, doxorubicin IV over 3 - 15 minutes on days 1, 8 and 15, methotrexate IT once on day 1 (patients with CNS1 or CNS2) or methotrexate IT, hydrocortisone IT and cytarabine IT once on day 1 (patients with CNS3), vincristine IV on days 1, 8 and 15, and pegaspargase IV over 1 - 2 hours or IM once on day 4 or calaspargase pegol-mknl IV over 1 - 2 hours once on day 4. Delayed intensification part 1 treatment continues over 28 days in the absence of disease progression or unacceptable toxicity.

PART 2: Patients receive daratumumab IV QD on days 29 and 43, cyclophosphamide IV over 30

  • 60 minutes once on day 29, cytarabine IV over 1 - 30 minutes or SC QD on days 29 - 32 and 36 - 39, thioguanine PO QD on days 29 - 42, methotrexate IT QD on days 29 and 36 (patients with CNS1 or CNS2) or methotrexate IT, hydrocortisone IT and cytarabine IT QD on days 29 and 36 (patients with CNS3), pegaspargase IV over 1 - 2 hours or IM once on day 44 or calaspargase pegol-mknl IV over 1 - 2 hours once on day 44, and vincristine IV QD on days 43 and 50. Delayed intensification part 2 treatment continues over 28 days in the absence of disease progression or unacceptable toxicity.

MAINTENANCE: Patients receive methotrexate IT once on day 1 (patients with CNS1 or CNS2) or methotrexate IT, hydrocortisone IT and cytarabine IT once on day 1 (patients with CNS3), mercaptopurine PO QD on days 1 - 84, prednisone PO or IV BID on days 1 - 5, 29 - 33 and 57 - 61 or prednisolone PO or IV BID on days 1 - 5, 29 - 33 and 57 - 61 or methylprednisolone IV BID on days 1 - 5, 29 - 33 and 57 - 61, vincristine IV on days 1, 29 and 57, and methotrexate PO on days 8, 15, 22, 29, 36, 43, 50, 57, 64, 71 and 78. Cycles repeat every 84 days for 2 years from the start of interim maintenance in the absence of disease progression or unacceptable toxicity.

Additionally, patients undergo ECHO during screening and lumbar puncture as well as computed tomography (CT) or MRI, PET or PET-CT or bone scan throughout the study. Patients may undergo ultrasound and biopsy on study as well as may undergo blood sample collection and bone marrow biopsy and aspiration throughout the study.

After completion of study treatment, patients are followed up for 10 years.