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NCT04293562 · CITED IN SOURCE DOCUMENTS

A Study to Compare Standard Chemotherapy to Therapy With CPX-351 and/or Gilteritinib for Patients With Newly Diagnosed AML With or Without FLT3 Mutations

An NCI or FDA source cites this study. A citation does not establish that it applies to an individual diagnosis.

Phase
PHASE3
Status at capture
RECRUITING
Registry last update
2026-07-29

This phase III trial compares standard chemotherapy to therapy with liposome-encapsulated daunorubicin-cytarabine (CPX-351) and/or gilteritinib for patients with newly diagnosed acute myeloid leukemia with or without FLT3 mutations. Drugs used in chemotherapy, such as daunorubicin, cytarabine, and gemtuzumab ozogamicin, 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. CPX-351 is made up of daunorubicin and cytarabine and is made in a way that makes the drugs stay in the bone marrow longer and could be less likely to cause heart problems than traditional anthracycline drugs, a common class of chemotherapy drug. Some acute myeloid leukemia patients have an abnormality in the structure of a gene called FLT3. Genes are pieces of DNA (molecules that carry instructions for development, functioning, growth and reproduction) inside each cell that tell the cell what to do and when to grow and divide. FLT3 plays an important role in the normal making of blood cells. This gene can have permanent changes that cause it to function abnormally by making cancer cells grow. Gilteritinib may block the abnormal function of the FLT3 gene that makes cancer cells grow. The overall goals of this study are, 1) to compare the effects, good and/or bad, of CPX-351 with daunorubicin and cytarabine on people with newly diagnosed AML to find out which is better, 2) to study the effects, good and/or bad, of adding gilteritinib to AML therapy for patients with high amounts of FLT3/ITD or other FLT3 mutations and 3) to study changes in heart function during and after treatment for AML. Giving CPX-351 and/or gilteritinib with standard chemotherapy may work better in treating patients with acute myeloid leukemia compared to standard chemotherapy alone.

Open the original ClinicalTrials.gov record → · Download preserved record

What did the study report?

Outcomes, safety and baseline populations are separate source sections. Quality-of-life measures appear under their original outcome titles.

No posted result sections were captured. Registered plans do not establish that a treatment works.

Who could take part
eligibility Criteria
Inclusion Criteria: * All patients must be enrolled on APEC14B1 and consented to Eligibility Screening (Part A) prior to enrollment and treatment on AAML1831 * Patients must be less than 22 years of age at the time of study enrollment * Patient must be newly diagnosed with de novo AML according to the 2016 World Health Organization (WHO) classification with or without extramedullary disease * Patient must have 1 of the following: * \>= 20% bone marrow blasts (obtained within 14 days prior to enrollment) * In cases where extensive fibrosis may result in a dry tap, blast count can be obtained from touch imprints or estimated from an adequate bone marrow core biopsy * \< 20% bone marrow blasts with one or more of the genetic abnormalities associated with childhood/young adult AML as provided in the protocol (sample obtained within 14 days prior to enrollment) * A complete blood count (CBC) documenting the presence of at least 1,000/uL (i.e., a white blood cell \[WBC\] count \>= 10,000/uL with \>= 10% blasts or a WBC count of \>= 5,000/uL with \>= 20% blasts) circulating leukemic cells (blasts) if a bone marrow aspirate or biopsy cannot be performed (performed within 7 days prior to enrollment) * ARM C: Patient must be \>= 2 years of age at the time of Late Callback * ARM C: Patient must have FLT3/ITD allelic ratio \> 0.1 as reported by Molecular Oncology * ARM C: Patient does not have any congenital long QT syndrome or congenital heart block * ARM C: Females of reproductive potential must agree to use effective contraception during treatment and for at least 6 months after the last dose of gilteritinib * ARM C: Lactating women must agree not to breastfeed during treatment with gilteritinib and for 2 months after the last dose of gilteritinib * ARM C: Males of reproductive potential must agree to use effective contraception during treatment and for at least 4 months after the last dose of gilteritinib * ARM D: Patient must be \>= 2 years of age at the time of Late Callback * ARM D: Patient must have one of the clinically relevant non-ITD FLT3 activating mutations as reported by Foundation Medicine * ARM D: Females of reproductive potential must agree to use effective contraception during treatment and for at least 6 months after the last dose of gilteritinib * ARM D: Lactating women must agree not to breastfeed during treatment with gilteritinib and for 2 months after the last dose of gilteritinib * ARM D: Males of reproductive potential must agree to use effective contraception during treatment and for at least 4 months after the last dose of gilteritinib * NEUROPSYCHOLOGICAL TESTING: Patient must be enrolled on Arm A or Arm B. Patients who transfer to Arm C or Arm D are not eligible * NEUROPSYCHOLOGICAL TESTING: Patient must be 5 years or older at the time of enrollment * NEUROPSYCHOLOGICAL TESTING: English-, French- or Spanish-speaking * NEUROPSYCHOLOGICAL TESTING: No known history of neurodevelopmental disorder prior to diagnosis of AML (e.g., Down syndrome, fragile X, William syndrome, mental retardation) * NEUROPSYCHOLOGICAL TESTING: No significant visual or motor impairment that would prevent computer use or recognition of visual test stimuli * All patients and/or their parents or legal guardians must sign a written informed consent * All institutional, Food and Drug Administration (FDA), and National Cancer Institute (NCI) requirements for human studies must be met Exclusion Criteria: * Fanconi anemia * Shwachman Diamond syndrome * Patients with constitutional trisomy 21 or with constitutional mosaicism of trisomy 21 * Telomere disorders * Germline predispositions known, or suspected by the treating physician to increase risk of toxicity with AML therapy * Any concurrent malignancy * Juvenile myelomonocytic leukemia (JMML) * Philadelphia chromosome positive AML * Mixed phenotype acute leukemia * Acute promyelocytic leukemia * Acute myeloid leukemia arising from myelodysplasia * Therapy-related myeloid neoplasms * Patients with persistent cardiac dysfunction prior to enrollment, defined as ejection fraction (EF) \< 50% (preferred method Biplane Simpson's EF) or if EF unavailable, shortening fraction (SF) \< 24%. \*Note: if clinically safe and feasible, repeat echocardiogram is strongly advised in order to confirm cardiac dysfunction following clinical stabilization, particularly if occurring in the setting of sepsis or other transient physiologic stressor. If the repeat echocardiogram demonstrates an EF \>= 50%, the patient is eligible to enroll and may receive an anthracycline-containing Induction regimen * Administration of prior anti-cancer therapy except as outlined below: * Hydroxyurea * All-trans retinoic acid (ATRA) * Corticosteroids (any route) * Intrathecal therapy given at diagnosis * In particular, strong inducers of CYP3A4 and/or P-glycoprotein (P-gp) should be avoided from the time of enrollment until it is determined whether the patient will receive gilteritinib. Patients receiving gilteritinib will be required to avoid strong CYP3A4 inducers and/or strong P-gp inducers for the duration of the study treatment * Female patients who are pregnant since fetal toxicities and teratogenic effects have been noted for several of the study drugs. A pregnancy test is required for female patients of childbearing potential * Lactating females who plan to breastfeed their infants * Sexually active patients of reproductive potential who have not agreed to use an effective contraceptive method for the duration of their study participation * ARM D: Patient does not have any congenital long QT syndrome or congenital heart block
healthy Volunteers
false
maximum Age
21 Years
sex
ALL
std Ages
  1. CHILD
  2. ADULT
Treatment arms and interventions
arm Groups
  1. description
    Arm A High Risk Group: See Detailed Description.
    intervention Names
    1. Procedure: Allogeneic Hematopoietic Stem Cell Transplantation
    2. Procedure: Biospecimen Collection
    3. Procedure: Bone Marrow Aspiration
    4. Procedure: Bone Marrow Biopsy
    5. Procedure: Computed Tomography
    6. Drug: Cytarabine
    7. Drug: Daunorubicin Hydrochloride
    8. Drug: Dexrazoxane Hydrochloride
    9. Drug: Etoposide
    10. Other: Fludeoxyglucose F-18
    11. Drug: Gemtuzumab Ozogamicin
    12. Procedure: Magnetic Resonance Imaging
    label
    Arm A High Risk Group
    type
    EXPERIMENTAL
  2. description
    Arm A Low Risk Group 1: See Detailed Description. (CLOSED TO ACCRUAL 11/19/2024)
    intervention Names
    1. Drug: Asparaginase Erwinia chrysanthemi
    2. Procedure: Biospecimen Collection
    3. Procedure: Bone Marrow Aspiration
    4. Procedure: Bone Marrow Biopsy
    5. Procedure: Computed Tomography
    6. Drug: Cytarabine
    7. Drug: Daunorubicin Hydrochloride
    8. Drug: Dexrazoxane Hydrochloride
    9. Drug: Etoposide
    10. Other: Fludeoxyglucose F-18
    11. Drug: Gemtuzumab Ozogamicin
    12. Procedure: Magnetic Resonance Imaging
    label
    Arm A Low Risk Group 1
    type
    EXPERIMENTAL
  3. description
    Arm A Low Risk Group 2: See Detailed Description.
    intervention Names
    1. Drug: Asparaginase Erwinia chrysanthemi
    2. Procedure: Biospecimen Collection
    3. Procedure: Bone Marrow Aspiration
    4. Procedure: Bone Marrow Biopsy
    5. Procedure: Computed Tomography
    6. Drug: Cytarabine
    7. Drug: Daunorubicin Hydrochloride
    8. Drug: Dexrazoxane Hydrochloride
    9. Drug: Etoposide
    10. Other: Fludeoxyglucose F-18
    11. Drug: Gemtuzumab Ozogamicin
    12. Procedure: Magnetic Resonance Imaging
    label
    Arm A Low Risk Group 2
    type
    EXPERIMENTAL
  4. description
    Arm AC High Risk Group: See Detailed Description.
    intervention Names
    1. Procedure: Allogeneic Hematopoietic Stem Cell Transplantation
    2. Procedure: Biospecimen Collection
    3. Procedure: Bone Marrow Aspiration
    4. Procedure: Bone Marrow Biopsy
    5. Procedure: Computed Tomography
    6. Drug: Cytarabine
    7. Drug: Daunorubicin Hydrochloride
    8. Drug: Dexrazoxane Hydrochloride
    9. Drug: Etoposide
    10. Other: Fludeoxyglucose F-18
    11. Drug: Gemtuzumab Ozogamicin
    12. Drug: Gilteritinib Fumarate
    label
    Arm AC High Risk Group
    type
    EXPERIMENTAL
  5. description
    Arm AC Low Risk Group 2: See Detailed Description.
    intervention Names
    1. Drug: Asparaginase Erwinia chrysanthemi
    2. Procedure: Biospecimen Collection
    3. Procedure: Bone Marrow Aspiration
    4. Procedure: Bone Marrow Biopsy
    5. Procedure: Computed Tomography
    6. Drug: Cytarabine
    7. Drug: Daunorubicin Hydrochloride
    8. Drug: Dexrazoxane Hydrochloride
    9. Drug: Etoposide
    10. Other: Fludeoxyglucose F-18
    11. Drug: Gemtuzumab Ozogamicin
    12. Drug: Gilteritinib Fumarate
    label
    Arm AC Low Risk Group 2
    type
    EXPERIMENTAL
  6. description
    Arm AD High Risk Group: See Detailed Description.
    intervention Names
    1. Procedure: Allogeneic Hematopoietic Stem Cell Transplantation
    2. Procedure: Biospecimen Collection
    3. Procedure: Bone Marrow Aspiration
    4. Procedure: Bone Marrow Biopsy
    5. Procedure: Computed Tomography
    6. Drug: Cytarabine
    7. Drug: Daunorubicin Hydrochloride
    8. Drug: Dexrazoxane Hydrochloride
    9. Drug: Etoposide
    10. Other: Fludeoxyglucose F-18
    11. Drug: Gemtuzumab Ozogamicin
    12. Drug: Gilteritinib Fumarate
    label
    Arm AD High Risk Group
    type
    EXPERIMENTAL
  7. description
    Arm AD Low Risk Group 2: See Detailed Description.
    intervention Names
    1. Drug: Asparaginase Erwinia chrysanthemi
    2. Procedure: Biospecimen Collection
    3. Procedure: Bone Marrow Aspiration
    4. Procedure: Bone Marrow Biopsy
    5. Procedure: Computed Tomography
    6. Drug: Cytarabine
    7. Drug: Daunorubicin Hydrochloride
    8. Drug: Dexrazoxane Hydrochloride
    9. Drug: Etoposide
    10. Other: Fludeoxyglucose F-18
    11. Drug: Gemtuzumab Ozogamicin
    12. Drug: Gilteritinib Fumarate
    label
    Arm AD Low Risk Group 2
    type
    EXPERIMENTAL
  8. description
    Arm B High Risk Group: See Detailed Description. (CLOSED TO ACCRUAL 11/19/2024)
    intervention Names
    1. Procedure: Allogeneic Hematopoietic Stem Cell Transplantation
    2. Procedure: Biospecimen Collection
    3. Procedure: Bone Marrow Aspiration
    4. Procedure: Bone Marrow Biopsy
    5. Procedure: Computed Tomography
    6. Drug: Cytarabine
    7. Drug: Etoposide
    8. Other: Fludeoxyglucose F-18
    9. Drug: Gemtuzumab Ozogamicin
    10. Drug: Liposome-encapsulated Daunorubicin-Cytarabine
    11. Procedure: Magnetic Resonance Imaging
    12. Drug: Methotrexate
    label
    Arm B High Risk Group
    type
    EXPERIMENTAL
  9. description
    Arm B Low Risk Group 1: See Detailed Description. (CLOSED TO ACCRUAL 11/19/2024)
    intervention Names
    1. Drug: Asparaginase Erwinia chrysanthemi
    2. Procedure: Biospecimen Collection
    3. Procedure: Bone Marrow Aspiration
    4. Procedure: Bone Marrow Biopsy
    5. Procedure: Computed Tomography
    6. Drug: Cytarabine
    7. Drug: Etoposide
    8. Other: Fludeoxyglucose F-18
    9. Drug: Gemtuzumab Ozogamicin
    10. Drug: Liposome-encapsulated Daunorubicin-Cytarabine
    11. Procedure: Magnetic Resonance Imaging
    12. Drug: Methotrexate
    label
    Arm B Low Risk Group 1
    type
    EXPERIMENTAL
  10. description
    Arm B Low Risk Group 2: See Detailed Description. (CLOSED TO ACCRUAL 11/19/2024)
    intervention Names
    1. Drug: Asparaginase Erwinia chrysanthemi
    2. Procedure: Biospecimen Collection
    3. Procedure: Bone Marrow Aspiration
    4. Procedure: Bone Marrow Biopsy
    5. Procedure: Computed Tomography
    6. Drug: Cytarabine
    7. Drug: Etoposide
    8. Other: Fludeoxyglucose F-18
    9. Drug: Gemtuzumab Ozogamicin
    10. Drug: Liposome-encapsulated Daunorubicin-Cytarabine
    11. Drug: Methotrexate
    12. Drug: Mitoxantrone Hydrochloride
    label
    Arm B Low Risk Group 2
    type
    EXPERIMENTAL
  11. description
    Arm BC High Risk Group: See Detailed Description. (CLOSED TO ACCRUAL 11/19/2024)
    intervention Names
    1. Procedure: Allogeneic Hematopoietic Stem Cell Transplantation
    2. Procedure: Biospecimen Collection
    3. Procedure: Bone Marrow Aspiration
    4. Procedure: Bone Marrow Biopsy
    5. Procedure: Computed Tomography
    6. Drug: Cytarabine
    7. Drug: Etoposide
    8. Other: Fludeoxyglucose F-18
    9. Drug: Gemtuzumab Ozogamicin
    10. Drug: Gilteritinib Fumarate
    11. Drug: Liposome-encapsulated Daunorubicin-Cytarabine
    12. Procedure: Magnetic Resonance Imaging
    label
    Arm BC High Risk Group
    type
    EXPERIMENTAL
  12. description
    Arm BC Low Risk Group 2: See Detailed Description. (CLOSED TO ACCRUAL 11/19/2024)
    intervention Names
    1. Drug: Asparaginase Erwinia chrysanthemi
    2. Procedure: Biospecimen Collection
    3. Procedure: Bone Marrow Aspiration
    4. Procedure: Bone Marrow Biopsy
    5. Procedure: Computed Tomography
    6. Drug: Cytarabine
    7. Drug: Dexrazoxane Hydrochloride
    8. Drug: Etoposide
    9. Other: Fludeoxyglucose F-18
    10. Drug: Gemtuzumab Ozogamicin
    11. Drug: Gilteritinib Fumarate
    12. Drug: Liposome-encapsulated Daunorubicin-Cytarabine
    label
    Arm BC Low Risk Group 2
    type
    EXPERIMENTAL
interventions
  1. arm Group Labels
    1. Arm A High Risk Group
    2. Arm AC High Risk Group
    3. Arm AD High Risk Group
    4. Arm B High Risk Group
    5. Arm BC High Risk Group
    6. Arm BD High Risk Group
    description
    Undergo allogeneic HSCT
    name
    Allogeneic Hematopoietic Stem Cell Transplantation
    other Names
    1. Allogeneic
    2. Allogeneic Hematopoietic Cell Transplantation
    3. Allogeneic Stem Cell Transplantation
    4. HSC
    5. HSCT
    6. Stem Cell Transplantation, Allogeneic
    type
    PROCEDURE
  2. arm Group Labels
    1. Arm A Low Risk Group 1
    2. Arm A Low Risk Group 2
    3. Arm AC Low Risk Group 2
    4. Arm AD Low Risk Group 2
    5. Arm B Low Risk Group 1
    6. Arm B Low Risk Group 2
    7. Arm BC Low Risk Group 2
    8. Arm BD Low Risk Group 2
    description
    Given IM or IV
    name
    Asparaginase Erwinia chrysanthemi
    other Names
    1. Asparaginase Erwinia chrysanthemi (Recombinant)-rywn
    2. Asparaginase Erwinia chrysanthemi, Recombinant-rywn
    3. Asparaginase Erwinia chrysanthemi-rywn
    4. Crisantaspase
    5. Crisantaspase Biobetter JZP-458
    6. Crisantaspasum
    7. Enrylaze
    8. Erwinase
    9. Erwinaze
    10. JZP 458
    11. JZP-458
    12. JZP458
    type
    DRUG
  3. arm Group Labels
    1. Arm A High Risk Group
    2. Arm A Low Risk Group 1
    3. Arm A Low Risk Group 2
    4. Arm AC High Risk Group
    5. Arm AC Low Risk Group 2
    6. Arm AD High Risk Group
    7. Arm AD Low Risk Group 2
    8. Arm B High Risk Group
    9. Arm B Low Risk Group 1
    10. Arm B Low Risk Group 2
    11. Arm BC High Risk Group
    12. Arm BC Low Risk Group 2
    description
    Undergo blood sample collection
    name
    Biospecimen Collection
    other Names
    1. Biological Sample Collection
    2. Biospecimen Collected
    3. Sample Collection
    4. Specimen Collection
    type
    PROCEDURE
  4. arm Group Labels
    1. Arm A High Risk Group
    2. Arm A Low Risk Group 1
    3. Arm A Low Risk Group 2
    4. Arm AC High Risk Group
    5. Arm AC Low Risk Group 2
    6. Arm AD High Risk Group
    7. Arm AD Low Risk Group 2
    8. Arm B High Risk Group
    9. Arm B Low Risk Group 1
    10. Arm B Low Risk Group 2
    11. Arm BC High Risk Group
    12. Arm BC Low Risk Group 2
    description
    Undergo BM aspiration
    name
    Bone Marrow Aspiration
    type
    PROCEDURE
  5. arm Group Labels
    1. Arm A High Risk Group
    2. Arm A Low Risk Group 1
    3. Arm A Low Risk Group 2
    4. Arm AC High Risk Group
    5. Arm AC Low Risk Group 2
    6. Arm AD High Risk Group
    7. Arm AD Low Risk Group 2
    8. Arm B High Risk Group
    9. Arm B Low Risk Group 1
    10. Arm B Low Risk Group 2
    11. Arm BC High Risk Group
    12. Arm BC Low Risk Group 2
    description
    BM biopsy
    name
    Bone Marrow Biopsy
    other Names
    1. Biopsy of Bone Marrow
    2. Biopsy, Bone Marrow
    type
    PROCEDURE
  6. arm Group Labels
    1. Arm A High Risk Group
    2. Arm A Low Risk Group 1
    3. Arm A Low Risk Group 2
    4. Arm AC High Risk Group
    5. Arm AC Low Risk Group 2
    6. Arm AD High Risk Group
    7. Arm AD Low Risk Group 2
    8. Arm B High Risk Group
    9. Arm B Low Risk Group 1
    10. Arm B Low Risk Group 2
    11. Arm BC High Risk Group
    12. Arm BC Low Risk Group 2
    description
    Undergo CT
    name
    Computed Tomography
    other Names
    1. CAT
    2. CAT Scan
    3. Computed Axial Tomography
    4. Computerized Axial Tomography
    5. Computerized axial tomography (procedure)
    6. Computerized Tomography
    7. Computerized Tomography (CT) scan
    8. CT
    9. CT Scan
    10. Diagnostic CAT Scan
    11. Diagnostic CAT Scan Service Type
    12. tomography
    type
    PROCEDURE
  7. arm Group Labels
    1. Arm A High Risk Group
    2. Arm A Low Risk Group 1
    3. Arm A Low Risk Group 2
    4. Arm AC High Risk Group
    5. Arm AC Low Risk Group 2
    6. Arm AD High Risk Group
    7. Arm AD Low Risk Group 2
    8. Arm B High Risk Group
    9. Arm B Low Risk Group 1
    10. Arm B Low Risk Group 2
    11. Arm BC High Risk Group
    12. Arm BC Low Risk Group 2
    description
    Given IV or IT
    name
    Cytarabine
    other Names
    1. .beta.-Cytosine arabinoside
    2. 1-.beta.-D-Arabinofuranosyl-4-amino-2(1H)pyrimidinone
    3. 1-.beta.-D-Arabinofuranosylcytosine
    4. 1-Beta-D-arabinofuranosyl-4-amino-2(1H)pyrimidinone
    5. 1-Beta-D-arabinofuranosylcytosine
    6. 1.beta.-D-Arabinofuranosylcytosine
    7. 2(1H)-Pyrimidinone, 4-Amino-1-beta-D-arabinofuranosyl-
    8. 2(1H)-Pyrimidinone, 4-amino-1.beta.-D-arabinofuranosyl-
    9. Alexan
    10. Ara-C
    11. ARA-cell
    12. Arabine
    type
    DRUG
  8. arm Group Labels
    1. Arm A High Risk Group
    2. Arm A Low Risk Group 1
    3. Arm A Low Risk Group 2
    4. Arm AC High Risk Group
    5. Arm AC Low Risk Group 2
    6. Arm AD High Risk Group
    7. Arm AD Low Risk Group 2
    description
    Given IV
    name
    Daunorubicin Hydrochloride
    other Names
    1. Cerubidin
    2. Cerubidine
    3. Cloridrato de Daunorubicina
    4. Daunoblastin
    5. Daunoblastina
    6. Daunoblastine
    7. Daunomycin Hydrochloride
    8. Daunomycin, hydrochloride
    9. Daunorubicin.HCl
    10. Daunorubicini Hydrochloridum
    11. FI-6339
    12. Ondena
    type
    DRUG
  9. arm Group Labels
    1. Arm A High Risk Group
    2. Arm A Low Risk Group 1
    3. Arm A Low Risk Group 2
    4. Arm AC High Risk Group
    5. Arm AC Low Risk Group 2
    6. Arm AD High Risk Group
    7. Arm AD Low Risk Group 2
    8. Arm BC Low Risk Group 2
    9. Arm BD Low Risk Group 2
    description
    Given IV
    name
    Dexrazoxane Hydrochloride
    other Names
    1. Cardioxane
    2. Totect
    3. Zinecard
    type
    DRUG
  10. arm Group Labels
    1. Arm A High Risk Group
    2. Arm A Low Risk Group 1
    3. Arm A Low Risk Group 2
    4. Arm AC High Risk Group
    5. Arm AC Low Risk Group 2
    6. Arm AD High Risk Group
    7. Arm AD Low Risk Group 2
    8. Arm B High Risk Group
    9. Arm B Low Risk Group 1
    10. Arm B Low Risk Group 2
    11. Arm BC High Risk Group
    12. Arm BC Low Risk Group 2
    description
    Given IV
    name
    Etoposide
    other Names
    1. Demethyl Epipodophyllotoxin Ethylidine Glucoside
    2. EPEG
    3. Lastet
    4. Toposar
    5. Vepesid
    6. VP 16
    7. VP 16-213
    8. VP 16213
    9. VP-16
    10. VP-16-213
    11. VP-16213
    12. VP16
    type
    DRUG
  11. arm Group Labels
    1. Arm A High Risk Group
    2. Arm A Low Risk Group 1
    3. Arm A Low Risk Group 2
    4. Arm AC High Risk Group
    5. Arm AC Low Risk Group 2
    6. Arm AD High Risk Group
    7. Arm AD Low Risk Group 2
    8. Arm B High Risk Group
    9. Arm B Low Risk Group 1
    10. Arm B Low Risk Group 2
    11. Arm BC High Risk Group
    12. Arm BC Low Risk Group 2
    description
    Undergo FDG-PET
    name
    Fludeoxyglucose F-18
    other Names
    1. 18FDG
    2. FDG
    3. Fludeoxyglucose (18F)
    4. fludeoxyglucose F 18
    5. Fludeoxyglucose F18
    6. Fluorine-18 2-Fluoro-2-deoxy-D-Glucose
    7. Fluorodeoxyglucose F18
    type
    OTHER
  12. arm Group Labels
    1. Arm A High Risk Group
    2. Arm A Low Risk Group 1
    3. Arm A Low Risk Group 2
    4. Arm AC High Risk Group
    5. Arm AC Low Risk Group 2
    6. Arm AD High Risk Group
    7. Arm AD Low Risk Group 2
    8. Arm B High Risk Group
    9. Arm B Low Risk Group 1
    10. Arm B Low Risk Group 2
    11. Arm BC High Risk Group
    12. Arm BC Low Risk Group 2
    description
    Given IV
    name
    Gemtuzumab Ozogamicin
    other Names
    1. Calicheamicin-Conjugated Humanized Anti-CD33 Monoclonal Antibody
    2. CDP-771
    3. CMA-676
    4. gemtuzumab
    5. hP67.6-Calicheamicin
    6. Mylotarg
    7. WAY-CMA-676
    type
    DRUG
Study design
allocation
RANDOMIZED
intervention Model
PARALLEL
masking Info
masking
NONE
primary Purpose
TREATMENT
Enrollment
count
1186
type
ESTIMATED
Registered outcome plans (not posted results)
other Outcomes
  1. description
    Median and range of the length of course duration will be determined.
    measure
    Course duration
    time Frame
    Up to 2 years
  2. description
    Median and range of the length of hospitalization time during protocol therapy will be determined.
    measure
    Length of hospitalization
    time Frame
    Up to 2 years
  3. description
    Cumulative incidence estimates that account for competing events will be used to estimate time to count recovery in days where deaths are competing events.
    measure
    Time to count recovery
    time Frame
    Up to 2 years
  4. description
    National Institutes of Health (NIH)-required analysis. The Kaplan-Meier method will be used to estimate 3-year EFS by sex. EFS is defined as the time from study entry until induction failure, relapse, or death.
    measure
    EFS by sex
    time Frame
    Up to 3 years
  5. description
    NIH-required analysis. The Kaplan-Meier method will be used to estimate 3-year EFS by race. EFS is defined as the time from study entry until induction failure, relapse, or death.
    measure
    EFS by race
    time Frame
    Up to 3 years
  6. description
    NIH-required analysis. The Kaplan-Meier method will be used to estimate 3-year EFS by ethnicity. EFS is defined as the time from study entry until induction failure, relapse, or death.
    measure
    EFS by ethnicity
    time Frame
    Up to 3 years
primary Outcomes
  1. description
    The Kaplan-Meier method will be used to estimate 3-year EFS, defined as the time from study entry until induction failure, relapse, or death.
    measure
    Event-free survival (EFS)
    time Frame
    Up to 3 years
secondary Outcomes
  1. description
    The Kaplan-Meier method will be used to estimate 3-year OS, defined as the time from study entry until death.
    measure
    Overall survival (OS)
    time Frame
    Up to 3 years
  2. description
    The proportion of patients MRD+ at end of induction 1 (EOI1) will be estimated as the number of patients MRD+ divided by the number of patients with evaluable EOI1 MRD results along with a corresponding 95% confidence interval determined using a binomial exact method.
    measure
    Proportion of patients positive for minimal residual disease (MRD+)
    time Frame
    Up to 4 weeks
  3. description
    The proportion of patients who died during protocol therapy will be estimated along with the corresponding 95% confidence interval determined using a binomial exact method.
    measure
    Proportion of patients who died during protocol therapy
    time Frame
    Up to 2 years
  4. description
    The proportion of patients experiencing at least one grade 3 or higher non-hematologic toxicity and infection while on protocol therapy will be estimated along with the corresponding 95% confidence interval determined using a binomial exact method. Toxicity will be assessed by Common Terminology Criteria for Adverse Events version 5.0.
    measure
    Incidence of adverse events
    time Frame
    Up to 2 years
  5. description
    Cumulative incidence estimates will be used to determine the 3 year relapse rate defined as time from study entry to induction failure or relapse where deaths or secondary malignancies are competing events.
    measure
    Relapse rate
    time Frame
    Up to 3 years
  6. description
    Cumulative incidence estimates will be used to determine the 3 year TRM defined as time from study entry to death where induction failure, relapse or secondary malignancies are competing events.
    measure
    Treatment-related mortality rate (TRM)
    time Frame
    Up to 3 years
  7. description
    The number of patients who undergo HSCT on protocol will be reported.
    measure
    Number of patients who undergo hematopoietic stem cell transplant (HSCT)
    time Frame
    Up to 3 years
Full study description
brief Summary
This phase III trial compares standard chemotherapy to therapy with liposome-encapsulated daunorubicin-cytarabine (CPX-351) and/or gilteritinib for patients with newly diagnosed acute myeloid leukemia with or without FLT3 mutations. Drugs used in chemotherapy, such as daunorubicin, cytarabine, and gemtuzumab ozogamicin, 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. CPX-351 is made up of daunorubicin and cytarabine and is made in a way that makes the drugs stay in the bone marrow longer and could be less likely to cause heart problems than traditional anthracycline drugs, a common class of chemotherapy drug. Some acute myeloid leukemia patients have an abnormality in the structure of a gene called FLT3. Genes are pieces of DNA (molecules that carry instructions for development, functioning, growth and reproduction) inside each cell that tell the cell what to do and when to grow and divide. FLT3 plays an important role in the normal making of blood cells. This gene can have permanent changes that cause it to function abnormally by making cancer cells grow. Gilteritinib may block the abnormal function of the FLT3 gene that makes cancer cells grow. The overall goals of this study are, 1) to compare the effects, good and/or bad, of CPX-351 with daunorubicin and cytarabine on people with newly diagnosed AML to find out which is better, 2) to study the effects, good and/or bad, of adding gilteritinib to AML therapy for patients with high amounts of FLT3/ITD or other FLT3 mutations and 3) to study changes in heart function during and after treatment for AML. Giving CPX-351 and/or gilteritinib with standard chemotherapy may work better in treating patients with acute myeloid leukemia compared to standard chemotherapy alone.
detailed Description
PRIMARY OBJECTIVE: I. To compare event-free survival (EFS) in children with de novo acute myeloid leukemia (AML) without FLT3 mutations who are randomly assigned to standard induction therapy on Arm A with daunorubicin, cytarabine (DA) and gemtuzumab ozogamicin (GO) (DA-GO) versus Arm B with CPX-351 and GO. SECONDARY OBJECTIVES: I. To compare overall survival (OS) and rates of end of Induction 1 (EOI1) minimal residual disease (MRD) in children with de novo AML without FLT3 mutations who are randomly assigned to standard induction therapy (Arm A) with DA-GO versus CPX-351 and GO (Arm B). II. To estimate the EFS and rate of EOI1 MRD in FLT3 internal tandem duplication mutation positive patients (FLT3/ITD+; as defined by allelic ratio \> 0.1) without favorable cytomolecular characteristics (NPM1 and/or CEBPA) receiving gilteritinib fumarate (gilteritinib) in combination with DA-GO (Arm AC). III. To estimate the EFS and rate of EOI1 MRD in patients with non-ITD FLT3 activating mutations who receive backbone therapy (DA-GO or CPX-351 and GO) with gilteritinib (Arms AD and BD). IV. To determine the feasibility of combining gilteritinib and DA-GO or CPX-351 and GO in patients with FLT3/ITD and FLT3/TKD mutations (Arm AC/Arm BC/Arm AD/Arm BD). V. To compare EOI1 MRD and EFS in patients with FLT3/ITD AML+ (allelic ratio \[AR\] \> 0.1) without favorable cytogenetic/molecular characteristics treated with DA-GO-gilteritinib versus (vs) CPX-GO-gilteritinib (Arm AC vs Arm BC). VI. To compare the incidence of significant left ventricular systolic dysfunction (LVSD) in children with de novo AML without FLT3 mutations who are randomly assigned to standard induction therapy (Arm A) with DA-GO versus CPX-351 and GO (Arm B). VII. To compare the changes in echocardiography-derived measures of cardiac function, including left ventricular ejection fraction (EF) and global longitudinal strain (GLS), throughout AML therapy in patients with low and high risk AML without FLT3 mutations receiving Arm A vs Arm B. VIII. Determine if early changes in sensitive echocardiographic measures of cardiac function (i.e., post-Induction 1 decline in GLS) and elevations in circulating cardiac biomarkers (i.e., cardiac troponin T and N-terminal pro b-type natriuretic peptide) are associated with subsequent declines in left ventricular ejection fraction in patients with non-FLT3 mutant AML receiving therapy on Arms A or B. IX. To compare longitudinal acute changes in neuropsychological functioning and neurocognitive late effects between those with central nervous system (CNS) disease and those without CNS disease and between those treated with hematopoietic stem cell transplant (HSCT) and those treated with chemotherapy only for patients on Arms A and B. X. To compare cardiotoxicity measures (EF, GLS, and cardiac biomarkers) in patients receiving standard induction with dexrazoxane hydrochloride (dexrazoxane) vs. CPX-351 in the context of gilteritinib therapy and explore whether the differential cardiotoxicity across arms varies from that observed in non-FLT3 mutant AML without gilteritinib exposure. EXPLORATORY OBJECTIVES: I. To estimate the EFS and rate of EOI1 MRD in patients with high allelic ratio (HAR) FLT3/ITD+ patients, as historically defined by an AR \> 0.4, receiving gilteritinib in combination with DA-GO (Arm AC with AR \> 0.4). II. To estimate the EFS, OS, and rate of EOI1 MRD in FLT3/ITD+ patients (as defined by allelic ratio \> 0.1) with NPM1 and/or bZIP CEBPA mutations receiving gilteritinib in combination with DA-GO (Arm AC). III. Compare the changes in high sensitivity troponin and natriuretic peptide elevations throughout AML therapy, as measured at the end of each chemotherapy course, in patients with low and high risk AML without FLT3 mutations receiving Arm A vs Arm B. IV. Quantify the association of host factors (age, sex, body mass index \[BMI\], race), treatment exposures (cumulative anthracycline dose, anthracycline arm, hematopoietic stem cell transplant vs. chemotherapy alone), early declines in GLS, and elevations in cardiac biomarkers (cTnT and NT-proBNP) with subsequent LVSD. V. To describe the rates of CNS disease utilizing an updated strategy for diagnosing and defining CNS disease in pediatric AML. VI. To describe the rates of CNS relapse (both isolated CNS and combined bone marrow/CNS) when utilizing this updated strategy as well as changing CNS prophylaxis and treatment to include triple intrathecal chemotherapy. VII. To describe the rate of bone marrow measurable residual disease, detected by multi-dimensional flow cytometry, prior to hematopoietic stem cell transplant (HSCT). VIII. To describe plasma metabolomics that may impact efficacy, toxicity, and/or pharmacokinetics of allogeneic HSCT. IX. To estimate the prevalence of non-risk stratifying cytogenetic/molecular variants and assess their impact on outcome in childhood AML. X. To describe the pharmacokinetic parameters of plasma cytarabine and daunorubicin after CPX-351 administration to pediatric and young adult patients with new diagnosis of AML. XI. To describe the pharmacokinetic parameters of orally administered gilteritinib when administered to pediatric and young adult patients with new diagnosis of AML. XII. To describe the pharmacodynamic parameters of gilteritinib using the FLT3 plasma inhibitory activity assay (PIA) when administered to children and young adults with new diagnosis of AML and FLT3 mutations. XIII. To estimate OS in patients with FLT3/ITD+ AML (AR \> 0.1) without favorable cytogenetic/molecular characteristics treated with DA-GO-gilteritinib or CPX-351-GO-gilteritinib (Separate analyses will be conducted for Arm AC vs Arm BC). OUTLINE: Patients are randomized to either Arm A or B and assigned to Arm C or D based on FLT3 testing results. As of 11/19/24 arms B, BC and BD are closed and new patients receive treatment in Arm A Low Risk Group 2 Induction 1 or Arm A High Risk Induction 1, and then assigned to arm AC or AD per FLT3 results. Risk group assignments are calculated based on cytogenetic, molecular and genomic findings (details in protocol) 1. Low Risk 1 2. Low Risk 2 3. High Risk TREATMENT FOR PATIENTS WITHOUT FLT3 MUTATIONS: ARM A LOW RISK GROUP 1: INDUCTION 1: Patients receive cytarabine intravenously (IV) over 1-30 minutes every 12 hours (Q12H) on days 1-10, dexrazoxane IV over 15 minutes and daunorubicin IV over 1-15 minutes on days 1, 3, and 5, and gemtuzumab ozogamicin IV over 2 hours on day 6. Patients with CNS1 receive methotrexate intrathecally (IT), therapeutic hydrocortisone (hydrocortisone) IT, and cytarabine IT on day 8. Patients with CNS2, CNS3a, and CNS3b receive methotrexate IT, hydrocortisone IT, and cytarabine IT once weekly (QW) starting on day 8 for 4-6 weeks (may continue into Induction 2) until the cerebral spinal fluid (CSF) is clear of blasts (CNS1 status). Patients with CNS3c receive methotrexate IT, hydrocortisone IT, and cytarabine IT QW starting on day 1 for 6 weeks (may continue into Induction 2). INDUCTION 2: Patients with CNS1 receive methotrexate IT, hydrocortisone IT, and cytarabine IT on day 0. Patients with CNS2 receive methotrexate IT, hydrocortisone IT, and cytarabine IT QW starting on day 0 until CNS1 status is reached. Patients also receive cytarabine IV over 1-30 minutes Q12H on days 1-8 and dexrazoxane IV over 15 minutes and daunorubicin IV over 1-15 minutes on days 1, 3, and 5. INTENSIFICATION 1: Patients receive methotrexate IT, hydrocortisone IT, and cytarabine IT on day 0. Patients also receive high-dose cytarabine IV over 1-3 hours Q12H and etoposide IV over 90-120 minutes on days 1-5. INTENSIFICATION 2: Patients receive high-dose cytarabine IV over 3 hours Q12H on days 1, 2, 8, and 9. Patients also receive asparaginase Erwinia chrysanthemi intramuscularly (IM) on days 2 and 9 or IV over 1-2 hours on days 2 and 9. ARM B LOW RISK GROUP 1: INDUCTION 1: Patients receive CPX-351 IV over 90 minutes on days 1, 3, and 5, and gemtuzumab ozogamicin IV over 2 hours on day 6. Patients with CNS1 receive methotrexate IT, hydrocortisone IT, and cytarabine IT on day 8. Patients with CNS2, CNS3a, and CNS3b receive methotrexate IT, hydrocortisone IT, and cytarabine IT QW starting on day 8 for 4-6 weeks (may continue into Induction 2) until the CSF is clear of blasts (CNS1 status). Patients with CNS3c receive methotrexate IT, hydrocortisone IT, and cytarabine IT QW starting on day 1 for 6 weeks (may continue into Induction 2). INDUCTION 2: Patients with CNS1 receive methotrexate IT, hydrocortisone IT, and cytarabine IT on day 0. Patients with CNS2 receive methotrexate IT, hydrocortisone IT, and cytarabine IT QW starting on day 0 until CNS1 status is reached. Patients also receive CPX-351 IV over 90 minutes on days 1, 3, and 5. INTENSIFICATION 1: Patients receive methotrexate IT, hydrocortisone IT, and cytarabine IT on day 0. Patients also receive high-dose cytarabine IV over 1-3 hours Q12H and etoposide IV over 90-120 minutes on days 1-5. INTENSIFICATION 2: Patients receive high-dose cytarabine IV over 3 hours Q12H on days 1, 2, 8, and 9. Patients also receive asparaginase Erwinia chrysanthemi IM on days 2 and 9 or IV over 1-2 hours on days 2 and 9. ARM A LOW RISK GROUP 2: INDUCTION 1: Patients receive cytarabine IV over 1-30 minutes Q12H on days 1-10, dexrazoxane IV over 15 minutes and daunorubicin IV over 1-15 minutes on days 1, 3, and 5, and gemtuzumab ozogamicin IV over 2 hours on day 6. Patients with CNS1 receive methotrexate IT, hydrocortisone IT, and cytarabine IT on day 8. Patients with CNS2, CNS3a, and CNS3b receive methotrexate IT, hydrocortisone IT, and cytarabine IT QW starting on day 8 for 4-6 weeks (may continue into Induction 2) until the CSF is clear of blasts (CNS1 status). Patients with CNS3c receive methotrexate IT, hydrocortisone IT, and cytarabine IT QW starting on day 1 for 6 weeks (may continue into Induction 2). INDUCTION 2: Patients with CNS1 receive methotrexate IT, hydrocortisone IT, and cytarabine IT on day 0. Patients with CNS2 receive methotrexate IT, hydrocortisone IT, and cytarabine IT QW starting on day 0 until CNS1 status is reached. Patients also receive cytarabine IV over 1-30 minutes Q12H on days 1-8 and dexrazoxane IV over 15 minutes and daunorubicin IV over 1-15 minutes on days 1, 3, and 5. INTENSIFICATION 1: Patients receive methotrexate IT, hydrocortisone IT, and cytarabine IT on day 0. Patients also receive high-dose cytarabine IV over 1-3 hours Q12H and etoposide IV over 90-120 minutes on days 1-5. INTENSIFICATION 2: Patients receive methotrexate IT, hydrocortisone IT, and cytarabine IT on day 0. Patients also receive high-dose cytarabine IV over 1-3 hours Q12H on days 1-4 and dexrazoxane IV over 15 minutes and mitoxantrone hydrochloride (mitoxantrone) IV over 5-15 minutes on days 3-6. INTENSIFICATION 3: Patients receive high-dose cytarabine IV over 3 hours Q12H on days 1, 2, 8, and 9. Patients also receive asparaginase Erwinia chrysanthemi IM on days 2 and 9 or IV over 1-2 hours on days 2 and 9. ARM B LOW RISK GROUP 2: INDUCTION 1: Patients receive CPX-351 IV over 90 minutes on days 1, 3, and 5, and gemtuzumab ozogamicin IV over 2 hours on day 6. Patients with CNS1 receive methotrexate IT, hydrocortisone IT, and cytarabine IT on day 8. Patients with CNS2, CNS3a, and CNS3b receive methotrexate IT, hydrocortisone IT, and cytarabine IT QW starting on day 8 for 4-6 weeks (may continue into Induction 2) until the CSF is clear of blasts (CNS1 status). Patients with CNS3c receive methotrexate IT, hydrocortisone IT, and cytarabine IT QW starting on day 1 for 6 weeks (may continue into Induction 2). INDUCTION 2: Patients with CNS1 receive methotrexate IT, hydrocortisone IT, and cytarabine IT on day 0. Patients with CNS2 receive methotrexate IT, hydrocortisone IT, and cytarabine IT QW starting on day 0 until CNS1 status is reached. Patients also receive CPX-351 IV over 90 minutes on days 1, 3, and 5. INTENSIFICATION 1: Patients receive methotrexate IT, hydrocortisone IT, and cytarabine IT on day 0. Patients also receive high-dose cytarabine IV over 1-3 hours Q12H and etoposide IV over 90-120 minutes on days 1-5. INTENSIFICATION 2: Patients receive methotrexate IT, hydrocortisone IT, and cytarabine IT on day 0. Patients also receive high-dose cytarabine IV over 1-3 hours Q12H on days 1-4 and dexrazoxane IV over 15 minutes and mitoxantrone hydrochloride (mitoxantrone) IV over 5-15 minutes on days 3-6. INTENSIFICATION 3: Patients receive high-dose cytarabine IV over 3 hours Q12H on days 1, 2, 8, and 9. Patients also receive asparaginase Erwinia chrysanthemi IM on days 2 and 9 or IV over 1-2 hours on days 2 and 9. ARM A HIGH RISK GROUP: INDUCTION 1: Patients receive cytarabine IV over 1-30 minutes Q12H on days 1-10, dexrazoxane IV over 15 minutes and daunorubicin IV over 1-15 minutes on days 1, 3, and 5, and gemtuzumab ozogamicin IV over 2 hours on day 6. Patients with CNS1 receive methotrexate IT, hydrocortisone IT, and cytarabine IT on day 8. Patients with CNS2, CNS3a, and CNS3b receive methotrexate IT, hydrocortisone IT, and cytarabine IT QW starting on day 8 for 4-6 weeks (may continue into Induction 2) until the CSF is clear of blasts (CNS1 status). Patients with CNS3c receive methotrexate IT, hydrocortisone IT, and cytarabine IT QW starting on day 1 for 6 weeks (may continue into Induction 2). INDUCTION 2: Patients with CNS1 receive methotrexate IT, hydrocortisone IT, and cytarabine IT on day 0. Patients with CNS2 receive methotrexate IT, hydrocortisone IT, and cytarabine IT QW starting on day 0 until CNS1 status is reached. Patients also receive cytarabine IV over 1-30 minutes Q12H on days 1-8 and dexrazoxane IV over 15 minutes and daunorubicin IV over 1-15 minutes on days 1, 3, and 5. INTENSIFICATION 1: Patients receive methotrexate IT, hydrocortisone IT, and cytarabine IT on day 0. Patients also receive high-dose cytarabine IV over 1-3 hours Q12H and etoposide IV over 90-120 minutes on days 1-5. HSCT: After completion of Intensification 1 and investigator assigned conditioning regimen, patients undergo allogeneic HSCT. ARM B HIGH RISK GROUP: INDUCTION 1: Patients receive CPX-351 IV over 90 minutes on days 1, 3, and 5, and gemtuzumab ozogamicin IV over 2 hours on day 6. Patients with CNS1 receive methotrexate IT, hydrocortisone IT, and cytarabine IT on day 8. Patients with CNS2, CNS3a, and CNS3b receive methotrexate IT, hydrocortisone IT, and cytarabine IT QW starting on day 8 for 4-6 weeks (may continue into Induction 2) until the CSF is clear of blasts (CNS1 status). Patients with CNS3c receive methotrexate IT, hydrocortisone IT, and cytarabine IT QW starting on day 1 for 6 weeks (may continue into Induction 2). INDUCTION 2: Patients with CNS1 receive methotrexate IT, hydrocortisone IT, and cytarabine IT on day 0. Patients with CNS2 receive methotrexate IT, hydrocortisone IT, and cytarabine IT QW starting on day 0 until CNS1 status is reached. Patients also receive CPX-351 IV over 90 minutes on days 1, 3, and 5. INTENSIFICATION 1: Patients receive methotrexate IT, hydrocortisone IT, and cytarabine IT on day 0. Patients also receive high-dose cytarabine IV over 1-3 hours Q12H and etoposide IV over 90-120 minutes on days 1-5. HSCT: After completion of Intensification 1 and investigator assigned conditioning regimen, patients undergo allogeneic HSCT. TREATMENT FOR PATIENTS WITH FLT3/ITD MUTATIONS (ITD AR \> 0.1): ARM AC LOW RISK GROUP 2: CONTINUED INDUCTION 1 (WITH GILTERITINIB): Patients receive cytarabine IV over 1-30 minutes Q12H on days 1-10, dexrazoxane IV over 15 minutes and daunorubicin IV over 1-15 minutes on days 1, 3, and 5, gemtuzumab ozogamicin IV over 2 hours on day 6, and gilteritinib orally (PO)/nasogastric (NG)/gastrostomy (G)-tube once daily (QD) on days 11-31. Patients with CNS1 receive methotrexate IT, hydrocortisone IT, and cytarabine IT on day 8. Patients with CNS2, CNS3a, and CNS3b receive methotrexate IT, hydrocortisone IT, and cytarabine IT QW starting on day 8 for 4-6 weeks (may continue into Induction 2) until the CSF is clear of blasts (CNS1 status). Patients with CNS3c receive methotrexate IT, hydrocortisone IT, and cytarabine IT QW starting on day 1 for 6 weeks (may continue into Induction 2). INDUCTION 2 (WITH GILTERITINIB): Patients with CNS1 receive methotrexate IT, hydrocortisone IT, and cytarabine IT on day 0. Patients with CNS2 receive methotrexate IT, hydrocortisone IT, and cytarabine IT QW starting on day 0 until CNS1 status is reached. Patients also receive cytarabine IV over 1-30 minutes Q12H on days 1-8, dexrazoxane IV over 15 minutes and daunorubicin IV over 1-15 minutes on days 1, 3, and 5, and gilteritinib PO/NG/G-tube QD on days 11-31. INTENSIFICATION 1 (WITH GILTERITINIB): Patients receive methotrexate IT, hydrocortisone IT, and cytarabine IT on day 0. Patients also receive high-dose cytarabine IV over 1-3 hours Q12H and etoposide IV over 90-120 minutes on days 1-5, and gilteritinib PO/NG/G-tube QD on days 6-26. INTENSIFICATION 2 (WITH GILTERITINIB): Patients receive methotrexate IT, hydrocortisone IT, and cytarabine IT on day 0. Patients also receive high-dose cytarabine IV over 1-3 hours Q12H on days 1-4, dexrazoxane IV over 15 minutes and mitoxantrone IV over 5-15 minutes on days 3-6, and gilteritinib PO/NG/G-tube QD on days 7-27. INTENSIFICATION 3 (WITH GILTERITINIB): Patients receive high-dose cytarabine IV over 3 hours Q12H on days 1, 2, 8, and 9, asparaginase Erwinia chrysanthemi IM or IV over 1-2 hours, and gilteritinib PO/NG/G-tube QD on days 10-30. POST-CHEMOTHERAPY GILTERITINIB MAINTENANCE: Patients receive gilteritinib PO/NG/G-tube QD on days 1-365. ARM BC LOW RISK GROUP 2: CONTINUED INDUCTION 1 (WITH GILTERITINIB): Patients receive CPX-351 IV over 90 minutes on days 1, 3, and 5, gemtuzumab ozogamicin IV over 2 hours on day 6, and gilteritinib PO/NG/G-tube QD on days 11-31. Patients with CNS1 receive methotrexate IT, hydrocortisone IT, and cytarabine IT on day 8. Patients with CNS2, CNS3a, and CNS3b receive methotrexate IT, hydrocortisone IT, and cytarabine IT QW starting on day 8 for 4-6 weeks (may continue into Induction 2) until the CSF is clear of blasts (CNS1 status). Patients with CNS3c receive methotrexate IT, hydrocortisone IT, and cytarabine IT QW starting on day 1 for 6 weeks (may continue into Induction 2). INDUCTION 2 (WITH GILTERITINIB): Patients with CNS1 receive methotrexate IT, hydrocortisone IT, and cytarabine IT on day 0. Patients with CNS2 receive methotrexate IT, hydrocortisone IT, and cytarabine IT QW starting on day 0 until CNS1 status is reached. Patients also receive CPX-351 IV over 90 minutes on days 1, 3, and 5 and gilteritinib PO/NG/G-tube QD on days 11-31. INTENSIFICATION 1 (WITH GILTERITINIB): Patients receive methotrexate IT, hydrocortisone IT, and cytarabine IT on day 0. Patients also receive high-dose cytarabine IV over 1-3 hours Q12H and etoposide IV over 90-120 minutes on days 1-5, and gilteritinib PO/NG/G-tube QD on days 6-26. INTENSIFICATION 2 (WITH GILTERITINIB): Patients receive methotrexate IT, hydrocortisone IT, and cytarabine IT on day 0. Patients also receive high-dose cytarabine IV over 1-3 hours Q12H on days 1-4, dexrazoxane IV over 15 minutes and mitoxantrone IV over 5-15 minutes on days 3-6, and gilteritinib PO/NG/G-tube QD on days 7-27. INTENSIFICATION 3 (WITH GILTERITINIB): Patients receive high-dose cytarabine IV over 3 hours Q12H on days 1, 2, 8, and 9, asparaginase Erwinia chrysanthemi IM or IV over 1-2 hours, and gilteritinib PO/NG/G-tube QD on days 10-30. POST-CHEMOTHERAPY GILTERITINIB MAINTENANCE: Patients receive gilteritinib PO/NG/G-tube QD on days 1-365. ARM AC HIGH RISK GROUP: CONTINUED INDUCTION 1 (WITH GILTERITINIB): Patients receive cytarabine IV over 1-30 minutes Q12H on days 1-10, dexrazoxane IV over 15 minutes and daunorubicin IV over 1-15 minutes on days 1, 3, and 5, gemtuzumab ozogamicin IV over 2 hours on day 6, and gilteritinib PO/NG/G-tube QD on days 11-31. Patients with CNS1 receive methotrexate IT, hydrocortisone IT, and cytarabine IT on day 8. Patients with CNS2, CNS3a, and CNS3b receive methotrexate IT, hydrocortisone IT, and cytarabine IT QW starting on day 8 for 4-6 weeks (may continue into Induction 2) until the CSF is clear of blasts (CNS1 status). Patients with CNS3c receive methotrexate IT, hydrocortisone IT, and cytarabine IT QW starting on day 1 for 6 weeks (may continue into Induction 2). INDUCTION 2 (WITH GILTERITINIB): Patients with CNS1 receive methotrexate IT, hydrocortisone IT, and cytarabine IT on day 0. Patients with CNS2 receive methotrexate IT, hydrocortisone IT, and cytarabine IT QW starting on day 0 until CNS1 status is reached. Patients also receive cytarabine IV over 1-30 minutes Q12H on days 1-8, dexrazoxane IV over 15 minutes and daunorubicin IV over 1-15 minutes on days 1, 3, and 5, and gilteritinib PO/NG/G-tube QD on days 11-31. INTENSIFICATION 1 (WITH GILTERITINIB): Patients receive methotrexate IT, hydrocortisone IT, and cytarabine IT on day 0. Patients also receive high-dose cytarabine IV over 1-3 hours Q12H and etoposide IV over 90-120 minutes on days 1-5, and gilteritinib PO/NG/G-tube QD on days 6-26. HSCT: After completion of Intensification 1 and investigator assigned conditioning regimen, patients undergo allogeneic HSCT. POST-HSCT GILTERITINIB MAINTENANCE: Beginning 30-120 days after completion of HSCT, patients receive gilteritinib PO/NG/G-tube QD on days 1-365. ARM BC HIGH RISK GROUP: CONTINUED INDUCTION 1 (WITH GILTERITINIB): Patients receive CPX-351 IV over 90 minutes on days 1, 3, and 5, gemtuzumab ozogamicin IV over 2 hours on day 6, and gilteritinib PO/NG/G-tube QD on days 11-31. Patients with CNS1 receive methotrexate IT, hydrocortisone IT, and cytarabine IT on day 8. Patients with CNS2, CNS3a, and CNS3b receive methotrexate IT, hydrocortisone IT, and cytarabine IT QW starting on day 8 for 4-6 weeks (may continue into Induction 2) until the CSF is clear of blasts (CNS1 status). Patients with CNS3c receive methotrexate IT, hydrocortisone IT, and cytarabine IT QW starting on day 1 for 6 weeks (may continue into Induction 2). INDUCTION 2 (WITH GILTERITINIB): Patients with CNS1 receive methotrexate IT, hydrocortisone IT, and cytarabine IT on day 0. Patients with CNS2 receive methotrexate IT, hydrocortisone IT, and cytarabine IT QW starting on day 0 until CNS1 status is reached. Patients also receive CPX-351 IV over 90 minutes on days 1, 3, and 5 and gilteritinib PO/NG/G-tube QD on days 11-31. INTENSIFICATION 1 (WITH GILTERITINIB): Patients receive methotrexate IT, hydrocortisone IT, and cytarabine IT on day 0. Patients also receive high-dose cytarabine IV over 1-3 hours Q12H and etoposide IV over 90-120 minutes on days 1-5, and gilteritinib PO/NG/G-tube QD on days 6-26. HSCT: After completion of Intensification 1 and investigator assigned conditioning regimen, patients undergo allogeneic HSCT. POST-HSCT GILTERITINIB MAINTENANCE: Beginning 30-120 days after completion of HSCT, patients receive gilteritinib PO/NG/G-tube QD on days 1-365. TREATMENT FOR NON-ITD FLT3 ACTIVATING MUTATIONS: ARM AD LOW RISK GROUP 2: CONTINUED INDUCTION 1 (WITH GILTERITINIB): Patients receive cytarabine IV over 1-30 minutes Q12H on days 1-10, dexrazoxane IV over 15 minutes and daunorubicin IV over 1-15 minutes on days 1, 3, and 5, gemtuzumab ozogamicin IV over 2 hours on day 6, and gilteritinib PO/NG/G-tube QD on days 11-31. Patients with CNS1 receive methotrexate IT, hydrocortisone IT, and cytarabine IT on day 8. Patients with CNS2, CNS3a, and CNS3b receive methotrexate IT, hydrocortisone IT, and cytarabine IT QW starting on day 8 for 4-6 weeks (may continue into Induction 2) until the CSF is clear of blasts (CNS1 status). Patients with CNS3c receive methotrexate IT, hydrocortisone IT, and cytarabine IT QW starting on day 1 for 6 weeks (may continue into Induction 2). INDUCTION 2 (WITH GILTERITINIB): Patients with CNS1 receive methotrexate IT, hydrocortisone IT, and cytarabine IT on day 0. Patients with CNS2 receive methotrexate IT, hydrocortisone IT, and cytarabine IT QW starting on day 0 until CNS1 status is reached. Patients also receive cytarabine IV over 1-30 minutes Q12H on days 1-8, dexrazoxane IV over 15 minutes and daunorubicin IV over 1-15 minutes on days 1, 3, and 5, and gilteritinib PO/NG/G-tube QD on days 11-31. INTENSIFICATION 1 (WITH GILTERITINIB): Patients receive methotrexate IT, hydrocortisone IT, and cytarabine IT on day 0. Patients also receive high-dose cytarabine IV over 1-3 hours Q12H and etoposide IV over 90-120 minutes on days 1-5, and gilteritinib PO/NG/G-tube QD on days 6-26. INTENSIFICATION 2 (WITH GILTERITINIB): Patients receive methotrexate IT, hydrocortisone IT, and cytarabine IT on day 0. Patients also receive high-dose cytarabine IV over 1-3 hours Q12H on days 1-4, dexrazoxane IV over 15 minutes and mitoxantrone IV over 5-15 minutes on days 3-6, and gilteritinib PO/NG/G-tube QD on days 7-27. INTENSIFICATION 3 (WITH GILTERITINIB): Patients receive high-dose cytarabine IV over 3 hours Q12H on days 1, 2, 8, and 9, asparaginase Erwinia chrysanthemi IM or IV over 1-2 hours, and gilteritinib PO/NG/G-tube QD on days 10-30. POST-CHEMOTHERAPY GILTERITINIB MAINTENANCE: Patients receive gilteritinib PO/NG/G-tube QD on days 1-365. ARM BD LOW RISK GROUP 2: CONTINUED INDUCTION 1 (WITH GILTERITINIB): Patients receive CPX-351 IV over 90 minutes on days 1, 3, and 5, gemtuzumab ozogamicin IV over 2 hours on day 6, and gilteritinib PO/NG/G-tube QD on days 11-31. Patients with CNS1 receive methotrexate IT, hydrocortisone IT, and cytarabine IT on day 8. Patients with CNS2, CNS3a, and CNS3b receive methotrexate IT, hydrocortisone IT, and cytarabine IT QW starting on day 8 for 4-6 weeks (may continue into Induction 2) until the CSF is clear of blasts (CNS1 status). Patients with CNS3c receive methotrexate IT, hydrocortisone IT, and cytarabine IT QW starting on day 1 for 6 weeks (may continue into Induction 2). INDUCTION 2 (WITH GILTERITINIB): Patients with CNS1 receive methotrexate IT, hydrocortisone IT, and cytarabine IT on day 0. Patients with CNS2 receive methotrexate IT, hydrocortisone IT, and cytarabine IT QW starting on day 0 until CNS1 status is reached. Patients also receive CPX-351 IV over 90 minutes on days 1, 3, and 5 and gilteritinib PO/NG/G-tube QD on days 11-31. INTENSIFICATION 1 (WITH GILTERITINIB): Patients receive methotrexate IT, hydrocortisone IT, and cytarabine IT on day 0. Patients also receive high-dose cytarabine IV over 1-3 hours Q12H and etoposide IV over 90-120 minutes on days 1-5, and gilteritinib PO/NG/G-tube QD on days 6-26. INTENSIFICATION 2 (WITH GILTERITINIB): Patients receive methotrexate IT, hydrocortisone IT, and cytarabine IT on day 0. Patients also receive high-dose cytarabine IV over 1-3 hours Q12H on days 1-4, dexrazoxane IV over 15 minutes and mitoxantrone IV over 5-15 minutes on days 3-6, and gilteritinib PO/NG/G-tube QD on days 7-27. INTENSIFICATION 3 (WITH GILTERITINIB): Patients receive high-dose cytarabine IV over 3 hours Q12H on days 1, 2, 8, and 9, asparaginase Erwinia chrysanthemi IM or IV over 1-2 hours, and gilteritinib PO/NG/G-tube QD on days 10-30. POST-CHEMOTHERAPY GILTERITINIB MAINTENANCE: Patients receive gilteritinib PO/NG/G-tube QD on days 1-365. ARM AD HIGH RISK GROUP: CONTINUED INDUCTION 1 (WITH GILTERITINIB): Patients receive cytarabine IV over 1-30 minutes Q12H on days 1-10, dexrazoxane IV over 15 minutes and daunorubicin IV over 1-15 minutes on days 1, 3, and 5, gemtuzumab ozogamicin IV over 2 hours on day 6, and gilteritinib PO/NG/G-tube QD on days 11-31. Patients with CNS1 receive methotrexate IT, hydrocortisone IT, and cytarabine IT on day 8. Patients with CNS2, CNS3a, and CNS3b receive methotrexate IT, hydrocortisone IT, and cytarabine IT QW starting on day 8 for 4-6 weeks (may continue into Induction 2) until the CSF is clear of blasts (CNS1 status). Patients with CNS3c receive methotrexate IT, hydrocortisone IT, and cytarabine IT QW starting on day 1 for 6 weeks (may continue into Induction 2). INDUCTION 2 (WITH GILTERITINIB): Patients with CNS1 receive methotrexate IT, hydrocortisone IT, and cytarabine IT on day 0. Patients with CNS2 receive methotrexate IT, hydrocortisone IT, and cytarabine IT QW starting on day 0 until CNS1 status is reached. Patients also receive cytarabine IV over 1-30 minutes Q12H on days 1-8, dexrazoxane IV over 15 minutes and daunorubicin IV over 1-15 minutes on days 1, 3, and 5, and gilteritinib PO/NG/G-tube QD on days 11-31. INTENSIFICATION 1 (WITH GILTERITINIB): Patients receive methotrexate IT, hydrocortisone IT, and cytarabine IT on day 0. Patients also receive high-dose cytarabine IV over 1-3 hours Q12H and etoposide IV over 90-120 minutes on days 1-5, and gilteritinib PO QD on days 6-26. HSCT: After completion of Intensification 1 and investigator assigned conditioning regimen, patients undergo allogeneic HSCT. POST-HSCT GILTERITINIB MAINTENANCE: Beginning 30-120 days after completion of HSCT, patients receive gilteritinib PO or NG or G tube QD on days 1-365. ARM BD HIGH RISK GROUP: CONTINUED INDUCTION 1 (WITH GILTERITINIB): Patients receive CPX-351 IV over 90 minutes on days 1, 3, and 5, gemtuzumab ozogamicin IV over 2 hours on day 6, and gilteritinib PO QD on days 11-31. Patients with CNS1 receive methotrexate IT, hydrocortisone IT, and cytarabine IT on day 8. Patients with CNS2, CNS3a, and CNS3b receive methotrexate IT, hydrocortisone IT, and cytarabine IT QW starting on day 8 for 4-6 weeks (may continue into Induction 2) until the CSF is clear of blasts (CNS1 status). Patients with CNS3c receive methotrexate IT, hydrocortisone IT, and cytarabine IT QW starting on day 1 for 6 weeks (may continue into Induction 2). INDUCTION 2 (WITH GILTERITINIB): Patients with CNS1 receive methotrexate IT, hydrocortisone IT, and cytarabine IT on day 0. Patients with CNS2 receive methotrexate IT, hydrocortisone IT, and cytarabine IT QW starting on day 0 until CNS1 status is reached. Patients also receive CPX-351 IV over 90 minutes on days 1, 3, and 5 and gilteritinib PO QD on days 11-31. INTENSIFICATION 1 (WITH GILTERITINIB): Patients receive methotrexate IT, hydrocortisone IT, and cytarabine IT on day 0. Patients also receive high-dose cytarabine IV over 1-3 hours Q12H and etoposide IV over 90-120 minutes on days 1-5, and gilteritinib PO QD on days 6-26. HSCT: After completion of Intensification 1 and investigator assigned conditioning regimen, patients undergo allogeneic HSCT. POST-HSCT GILTERITINIB MAINTENANCE: Beginning 30-120 days after completion of HSCT, patients receive gilteritinib PO or NG or G tube QD on days 1-365. NOTE: During Induction 2 or Intensification 2, patients in Arms A and B with left ventricular systolic dysfunction receive a replacement course of high-dose cytarabine IV over 3 hours on days 1, 2, 8, and 9, and asparaginase Erwinia chrysanthemi IM or IV over 1-2 hours. Patients in Arms AC, BC, AD, and BD receive treatment as in Arms A and B and also receive gilteritinib PO QD on days 10-30 (Induction 2) or days 10-30 (Intensification 2). OPTIONAL NEUROCOGNITIVE STUDY: Patients may complete the Cogstate assessment battery at the end of Induction 1, at the end of therapy, and at 9 and 60 months post-enrollment.
Source references
references
  1. citation
    Pollard JA, Alonzo TA, Gerbing RB, Kutny M, Hirsch B, Raca G, Leger K, Wilkes J, Pabari R, Wadhwa A, Graff Z, Kahwash S, Chisholm K, Chewning J, Horan J, Aplenc R, Place A, Tasian SK, Tarlock K, Menig S, Militano O, Ky B, Hudson C, Loken MR, Menssen A, Brodersen LE, Meshinchi S, Kolb EA, Cooper TM. AAML1831: A Phase III Trial Comparing Standard Induction Therapy With CPX-351 in De Novo Pediatric AML: A Report From the Children's Oncology Group. J Clin Oncol. 2026 Jul 24:JCO2502979. doi: 10.1200/JCO-25-02979. Online ahead of print.
    pmid
    42497367
    type
    DERIVED
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    Leger KJ, Absalon MJ, Demissei BG, Smith AM, Gerbing RB, Alonzo TA, Narayan HK, Hirsch BA, Pollard JA, Razzouk BI, Getz KD, Aplenc R, Kolb EA, Ky B, Cooper TM. Cardiotoxicity of CPX-351 in children and adolescents with relapsed AML: a Children's Oncology Group report. Front Cardiovasc Med. 2024 Jun 14;11:1347547. doi: 10.3389/fcvm.2024.1347547. eCollection 2024.
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    38947228
    type
    DERIVED
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    Leger KJ, Robison N, Narayan HK, Smith AM, Tsega T, Chung J, Daniels A, Chen Z, Englefield V, Demissei BG, Lefebvre B, Morrow G, Dizon I, Gerbing RB, Pabari R, Getz KD, Aplenc R, Pollard JA, Chow EJ, Tang WHW, Border WL, Sachdeva R, Alonzo TA, Kolb EA, Cooper TM, Ky B. Rationale and design of the Children's Oncology Group study AAML1831 integrated cardiac substudies in pediatric acute myeloid leukemia therapy. Front Cardiovasc Med. 2023 Dec 1;10:1286241. doi: 10.3389/fcvm.2023.1286241. eCollection 2023.
    pmid
    38107263
    type
    DERIVED
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    Andolina JR, Fries C, Boulware R, Vargas A, Fraint E, Barth M, Ambrusko S, Comito M, Monteleone P. Successful Bone Marrow Transplantation With Intensive Post-transplant Intrathecal Chemotherapy for CNS Relapsed AML in 2 Infants. J Pediatr Hematol Oncol. 2022 Jan 1;44(1):e264-e267. doi: 10.1097/MPH.0000000000002151.
    pmid
    33843815
    type
    DERIVED
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        de novo AML The safety and effectiveness of VYXEOS in pediatric patients with de novo AML were assessed but not established in an open-label, randomized study (NCT04293562) comparing VYXEOS plus gemtuzumab ozogamicin to standard chemotherapy plus gemtuzumab ozogamicin. The VYXEOS arm included 324 pediatric patients less than 17 y
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        nts with AML who have <em class="gene-name">NPM1</em> and <em class="gene-name">FLT3</em> ITD variants. The COG <a href="/clinicaltrials/NCT04293562">AAML1831 (NCT04293562)</a> trial will determine if patients with <em class="gene-name">NPM1</em> and <em class="gene-name">FLT3</em> ITD variants who are MRD negative after inductio
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        stic CSF examinations and initial intrathecal administration were done on or before day 1 of induction therapy. Beginning with the COG <a href="/clinicaltrials/NCT04293562">AAML1831 (NCT04293562)</a> trial, to minimize the contamination risk, the newer guidance is to delay the diagnostic lumbar puncture to day 8, when most patien
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        nd initial intrathecal administration were done on or before day 1 of induction therapy. Beginning with the COG <a href="/clinicaltrials/NCT04293562">AAML1831 (NCT04293562)</a> trial, to minimize the contamination risk, the newer guidance is to delay the diagnostic lumbar puncture to day 8, when most patients have cleared their p
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        colspan="2">Unfavorable</th></tr></THead><TFoot class="pdq-footer"><tr><td colspan="3"><span class="sup">a</span>Adapted from the COG <a href="/clinicaltrials/NCT04293562">AAML1831 (NCT04293562)</a> trial.</td></tr></TFoot><tbody><tr><td>t(8;21)(q22;q22); <em class="gene-name">RUNX1</em>::<em class="gene-name">RUNX1T1</em></td><
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        e</th></tr></THead><TFoot class="pdq-footer"><tr><td colspan="3"><span class="sup">a</span>Adapted from the COG <a href="/clinicaltrials/NCT04293562">AAML1831 (NCT04293562)</a> trial.</td></tr></TFoot><tbody><tr><td>t(8;21)(q22;q22); <em class="gene-name">RUNX1</em>::<em class="gene-name">RUNX1T1</em></td><td colspan="2"> inv(3)(
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        if they relapsed.[<a href="#cit/section_4.68">68</a>,<a href="#cit/section_4.82">82</a>]</p> <p id="_2191" tabindex="-1">The COG <a href="/clinicaltrials/NCT04293562">AAML1831 (NCT04293562)</a> trial for patients with newly diagnosed AML uses a more complex risk-stratification system. This system incorporates more genetic l
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        295760
        exact text
        NCT04293562
        start
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      8. context exact
        ef="#cit/section_4.68">68</a>,<a href="#cit/section_4.82">82</a>]</p> <p id="_2191" tabindex="-1">The COG <a href="/clinicaltrials/NCT04293562">AAML1831 (NCT04293562)</a> trial for patients with newly diagnosed AML uses a more complex risk-stratification system. This system incorporates more genetic lesions into the high-ri
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        NCT04293562
        start
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      9. context exact
        s and therapy. Other groups have attempted to prevent CNS relapse by using additional intrathecal agents. Similarly, the ongoing COG <a href="/clinicaltrials/NCT04293562">AAML1831 (NCT04293562)</a> trial incorporates the use of intrathecal triples (methotrexate, cytarabine, and hydrocortisone).</p> <p id="_2148" tabindex=
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        383042
        exact text
        NCT04293562
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        roups have attempted to prevent CNS relapse by using additional intrathecal agents. Similarly, the ongoing COG <a href="/clinicaltrials/NCT04293562">AAML1831 (NCT04293562)</a> trial incorporates the use of intrathecal triples (methotrexate, cytarabine, and hydrocortisone).</p> <p id="_2148" tabindex="-1">CNS involvement in
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        NCT04293562
        start
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        2030" tabindex="-1">Gilteritinib is now being studied in children with <em class="gene-name">FLT3</em>-positive de novo AML in the COG <a href="/clinicaltrials/NCT04293562">AAML1831 (NCT04293562)</a> trial.</p> </section> <section id="_2171"> <h6 id="_2171_toc">Sorafenib</h6> <p id="_21
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        teritinib is now being studied in children with <em class="gene-name">FLT3</em>-positive de novo AML in the COG <a href="/clinicaltrials/NCT04293562">AAML1831 (NCT04293562)</a> trial.</p> </section> <section id="_2171"> <h6 id="_2171_toc">Sorafenib</h6> <p id="_2172" tabindex="-1">Soraf
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        de novo AML The safety and effectiveness of VYXEOS in pediatric patients with de novo AML were assessed but not established in an open-label, randomized study (NCT04293562) comparing VYXEOS plus gemtuzumab ozogamicin to standard chemotherapy plus gemtuzumab ozogamicin. The VYXEOS arm included 324 pediatric patients less than 17 y
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    Preserved source evidence · Independent clinical review pending · Not medical advice