Chemotherapy With Liposomal Cytarabine CNS Prophylaxis for Adult Acute Lymphoblastic Leukemia & Lymphoblastic Lymphoma

This treatment regimen builds on the "Linker" regimen/UCSF Protocol 8707 ALL regimen backbone
with the goal of improved efficacy and acceptable toxicity by substituting pegylated
asparaginase for native L-asparaginase, the addition of rituximab for pre-B-cell ALL, and the
addition of dasatinib for Philadelphia chromosome/BCR-ABL positive ALL, and the addition of
cyclophosphamide for younger adults. In addition, the study regimen aims to reduce CNS
relapse through the use of intrathecal liposomal cytarabine in place of intrathecal
methotrexate for CNS relapse prophylaxis and

The regimen uses 3 modules of therapy with non-cross-resistant chemotherapy agents. Rituximab
is added for a total of 8 doses for patients with pre-B-cell ALL. Dasatinib is added for
patients with Ph+ ALL.

Course 1A (Induction): Daunorubicin, vincristine, PEG-asparaginase, and prednisone for all
patients with the addition of cyclophosphamide for patients 18-39 years of age. Treatment is
intensified for patients with disease present on a day 14 bone marrow biopsies during
Induction Course 1A. In addition to standard analyses, minimal residual disease will be
assessed on day 14 and remission bone marrow aspirates and correlated with outcomes.

Course 1B: High-dose methotrexate, oral 6-mercaptopurine, and PEG-asparaginase.

Course 1C: High-dose cytarabine and etoposide.

The 3 courses then repeat (2A (Intensification), 2B, 2C) followed by a final "B" cycle (3B)
of high-dose methotrexate, 6-mercaptopurine, and PEG-asparaginase.

After completion of Course 3B, patients proceed to maintenance chemotherapy with monthly
methotrexate, vincristine, 6-mercaptopurine, and prednisone cycles for 24 months with a
single dose PEG-asparaginase given in month 1 of Maintenance.

CNS prophylaxis: Intrathecal liposomal cytarabine replaces intrathecal methotrexate CNS
prophylaxis and is given every 2 weeks during the "A" Induction and Intensification courses
then every 3 months during Maintenance for a total of 8 doses. Given the presence of CNS
penetrating chemotherapy in the "B" and "C" cycles, intrathecal liposomal cytarabine is not
given due to risk of excessive CNS toxicity.

There is a randomization to hydrocortisone or placebo premedication prior to
PEG-asparaginase.

Inclusion Criteria:

- Ability to understand and the willingness to sign a written informed consent.

- Diagnosis of acute lymphoblastic leukemia or lymphoblastic lymphoma as defined by the
World Health Organization [94]

- Untreated disease EXCEPT for corticosteroids, hydroxyurea, leukapheresis, and/or
tyrosine kinase inhibitors for up to 2 weeks prior to initiation of study therapy.

- Age 18 through 60 years

- ECOG performance status 0,1, or 2 (see Appendix A)

- Adequate organ function defined as:

- Total bilirubin < 2 mg/dL (unless due to ALL)

- AST(SGOT)/ALT(SGPT) < 3 times institutional upper limit of normal (unless due to ALL)

- Serum creatinine < 2 mg/dL (unless elevated creatinine felt by investigator to be
acute and reversible) OR creatinine clearance >60 mL/min/1.73 m2 for patients with
creatinine levels above institutional normal

- Left ventricular ejection fraction ≥50%

- Women of child-bearing potential and men with partners of child- bearing potential
must agree to use adequate contraception (hormonal or barrier method of birth control;
abstinence) prior to study entry, for the duration of study participation, and for 90
days following completion of therapy. Should a woman become pregnant or suspect she is
pregnant while participating in this study, she should inform her treating physician
immediately.

- A woman of child-bearing potential is any female (regardless of sexual orientation,
having undergone a tubal ligation, or remaining celibate by choice) who meets the
following criteria:

- Has not undergone a hysterectomy or bilateral oophorectomy; or

- Has not been naturally postmenopausal for at least 12 consecutive months (i.e.,
has had menses at any time in the preceding 12 consecutive months)

Exclusion Criteria:

- Current or anticipated use of other investigational agents during the study

- Known central nervous system mass lesion

- History of allergic reactions attributed to compounds of similar chemical or biologic
composition to liposomal cytarabine or other agents used in study inclusive of known
allergy to polyethylene glycol.

- History of unprovoked venous thrombosis/thromboembolism

- Recurrent or chronic pancreatitis

- Uncontrolled diabetes mellitus

- Uncontrolled intercurrent illness that would limit compliance with study requirements
including, but not limited to, ongoing or active infection, symptomatic congestive
heart failure, unstable angina pectoris, cardiac arrhythmia, or psychiatric
illness/social situations that would limit compliance with study requirements.

- Pregnant or nursing.

- Any condition, in the opinion of the investigator, that compromises compliance with
study requirements

- Known HIV positivity