Total Therapy Study XVI for Newly Diagnosed Patients With Acute Lymphoblastic Leukemia

Sponsor
St. Jude Children's Research Hospital (Other)
Overall Status
Completed
CT.gov ID
NCT00549848
Collaborator
National Cancer Institute (NCI) (NIH), Enzon Pharmaceuticals, Inc. (Industry), National Institute of General Medical Sciences (NIGMS) (NIH)
600
1
2
172.9
3.5

Study Details

Study Description

Brief Summary

The primary objective of this study (TOTXVI) is to compare the clinical benefit, the pharmacokinetics, and the pharmacodynamics of polyethylene glycol-conjugated (PEG) asparaginase given in higher dose (HD PEG) versus those of PEG-asparaginase given in conventional dose (CD PEG) during the continuation phase.

This study has several secondary objectives:
Therapeutic Objectives:

To estimate the event-free survival and overall survival of children with ALL who are treated with risk-directed therapy.

To study whether intensifying induction, including fractionated cyclophosphamide and thioguanine, in patients with day 15 MRD > 5%, will result in improved leukemia cytoreduction in this subgroup compared to TOTXV.

To assess whether intensification of central nervous system (CNS)-directed intrathecal and systemic chemotherapy will improve outcome in patients at high risk of CNS relapse.

Exploratory Pharmacologic Objectives:

To identify pharmacogenetic, pharmacokinetic and pharmacodynamic predictors for treatment-related outcomes in the context of the systemic therapy used in the protocol.

To compare the pharmacokinetics and pharmacodynamics of PEG-asparaginase given in higher dose (3,500 or 3,000 units/m2) versus those of PEG-asparaginase given in conventional dose (2,500 units/m2) in the continuation phase.

Exploratory Biologic Objectives:

To determine the prognostic value of levels of minimal residual disease in peripheral blood at day 8 of remission induction.

To validate new markers and methods for MRD detection. To genotype natural killer (NK) cell receptors and measure their expressions at diagnosis and before reinduction, and to associate these features with treatment outcome.

To identify new prognostic factors by applying new technologies to study patient material (e.g., stored plasma, serum, cerebrospinal fluid, and normal and leukemic cells).

Exploratory Neuroimaging Objectives:

To use quantitative MR measures (Diffusion Tensor Imaging and high resolution volumetric imaging) to assess differences in myelin and cortical thickness development in patients treated for ALL relative to healthy controls matched for age and gender.

To assess the impact of folate pathway genetic polymorphisms on myelin and cortical thickness development and neurocognitive performance.

To assess the impact of frontal-parietal lobe myelin and cortical thickness development on neurocognitive performance in attention, working memory, fluency, visual-spatial reasoning and processing speed.

Condition or Disease Intervention/Treatment Phase
  • Drug: Prednisone, Vincristine, Daunorubicin, PEG-L-asparaginase, Erwinia L-asparaginase, Doxorubicin, Cyclophosphamide, Cytarabine, Thioguanine
  • Drug: Clofarabine, Methotrexate, Mercaptopurine, Dexamethasone, Etoposide, Dasatinib
Phase 3

Detailed Description

Details of the Treatment Plan:

Treatment will consist of three main phases: Remission Induction, Consolidation, and Continuation.

  1. Remission Induction
  • Intrathecal Treatment during Induction

Frequency and total number of triple intrathecal treatments for Remission Induction is based on the patient's risk of CNS relapse.All patients will receive triple intrathecal treatment on days 1 and 15. Patients with high risk features may receive additional triple intrathecal treatment on days 4, 8, 11, and 22.[t(1;19)/E2A-PBX1.

Induction treatment will begin with prednisone, vincristine, daunorubicin, PEG-asparaginase and triple intrathecal treatment, followed by cyclophosphamide plus cytarabine plus thioguanine.

Remission Induction Chemotherapy (6-7 weeks) Prednisone 40 mg/m2/day PO (divided t.i.d.) Days 1 - 28 Dexamethasone will be substituted for prednisone in patients with early T-cell precursor (ETP) immunophenotype.

Mercaptopurine will be substituted for thiopurine in TPMT HET/deficient patients Dexamethasone (for ETP immunophenotype only) 10 mg/m2/day PO (divided t.i.d.)Days 1-21; 4 mg/m2/day PO (divided t.i.d) Days 22-24; 2 mg/m2/day PO(divided t.i.d) Days 25-28 Vincristine 1.5 mg/m2 IV (max 2 mg) Days 1, 8, 15, 22 Daunorubicin 25 mg/m2 IV Days 1 and 8 PEG-asparaginase 3,000 Units/m2 IV Day 3

  • Participants with Day 15 MRD greater than or equal to 1%: PEG-asparaginase 3,000 Units/m2 IV Day 15

  • Participants with Day 15 MRD less than 5% (excluding MLL positive infants): Cyclophosphamide 1000 mg/m2 IV Day 22 Cytarabine 75 mg/m2/dose IV Days 23-26, 30-33 Thioguanine [Mercaptopurine (TPMT HET/deficient patients only)]60 mg/m2/dose PO Days 22-35 Dasatinib (Ph+ participants only) 40 mg/m2 b.i.d starting Day 22 of induction to continue until end of treatment

Day 15 MRD > or equal to 5% (excluding MLL+ infants) Cyclophosphamide† 300 mg/m2 IV/ q12 hrs on Days 22-23 Cytarabine 75 mg/m2/dose IV Days 23-26, 30-33 Thioguanine [Mercaptopurine (TPMT HET/deficient patients only) 60 mg/m2/dose PO Days 22-35 Dasatinib‡ (Ph+ participants only) 40 mg/m2 b.i.d Daily Starting Day 22 of induction to continue until end of treatment

  • Infants with MLL positive rearrangement: Clofarabine 40 mg/m2/dose IV Days 22-26 Etoposide 100 mg/m2/dose IV Days 22-26 Cyclophosphamide 300 mg/m2/dose IV Days 22-26
  1. Consolidation Treatment (8 weeks) High Dose Methotrexate (HDMTX) 2.5 gm/ (low risk), or targeted 65 μM (std/high-risk) days 1, 15, 29 and 43. Mercaptopurine 50 mg/m2/day Days 1 to 56. All patients will receive triple intrathecal therapy every other week for four doses on Days 1, 15, 29, and 43. Dose is age dependent.
  • Reintensification

Patients with high-risk leukemia may receive reintensification therapy and then will be offered the option of transplant. This treatment will attempt to maximize leukemic cell kill before allogeneic hematopoietic stem cell transplantation.

Dexamethasone 20 mg/m2/day PO or IV Days 1-6.Cytarabine 2 grams/m2, 3-hour IV infusion every 12 hours Days 1-2. Etoposide 100 mg/m2, 1-hour IV infusion every 12 hours Days 3-5. Intrathecal methotrexate+hydrocortisone+cytarabine (ITMHA) Day 5; PEG-asparaginase 3,000 units/m2 IV Day 6

Patients with suboptimal response to reintensification may receive one to two cycles of clofarabine/cyclophosphamide/etoposide/dexamethasone:

Clofarabine 40 mg/m2/day, 2-hour IV infusion Days 1-5 Etoposide 100 mg/m2/day, 2-hour IV infusion Days 1-5 Cyclophosphamide 300 mg/m2/day, 30-60 minute IV infusion Days 1-5 Dexamethasone 8 mg/m2/day (divided t.i.d) Days 1-5

  1. Continuation Treatment (120 weeks)

Abbreviations used below: DEX=dexamethasone; DOX=doxorubicin; VCR=vincristine; MP=mercaptopurine; PEG-ASP=polyethylene glycol-conjugated asparaginase; MTX=methotrexate; 6MP=mercaptopurine

Weeks 1 through 20 - treatment depends on risk assignment standard-high versus low-risk

Week Standard-/High-Risk Low-Risk

  1. DEX+DOX+VCR+MP + PEG-ASP/MP + DEX + VCR

  2. MP MP + MTX

  3. MP + PEG-ASP/MP + MTX

  4. DEX + DOX + VCR + MP/MP + DEX + VCR

  5. MP + PEG-ASP MP + MTX

  6. MP MP + MTX

  7. Reinduction I

  8. Reinduction I

  9. Reinduction I

  10. MP/MP + MTX

  11. DOX + VCR +MP + PEG-ASP/MP + MTX

  12. MP/MP + MTX

  13. MP + PEG-ASP/MP + MTX

  14. DEX + DOX + VCR +6MP/MP + DEX + VCR

  15. MP + PEG-ASP/MP + MTX

  16. MP/MP + MTX

  17. Reinduction II

  18. Reinduction II

  19. Reinduction II

  20. No chemotherapy/MP + MTX

Drug Dosages, Schedules and Routes for Continuation Therapy Weeks 1 to 6 and 10 to 16:

Dexamethasone 12 mg/m2 (std/high risk) or 8 mg/m2 (low risk) PO daily (divided t.i.d.) for 5 days, Days 1-5. Doxorubicin 30 mg/m2 IV, Day 1. Vincristine 2 mg/m2 IV push (max. 2 mg), Day 1 (0.05 mg/kg for patients < 1 year of age or < 10kg in weight). MP (mercaptopurine) 50 mg/m2 PO daily for 7 days (std/high risk), Days 1-7, 75 mg/m2 PO daily for 7 days (low risk), Days 1-7. PEG-ASP (PEG-asparaginase) 2,500 vs. 3,500 units/m2 IV randomization, Day 1. Methotrexate 40 mg/m2 IV Day 1.

Dexamethasone, vincristine, and asparaginase will be given regardless of blood counts, provided that the patient is clinically well. Doxorubicin, mercaptopurine and methotrexate will be held if white blood count (WBC) <1000/mm3 or absolute neutrophil count (ANC) <300/mm3. Doxorubicin, mercaptopurine and methotrexate will be reduced for WBC < 1500/mm3, or if WBC and ANC not increase by at least 2 folds a week after the start date of dexamethasone pulse.

Reinduction Treatment - This phase of treatment is part of continuation and will be started at weeks 7 and 17 after bone marrow examination confirms complete remission. Doxorubicin and HD-cytarabine will be held if ANC < or equal to 300/mm3 or WBC < 1000/mm3.It is preferable to start HD-cytarabine when WBC > or equal to 1800/mm3 and ANC

300/mm3 Reinduction treatment will be given twice: weeks 7 to 9 and weeks 17 to 19 for all patients. Intrathecal treatment will be followed by leucovorin rescue (5 mg/m2/dose PO, max 5 mg) at 24 and 30 hours only in patients with prior CNS toxicities or in patients with WBC < 1500/mm3, or ANC < 500/mm3.

  • Reinduction I for Standard/High Risk ALL excluding MLL infants: Dexamethasone 8 mg/m2/day PO (divided t.i.d.) Days 1-8, 15-21. Vincristine 1.5 mg/m2/week IV Days 1, 8, 15 Doxorubicin 30 mg/m2 IV Days 1, 8. PEG-asparaginase 2,500 or 3,500 units/m2 IV Days 1, 15.

Intrathecal chemotherapy, Methotrexate + hydrocortisone + Ara-C dose age dependent, Day 1.

  • Reinduction II for Standard/High Risk ALL including MLL infants: Dexamethasone 8 mg/m2/day PO (t.i.d.) Days 1-8, 15-21. Vincristine 1.5 mg/m2/week IV Days 1, 8, 15. PEG-asparaginase 2,500 or 3,500 units/m2 IV Days 1, 15. High-dose cytarabine 2 gm/m2 IV q 12 hr Days 15, 16. Intrathecal chemotherapy, dose age dependent, Day 1.

  • Reinduction I for Low-Risk ALL: Dexamethasone 8 mg/m2/day PO (divided t.i.d.) Days 1-8, 15-21. Vincristine 1.5 mg/m2/week IV Days 1, 8, 15. PEG-asparaginase 2,500 or 3,500 units/m2 IV Days 1, 15. Doxorubicin 30 mg/m2/IV Day 1. Intrathecal chemotherapy, dose age dependent, Day 1.

  • Reinduction II for Low-Risk ALL: Dexamethasone 8 mg/m2/day PO (divided t.i.d.) Days 1-8, 15-21. Vincristine 1.5 mg/m2/week IV Days 1, 8, 15. PEG-asparaginase 2,500 or 3,500 units/m2 IV Days 1, 15. Intrathecal chemotherapy, dose age dependent, Day 1.

  • Reinduction I for MLL Infants: Dexamethasone 8 mg/m2/day PO (divided t.i.d.) Days 1-8 and 15-21. Clofarabine 40 mg/m2/day, -hour IV Days 1-5. Etoposide 100 mg/m2/day, 2-hour IV Days 1-5. cyclophosphamide 300 mg/m2/day, 1-hour IV Days 1-5. PEG-asparaginase 2,500 or 3,500 units/m2 IV Days 1, 15. Intrathecal chemotherapy, dose age dependent, on Day 1.

  • Intrathecal Chemotherapy:

  • Triple intrathecal treatment will be given to low-risk cases with CNS-1 status (no identifiable blasts in CSF) on weeks 7, 12, 17, 25, 33, 41, and 49.

  • Triple intrathecal treatment will be given to low-risk cases with CNS-2, traumatic CSF with blasts status, or WBC > 100 x 109/L on weeks 3, 7, 12, 17, 25, 29, 33, 37, 41, 45 and 49.

  • Triple intrathecal treatment will be given to standard/high-risk cases on weeks 7, 12, 17, 25, 29, 33, 37, 41, 45 and 49.

  • Triple intrathecal treatment will be given to other standard/high-risk cases with WBC > or equal to 100 x 109/L, T-cell ALL, t (1;19)/E2A-PBX1, presence of Philadelphia chromosome, MLL rearrangement, hypodiploidy <44, CNS-2 or CNS-3 status, or traumatic lumbar puncture with blasts on weeks 3, 7, 12, 17, 25, 29, 33, 37, 41, 45, 49, 57, 65, 73, 81, 89 and 97

Treatment (weeks 21 to 29)

Week Standard/High Risk Low Risk

  1. MP + PEG-ASP+Dasatinib MP + MTX

  2. MP +Dasatinib MP + MTX

  3. MP + PEG-ASP + Dasatinib MP + MTX

  4. Cyclo + Ara-C + Dasatinib MP + MTX

  5. DEX + VCR + PEG-ASP + Dasatinib MP + DEX + VCR

  6. MP + Dasatinib MP + MTX

  7. MP + PEG-ASP+Dasatinib MP + MTX

  8. Cyclo + Ara-C + Dasatinib MP + MTX

  9. DEX + VCR +PEG-ASP + Dasatinib MP + DEX + VCR Dasatinib in Ph+ only

Treatment (weeks 30 to end of therapy)

Week Standard/High Risk Low Risk

  1. MP + MTX + Dasatinib MP + MTX

  2. MP + MTX + Dasatinib MP + MTX

  3. Cyclo + Ara-C+Dasatinib MP + MTX

  4. DEX + VCR + Dasatinib MP + DEX + VCR

  5. MP + MTX + Dasatinib MP + MTX

  6. MP + MTX + Dasatinib MP + MTX

  7. Cyclo + Ara-C + Dasatinib/MP + MTX

  8. DEX + VCR + Dasatinib /MP + DEX + VCR Dasatinib in Ph positive patients only

Drug Dosages, Schedules and Routes for Continuation Therapy from Week 21 to End of Therapy:

Mercaptopurine 75 mg/m2 PO daily for 7 days, Days 1-7. Methotrexate 40 mg/m2 IV or intramuscularly (IM) Day 1. Cyclophosphamide 300 mg/m2 IV, Day 1. Cytarabine 300 mg/m2 IV, Day 1. Dexamethasone 12 mg/m2 (std/high risk) or 8 mg/m2 (low risk) PO daily (divided t.i.d.) for 5 days, Day 1-5 (between week 21 and week 68).Decrease dexamethasone to 6 mg/m2 PO daily (divided t.i.d.) x 5 days,Day 1-5 between week 69 and week 101 for all risk groups.

Vincristine2 mg/m2 IV push (max 2 mg), Day 1 (0.05mg/kg for patients < 1 year or < 10 kg).

PEG-ASP 2,500 vs 3,500 units/m2 IV randomization (until week 30)

Dexamethasone, vincristine, and asparaginase will be given regardless of blood counts, provided that the patient is clinically well. Cyclophosphamide, cytarabine, mercaptopurine and methotrexate will be held if WBC <1000/mm3 or ANC <300/mm3. Mercaptopurine and methotrexate will be reduced for WBC < 1500/mm3, or if WBC and ANC do not increase by at least 2 folds a week after the start date of dexamethasone pulse. Doses of cyclophosphamide and cytarabine may need to be reduced if patient misses 25% of chemotherapy and if the low counts deem to be related to this combination.

The same treatment (weeks 30-37) will be repeated for a total of 5 times, until week 69 (see Section 5.5.3 for intrathecal therapy). After week 69, all patients will receive daily mercaptopurine and weekly methotrexate interrupted with pulses of dexamethasone, vincristine, and mercaptopurine every 4 weeks. The dose of dexamethasone will be decreased to 6 mg/m2 between week 69 and week 101, after which only mercaptopurine and methotrexate will be given. Intrathecal treatment will be given every 8 weeks only to patients at risk of CNS relapse after week 49 and will be discontinued after week 97. Continuation therapy will be discontinued after 120 weeks.

Hematopoietic Stem Cell Transplantation (for patients who meet the criteria of high-risk ALL are candidates for allogeneic hematopoietic stem cell transplantation). However, if the option is declined by the patients or guardians, or the procedure is deemed unsuitable by the attending physician and the principal investigator, the patient will remain on study and continue to receive chemotherapy.

Study Design

Study Type:
Interventional
Actual Enrollment :
600 participants
Allocation:
Randomized
Intervention Model:
Parallel Assignment
Masking:
None (Open Label)
Primary Purpose:
Treatment
Official Title:
Total Therapy Study XVI for Newly Diagnosed Patients With Acute Lymphoblastic Leukemia
Actual Study Start Date :
Oct 29, 2007
Actual Primary Completion Date :
Sep 26, 2020
Actual Study Completion Date :
Mar 26, 2022

Arms and Interventions

Arm Intervention/Treatment
Experimental: HD PEG

Participants randomized to receive higher dose PEG-asparaginase during the continuation phase. Interventions: Prednisone, Vincristine, Daunorubicin, PEG-L-asparaginase, Erwinia L-asparaginase, Doxorubicin, Cyclophosphamide, Cytarabine, Thioguanine Clofarabine, Methotrexate, Mercaptopurine, Dexamethasone, Etoposide, Dasatinib

Drug: Prednisone, Vincristine, Daunorubicin, PEG-L-asparaginase, Erwinia L-asparaginase, Doxorubicin, Cyclophosphamide, Cytarabine, Thioguanine
See Detailed Description section for details of treatment interventions.
Other Names:
  • Prednisone: prednisolone
  • Vincristine: Oncovin(R)
  • Daunorubicin: daunomycin, Cerubidine(R)
  • PEG-L-asparaginase: pegaspargase, Oncaspar(R)
  • Erwinia L-Asparaginase: Erwinase(R)
  • Doxorubicin: Adriamycin(R)
  • Cyclophosphamide: Cytoxan(R)
  • Cytarabine: Ara-C, Cytosar-U(R)
  • Thioguanine: 6-TG
  • Drug: Clofarabine, Methotrexate, Mercaptopurine, Dexamethasone, Etoposide, Dasatinib
    See Detailed Description section for details of treatment interventions.
    Other Names:
  • Clofarabine: clofarex, Clolar(TM)
  • Methotrexate: MTX
  • Mercaptopurine: 6-MP, Purinethol(R)
  • Dexamethasone: Decadron(R)
  • Etoposide: VP-16, Vepesid(R)
  • Dasatinib: Sprycel(R)
  • Active Comparator: CD PEG

    Participants randomized to receive conventional dose PEG-asparaginase during the continuation phase.. Interventions: Prednisone, Vincristine, Daunorubicin, PEG-L-asparaginase, Erwinia L-asparaginase, Doxorubicin, Cyclophosphamide, Cytarabine, Thioguanine Clofarabine, Methotrexate, Mercaptopurine, Dexamethasone, Etoposide, Dasatinib

    Drug: Prednisone, Vincristine, Daunorubicin, PEG-L-asparaginase, Erwinia L-asparaginase, Doxorubicin, Cyclophosphamide, Cytarabine, Thioguanine
    See Detailed Description section for details of treatment interventions.
    Other Names:
  • Prednisone: prednisolone
  • Vincristine: Oncovin(R)
  • Daunorubicin: daunomycin, Cerubidine(R)
  • PEG-L-asparaginase: pegaspargase, Oncaspar(R)
  • Erwinia L-Asparaginase: Erwinase(R)
  • Doxorubicin: Adriamycin(R)
  • Cyclophosphamide: Cytoxan(R)
  • Cytarabine: Ara-C, Cytosar-U(R)
  • Thioguanine: 6-TG
  • Drug: Clofarabine, Methotrexate, Mercaptopurine, Dexamethasone, Etoposide, Dasatinib
    See Detailed Description section for details of treatment interventions.
    Other Names:
  • Clofarabine: clofarex, Clolar(TM)
  • Methotrexate: MTX
  • Mercaptopurine: 6-MP, Purinethol(R)
  • Dexamethasone: Decadron(R)
  • Etoposide: VP-16, Vepesid(R)
  • Dasatinib: Sprycel(R)
  • Outcome Measures

    Primary Outcome Measures

    1. Percentage of Participants With Continuous Complete Remission of Patients Receiving High-dose and Conventional Dose PEG-asparaginase. [3.5 years after the last enrollment up to 12.5 years]

      The primary objective of this study is to compare the distributions of continuous complete remission of patients randomized on the first day of the continuation phase to receive a higher dose of PEG-asparaginase or to receive the conventional dose (2,500 units/m2). The randomization will occur on the starting day of the continuation phase, at which time all information necessary for performing the randomization should be available. In the rare case that immunophenotype and/or Day-15 MRD is not available, we will make the following assumptions: If immunophenotype is unknown at the time the randomization is to be executed, then it will be assumed B-lineage. If Day-15 MRD is unknown at the time of randomization, then it will be assumed negative (<0.01%). Past experience indicate that few patients will fall into these unknown categories.

    Secondary Outcome Measures

    1. Probability of Event-free Survival [For Total XVI: 3.5 years after the last enrollment, up to approximately 13.5 years For Total XV: patients are followed continuously, up to 20.5 years]

      To estimate the event-free survival of children with ALL who are treated with risk-directed therapy and to compare the EFS results of TOTXVI with that of TOTXV (NCT00137111). EFS will be measured from the date of complete response to the date of initial failure for patients who fail. Failure includes the traditional endpoints of failure to achieve a complete remission, relapse in any site, secondary malignancy, and death during induction or remission. EFS time will be measured to the date of last contact for patients who are failure free at the time of analysis. The EFS time is defined to be zero (0) for patients who die during induction therapy or fail to achieve a complete remission.

    2. Probability of Overall Survival [For Total XVI: 3.5 years after the last enrollment, up to approximately 13.5 years For Total XV: patients are followed continuously, up to 20.5 years]

      To estimate the overall survival of children with ALL who are treated with risk-directed therapy and to compare the EFS results of TOTXVI with that of TOTXV.

    3. Proportion of Participants With Minimal Residual Disease (MRD) on the 15th Day of Remission Induction ≥ 5% [Middle of remission induction, Day 15 in Total XVI and Day 19 in Total XV]

      To study whether intensifying induction, including fractionated cyclophosphamide and thioguanine, in patients with day 15 MRD ≥ 5% will result in improved leukemia cytoreduction in this subgroup compared to therapy followed in the TOTXV protocol.

    4. Proportion of Participants With Minimal Residual Disease (MRD) at End of Remission Induction ≥ 0.01% [End of remission induction; day 42 in Total XVI and day 46 in Total XV]

      To study whether intensifying induction, including fractionated cyclophosphamide and thioguanine, in patients with day 15 MRD ≥ 5% will result in improved leukemia cytoreduction in this subgroup compared to therapy followed in the TOTXV protocol.

    5. Probability of CNS Relapse [For Total XVI: 3.5 years after the last enrollment, up to approximately 13.5 years For Total XV: patients are followed continuously, up to 20.5 years]

      To assess whether intensification of CNS-directed intrathecal and systemic chemotherapy will improve outcome in patients at high-risk of CNS relapse.

    Eligibility Criteria

    Criteria

    Ages Eligible for Study:
    N/A to 18 Years
    Sexes Eligible for Study:
    All
    Accepts Healthy Volunteers:
    No
    Inclusion Criteria:
    • Participant has a confirmed diagnosis of precursor B-cell or precursor T-cell acute lymphocytic leukemia (ALL) by immunophenotyping

    • Participant is less than or equal to 18 years of age

    • Limited prior therapy, including systemic glucocorticoids for one week or less, one dose of vincristine, emergency radiation therapy to the mediastinum and one dose of intrathecal chemotherapy. Other circumstances must be cleared by principal investigator (PI) or co-PI.

    • Written, informed consent and assent following Institutional Review Board, NCI, FDA, and Office for Human Research Protections (OHRP) Guidelines.

    Exclusion Criteria:
    • Participants with prior therapy, other than that listed above

    • Pregnant or lactating

    • Inability or unwillingness of research participant or legal guardian/representative to give written informed consent.

    Contacts and Locations

    Locations

    Site City State Country Postal Code
    1 St. Jude Children's Research Hospital Memphis Tennessee United States 38105

    Sponsors and Collaborators

    • St. Jude Children's Research Hospital
    • National Cancer Institute (NCI)
    • Enzon Pharmaceuticals, Inc.
    • National Institute of General Medical Sciences (NIGMS)

    Investigators

    • Principal Investigator: Sima Jeha, MD, St. Jude Children's Research Hospital

    Study Documents (Full-Text)

    More Information

    Additional Information:

    Publications

    None provided.
    Responsible Party:
    St. Jude Children's Research Hospital
    ClinicalTrials.gov Identifier:
    NCT00549848
    Other Study ID Numbers:
    • TOTXVI
    • R01CA140729
    • F32CA141762
    • R37CA036401
    • R01CA090246
    • Aspar PK-PD-T16
    • NCI-2011-01254
    • P50GM115279
    First Posted:
    Oct 26, 2007
    Last Update Posted:
    Aug 23, 2022
    Last Verified:
    Jul 1, 2022

    Study Results

    Participant Flow

    Recruitment Details Between October 29, 2007 and March 26, 2017, 600 patients younger than 19 years of age with newly diagnosed Acute Lymphoblastic Leukemia (ALL) were enrolled.
    Pre-assignment Detail Two (2) were later found ineligible and excluded. Of the 598 eligible patients, 414 patients were randomized to the two treatment arms, 184 were not randomized for various reasons: Not Eligible for Randomization (n=41) Death (n=5) Transplant (n=13) Withdrawal of Consent (n=3) Down's Syndrome (n=12) Poor Organ Function (n=8) Parent/Patient Decision (n=70) Attending Physician Decision (n=4) Enrollment after Completion of Randomization (n=69)
    Arm/Group Title PEG 3500 Units/m^2 PEG 2500 Units/m^2 Not Randomized
    Arm/Group Description Patients randomized on the first day of continuation phase to receive 3500 units/m^2 dose of PEG-asparaginase Patients randomized on the first day of continuation phase to receive 2,500 units/m^2 dose of PEG-asparaginase Patients who came off study prior to randomization
    Period Title: Overall Study
    STARTED 206 208 184
    COMPLETED 194 188 133
    NOT COMPLETED 12 20 51

    Baseline Characteristics

    Arm/Group Title PEG 3500 Units/m^2 PEG 2500 Units/m^2 Not Randomized Total
    Arm/Group Description Patients randomized on the first day of continuation phase to receive 3500 units/m^2 dose of PEG-asparaginase Patients randomized on the first day of continuation phase to receive 2,500 units/m^2 dose of PEG-asparaginase Patients who came off study prior to randomization Total of all reporting groups
    Overall Participants 206 208 184 598
    Age (years) [Mean (Standard Deviation) ]
    Mean (Standard Deviation) [years]
    7.13
    (4.78)
    7.04
    (4.73)
    7.75
    (5.04)
    7.29
    (4.85)
    Age, Customized (Count of Participants)
    <1 year
    5
    2.4%
    3
    1.4%
    4
    2.2%
    12
    2%
    1-10 years
    152
    73.8%
    160
    76.9%
    131
    71.2%
    443
    74.1%
    >10 years
    49
    23.8%
    45
    21.6%
    49
    26.6%
    143
    23.9%
    Sex: Female, Male (Count of Participants)
    Female
    91
    44.2%
    85
    40.9%
    72
    39.1%
    248
    41.5%
    Male
    115
    55.8%
    123
    59.1%
    112
    60.9%
    350
    58.5%
    Race/Ethnicity, Customized (Count of Participants)
    Cuban
    1
    0.5%
    0
    0%
    0
    0%
    1
    0.2%
    Mexican/Chicano
    7
    3.4%
    5
    2.4%
    7
    3.8%
    19
    3.2%
    NOS Spanish,Hispanic,Latino
    13
    6.3%
    14
    6.7%
    13
    7.1%
    40
    6.7%
    Non Spanish speaking, Non Hispanic
    182
    88.3%
    187
    89.9%
    161
    87.5%
    530
    88.6%
    Puerto Rican
    0
    0%
    0
    0%
    1
    0.5%
    1
    0.2%
    South or Central Amercian
    2
    1%
    0
    0%
    2
    1.1%
    4
    0.7%
    Unknown
    1
    0.5%
    2
    1%
    0
    0%
    3
    0.5%
    White
    154
    74.8%
    167
    80.3%
    143
    77.7%
    464
    77.6%
    Black
    34
    16.5%
    29
    13.9%
    25
    13.6%
    88
    14.7%
    Other
    18
    8.7%
    12
    5.8%
    16
    8.7%
    46
    7.7%
    Region of Enrollment (participants) [Number]
    United States
    206
    100%
    208
    100%
    184
    100%
    598
    100%

    Outcome Measures

    1. Primary Outcome
    Title Percentage of Participants With Continuous Complete Remission of Patients Receiving High-dose and Conventional Dose PEG-asparaginase.
    Description The primary objective of this study is to compare the distributions of continuous complete remission of patients randomized on the first day of the continuation phase to receive a higher dose of PEG-asparaginase or to receive the conventional dose (2,500 units/m2). The randomization will occur on the starting day of the continuation phase, at which time all information necessary for performing the randomization should be available. In the rare case that immunophenotype and/or Day-15 MRD is not available, we will make the following assumptions: If immunophenotype is unknown at the time the randomization is to be executed, then it will be assumed B-lineage. If Day-15 MRD is unknown at the time of randomization, then it will be assumed negative (<0.01%). Past experience indicate that few patients will fall into these unknown categories.
    Time Frame 3.5 years after the last enrollment up to 12.5 years

    Outcome Measure Data

    Analysis Population Description
    Per protocol, the comparison was between the two randomization arms.
    Arm/Group Title PEG 3500 Units/m^2 PEG 2500 Units/m^2
    Arm/Group Description Patients randomized on the first day of continuation phase to receive 3500 units/m^2 dose of PEG-asparaginase Patients randomized on the first day of continuation phase to receive 2,500 units/m^2 dose of PEG-asparaginase
    Measure Participants 206 208
    Number (95% Confidence Interval) [Percentage of participants]
    91.6
    44.5%
    90.7
    43.6%
    Statistical Analysis 1
    Statistical Analysis Overview Comparison Group Selection PEG 3500 Units/m^2, PEG 2500 Units/m^2
    Comments
    Type of Statistical Test Superiority
    Comments
    Statistical Test of Hypothesis p-Value 0.778
    Comments
    Method Cochran-Mantel-Haenszel
    Comments
    2. Secondary Outcome
    Title Probability of Event-free Survival
    Description To estimate the event-free survival of children with ALL who are treated with risk-directed therapy and to compare the EFS results of TOTXVI with that of TOTXV (NCT00137111). EFS will be measured from the date of complete response to the date of initial failure for patients who fail. Failure includes the traditional endpoints of failure to achieve a complete remission, relapse in any site, secondary malignancy, and death during induction or remission. EFS time will be measured to the date of last contact for patients who are failure free at the time of analysis. The EFS time is defined to be zero (0) for patients who die during induction therapy or fail to achieve a complete remission.
    Time Frame For Total XVI: 3.5 years after the last enrollment, up to approximately 13.5 years For Total XV: patients are followed continuously, up to 20.5 years

    Outcome Measure Data

    Analysis Population Description
    Per protocol this objective is to study whether intensifying induction will result in improved outcome compared to TOTXV. All eligible patients entered on TOTXVI will be included in these analyses, as appropriate. Infants will be excluded from the Total XVI for comparisons with TOTXV as only children at least one year of age at diagnosis were treated on Total XV.
    Arm/Group Title TOTXVI PEG 3500 TOTXVI PEG 2500 TOTXVI Not Randomized All Eligible Patients in TOTXV
    Arm/Group Description Patients randomized on the first day of continuation phase to receive 3500 units/m^2 dose of PEG-asparaginase Patients randomized on the first day of continuation phase to receive 2,500 units/m^2 dose of PEG-asparaginase Patients who came off study prior to randomization All 498 eligible children with ALL who are treated with risk-directed therapy.
    Measure Participants 201 205 180 498
    Number (95% Confidence Interval) [Percentage of participants]
    92.4
    44.9%
    91.1
    43.8%
    86.3
    46.9%
    87.1
    14.6%
    3. Secondary Outcome
    Title Probability of Overall Survival
    Description To estimate the overall survival of children with ALL who are treated with risk-directed therapy and to compare the EFS results of TOTXVI with that of TOTXV.
    Time Frame For Total XVI: 3.5 years after the last enrollment, up to approximately 13.5 years For Total XV: patients are followed continuously, up to 20.5 years

    Outcome Measure Data

    Analysis Population Description
    All eligible patients entered on TOTXVI will be included in these analyses, as appropriate. Infants will be excluded from the Total XVI for comparisons with TOTXV as only children at least one year of age at diagnosis were treated on Total XV.
    Arm/Group Title TOTXVI PEG 3500 TOTXVI PEG 2500 TOTVI Not Randomized All Eligible Patients in TOTXV
    Arm/Group Description Patients randomized on the first day of continuation phase to receive 3500 units/m^2 dose of PEG-asparaginase Patients randomized on the first day of continuation phase to receive 2,500 units/m^2 dose of PEG-asparaginase Patients who came off study prior to randomization All eligible children with ALL who are treated with risk-directed therapy.
    Measure Participants 201 205 180 498
    Number (95% Confidence Interval) [Percentage of participants]
    97.5
    47.3%
    95.6
    46%
    90.8
    49.3%
    93.5
    15.6%
    4. Secondary Outcome
    Title Proportion of Participants With Minimal Residual Disease (MRD) on the 15th Day of Remission Induction ≥ 5%
    Description To study whether intensifying induction, including fractionated cyclophosphamide and thioguanine, in patients with day 15 MRD ≥ 5% will result in improved leukemia cytoreduction in this subgroup compared to therapy followed in the TOTXV protocol.
    Time Frame Middle of remission induction, Day 15 in Total XVI and Day 19 in Total XV

    Outcome Measure Data

    Analysis Population Description
    The analysis will compare the proportion of TOTXV patients who had Day-19 MRD≥5% with the proportion of patients on TOTXVI with Day-15 MRD≥5%.
    Arm/Group Title TOTXVI PEG 3500 TOTXVI PEG 2500 TOTXVI Not Randomized All Eligible Patients in TOTXV
    Arm/Group Description Patients randomized on the first day of continuation phase to receive 3500 units/m^2 dose of PEG-asparaginase Patients randomized on the first day of continuation phase to receive 2,500 units/m^2 dose of PEG-asparaginase Patients who came off study prior to randomization Eligible Patients in TOTXV
    Measure Participants 203 206 183 488
    Count of Participants [Participants]
    22
    10.7%
    26
    12.5%
    31
    16.8%
    55
    9.2%
    5. Secondary Outcome
    Title Proportion of Participants With Minimal Residual Disease (MRD) at End of Remission Induction ≥ 0.01%
    Description To study whether intensifying induction, including fractionated cyclophosphamide and thioguanine, in patients with day 15 MRD ≥ 5% will result in improved leukemia cytoreduction in this subgroup compared to therapy followed in the TOTXV protocol.
    Time Frame End of remission induction; day 42 in Total XVI and day 46 in Total XV

    Outcome Measure Data

    Analysis Population Description
    We will compare the proportion of patients with Day-15 MRD≥5% on TOTXVI who are Day-42 MRD positive with the proportion of Day-46 MRD positives in the corresponding subgroup in TOTXV by Fisher's exact test.
    Arm/Group Title TOTXVI PEG 3500 TOTXVI PEG 2500 TOTXVI Not Randomized All Eligible Patients in TOTXV
    Arm/Group Description Patients randomized on the first day of continuation phase to receive 3500 units/m^2 dose of PEG-asparaginase Patients randomized on the first day of continuation phase to receive 2,500 units/m^2 dose of PEG-asparaginase Patients who came off study prior to randomization Day 15 MRD > or equal to 5% in Total XV
    Measure Participants 22 26 30 54
    Count of Participants [Participants]
    7
    3.4%
    12
    5.8%
    20
    10.9%
    44
    7.4%
    6. Secondary Outcome
    Title Probability of CNS Relapse
    Description To assess whether intensification of CNS-directed intrathecal and systemic chemotherapy will improve outcome in patients at high-risk of CNS relapse.
    Time Frame For Total XVI: 3.5 years after the last enrollment, up to approximately 13.5 years For Total XV: patients are followed continuously, up to 20.5 years

    Outcome Measure Data

    Analysis Population Description
    Patients with features associated with increased risk for CNS relapse in Total XVI and Total XV.
    Arm/Group Title TOTXVI PEG 3500 TOTXVI PEG 2500 TOTXVI Not Randomized All Eligible Patients in TOTXV
    Arm/Group Description Patients randomized on the first day of continuation phase to receive 3500 units/m^2 dose of PEG-asparaginase Patients randomized on the first day of continuation phase to receive 2,500 units/m^2 dose of PEG-asparaginase Patients who came off study prior to randomization Patients with features associated with increased risk for CNS relapse in Total XV
    Measure Participants 121 125 113 248
    Number (95% Confidence Interval) [Percentage of participants]
    0.8
    0.4%
    1.8
    0.9%
    2.7
    1.5%
    5.7
    1%

    Adverse Events

    Time Frame Through 1 month after therapy completion, approximately 25 months
    Adverse Event Reporting Description Systemic assessment was used for collection of adverse events including: Real time reporting of significant events by treating team Regular communication with families and close monitoring of medical records, laboratory results, and imaging by dedicated research nurse (daily for inpatient setting and weekly for outpatient setting) Biweekly review of AEs by PI and treating team for accuracy and completion
    Arm/Group Title PEG 3500 Units/m^2 PEG 2500 Units/m^2 Not Randomized
    Arm/Group Description Patients randomized on the first day of continuation phase to receive 3500 units/m^2 dose of PEG-asparaginase Patients randomized on the first day of continuation phase to receive 2,500 units/m^2 dose of PEG-asparaginase Patients who came off study prior to randomization
    All Cause Mortality
    PEG 3500 Units/m^2 PEG 2500 Units/m^2 Not Randomized
    Affected / at Risk (%) # Events Affected / at Risk (%) # Events Affected / at Risk (%) # Events
    Total 9/206 (4.4%) 15/208 (7.2%) 22/184 (12%)
    Serious Adverse Events
    PEG 3500 Units/m^2 PEG 2500 Units/m^2 Not Randomized
    Affected / at Risk (%) # Events Affected / at Risk (%) # Events Affected / at Risk (%) # Events
    Total 0/206 (0%) 0/208 (0%) 2/184 (1.1%)
    Infections and infestations
    Infection, Blood 0/206 (0%) 0 0/208 (0%) 0 1/184 (0.5%) 1
    Vascular disorders
    Thrombosis/thrombus/embolism 0/206 (0%) 0 0/208 (0%) 0 1/184 (0.5%) 1
    Other (Not Including Serious) Adverse Events
    PEG 3500 Units/m^2 PEG 2500 Units/m^2 Not Randomized
    Affected / at Risk (%) # Events Affected / at Risk (%) # Events Affected / at Risk (%) # Events
    Total 206/206 (100%) 208/208 (100%) 184/184 (100%)
    Blood and lymphatic system disorders
    Febrile neutropenia 163/206 (79.1%) 392 160/208 (76.9%) 404 124/184 (67.4%) 239
    Gastrointestinal disorders
    Diarrhea 17/206 (8.3%) 19 12/208 (5.8%) 13 11/184 (6%) 12
    Mucositis/stomatitis (functional/symptomatic), Oral cavity 47/206 (22.8%) 64 63/208 (30.3%) 78 36/184 (19.6%) 46
    Typhlitis (cecal inflammation) 19/206 (9.2%) 25 25/208 (12%) 37 19/184 (10.3%) 21
    Vomiting 16/206 (7.8%) 17 16/208 (7.7%) 18 17/184 (9.2%) 18
    Pancreatitis 13/206 (6.3%) 17 19/208 (9.1%) 24 28/184 (15.2%) 44
    Pain, Abdomen NOS 43/206 (20.9%) 53 32/208 (15.4%) 40 22/184 (12%) 28
    General disorders
    Fever (in the absence of neutropenia, where neutropenia is defined as ANC <1.0 x 10e9/L) 156/206 (75.7%) 395 147/208 (70.7%) 381 116/184 (63%) 283
    Infections and infestations
    Colitis, infectious (e.g., Clostridium difficile) 83/206 (40.3%) 168 61/208 (29.3%) 103 55/184 (29.9%) 113
    Infection, Blood 38/206 (18.4%) 49 48/208 (23.1%) 66 45/184 (24.5%) 51
    Infection, Catheter-related 14/206 (6.8%) 16 17/208 (8.2%) 22 8/184 (4.3%) 8
    Infection, Lip/perioral 9/206 (4.4%) 13 17/208 (8.2%) 23 8/184 (4.3%) 10
    Infection, Lung (pneumonia) 37/206 (18%) 42 47/208 (22.6%) 63 22/184 (12%) 28
    Infection, Middle ear (otitis media) 30/206 (14.6%) 36 38/208 (18.3%) 48 22/184 (12%) 28
    Infection, Oral cavity-gums (gingivitis) 32/206 (15.5%) 41 35/208 (16.8%) 55 27/184 (14.7%) 36
    Infection, Rectum 7/206 (3.4%) 7 15/208 (7.2%) 15 11/184 (6%) 11
    Infection, Sinus 21/206 (10.2%) 25 23/208 (11.1%) 25 6/184 (3.3%) 8
    Infection, Skin (cellulitis) 42/206 (20.4%) 52 41/208 (19.7%) 47 39/184 (21.2%) 49
    Infection, Upper airway NOS 92/206 (44.7%) 129 110/208 (52.9%) 186 85/184 (46.2%) 143
    Infection, Urinary tract NOS 11/206 (5.3%) 15 14/208 (6.7%) 22 7/184 (3.8%) 8
    Infection with normal ANC or Grade 1 or 2 neutrophils, Blood 23/206 (11.2%) 33 26/208 (12.5%) 27 20/184 (10.9%) 25
    Infection with normal ANC or Grade 1 or 2 neutrophils, Catheter-related 16/206 (7.8%) 18 8/208 (3.8%) 8 8/184 (4.3%) 8
    Infection with normal ANC or Grade 1 or 2 neutrophils, Conjunctiva 20/206 (9.7%) 22 18/208 (8.7%) 23 15/184 (8.2%) 16
    Infection with normal ANC or Grade 1 or 2 neutrophils, External ear (otitis externa) 11/206 (5.3%) 13 13/208 (6.3%) 15 7/184 (3.8%) 8
    Infection with normal ANC or Grade 1 or 2 neutrophils, Lip/perioral 35/206 (17%) 74 28/208 (13.5%) 56 14/184 (7.6%) 32
    Infection with normal ANC or Grade 1 or 2 neutrophils, Lung (pneumonia) 49/206 (23.8%) 57 46/208 (22.1%) 50 30/184 (16.3%) 38
    Infection with normal ANC or Grade 1 or 2 neutrophils, Middle ear (otitis media) 84/206 (40.8%) 197 80/208 (38.5%) 146 56/184 (30.4%) 117
    Infection with normal ANC or Grade 1 or 2 neutrophils, Oral cavity-gums (gingivitis) 50/206 (24.3%) 82 48/208 (23.1%) 92 47/184 (25.5%) 96
    Infection with normal ANC or Grade 1 or 2 neutrophils, Sinus 66/206 (32%) 136 51/208 (24.5%) 78 29/184 (15.8%) 46
    Infection with normal ANC or Grade 1 or 2 neutrophils, Skin (cellulitis) 91/206 (44.2%) 167 80/208 (38.5%) 127 70/184 (38%) 116
    Infection with normal ANC or Grade 1 or 2 neutrophils, Ungual (nails) 19/206 (9.2%) 28 6/208 (2.9%) 6 9/184 (4.9%) 12
    Infection with normal ANC or Grade 1 or 2 neutrophils, Upper airway NOS 133/206 (64.6%) 306 136/208 (65.4%) 301 105/184 (57.1%) 262
    Infection with normal ANC or Grade 1 or 2 neutrophils, Urinary tract NOS 25/206 (12.1%) 34 23/208 (11.1%) 33 16/184 (8.7%) 32
    Infection with normal ANC or Grade 1 or 2 neutrophils, Vagina 11/206 (5.3%) 21 13/208 (6.3%) 15 8/184 (4.3%) 15
    Injury, poisoning and procedural complications
    Allergic reaction to Asparaginase 28/206 (13.6%) 36 30/208 (14.4%) 35 18/184 (9.8%) 20
    Fracture 19/206 (9.2%) 24 25/208 (12%) 29 21/184 (11.4%) 23
    Thrombosis/embolism (vascular access-related) 8/206 (3.9%) 9 12/208 (5.8%) 12 12/184 (6.5%) 12
    Investigations
    ALT, SGPT (serum glutamic pyruvic transaminase) 32/206 (15.5%) 39 30/208 (14.4%) 47 29/184 (15.8%) 41
    AST, SGOT(serum glutamic oxaloacetic transaminase) 22/206 (10.7%) 25 25/208 (12%) 34 21/184 (11.4%) 23
    Bilirubin (hyperbilirubinemia) 11/206 (5.3%) 12 14/208 (6.7%) 17 19/184 (10.3%) 24
    Metabolism and nutrition disorders
    Dehydration 19/206 (9.2%) 22 10/208 (4.8%) 11 13/184 (7.1%) 14
    Glucose, serum-high (hyperglycemia) 22/206 (10.7%) 35 23/208 (11.1%) 30 25/184 (13.6%) 38
    Potassium, serum-low (hypokalemia) 19/206 (9.2%) 22 22/208 (10.6%) 30 13/184 (7.1%) 13
    Triglyceride, serum-high (hypertriglyceridemia) 19/206 (9.2%) 23 18/208 (8.7%) 19 17/184 (9.2%) 18
    Tumor lysis syndrome 25/206 (12.1%) 25 36/208 (17.3%) 36 24/184 (13%) 24
    Musculoskeletal and connective tissue disorders
    Osteonecrosis (avascular necrosis) 85/206 (41.3%) 188 79/208 (38%) 189 57/184 (31%) 152
    Pain, Back 22/206 (10.7%) 26 14/208 (6.7%) 19 12/184 (6.5%) 12
    Pain, Extremity-limb 11/206 (5.3%) 11 17/208 (8.2%) 18 4/184 (2.2%) 4
    Nervous system disorders
    Neuropathy: motor 53/206 (25.7%) 53 54/208 (26%) 57 56/184 (30.4%) 58
    Seizure 14/206 (6.8%) 14 9/208 (4.3%) 10 12/184 (6.5%) 13
    Pain, Head/headache 22/206 (10.7%) 27 20/208 (9.6%) 24 18/184 (9.8%) 19
    Pain, Neuralgia/peripheral nerve 155/206 (75.2%) 221 160/208 (76.9%) 218 128/184 (69.6%) 157
    Respiratory, thoracic and mediastinal disorders
    Hypoxia 36/206 (17.5%) 45 38/208 (18.3%) 53 36/184 (19.6%) 42
    Pleural effusion (non-malignant) 11/206 (5.3%) 12 10/208 (4.8%) 10 9/184 (4.9%) 9
    Vascular disorders
    Hypertension 50/206 (24.3%) 58 47/208 (22.6%) 56 58/184 (31.5%) 66
    Hypotension 16/206 (7.8%) 17 19/208 (9.1%) 23 10/184 (5.4%) 13

    Limitations/Caveats

    [Not Specified]

    More Information

    Certain Agreements

    All Principal Investigators ARE employed by the organization sponsoring the study.

    There is NOT an agreement between Principal Investigators and the Sponsor (or its agents) that restricts the PI's rights to discuss or publish trial results after the trial is completed.

    Results Point of Contact

    Name/Title Sima Jeha, MD
    Organization St. Jude Children's Research Hospital
    Phone (901) 595-3901
    Email sima.jeha@stjude.org
    Responsible Party:
    St. Jude Children's Research Hospital
    ClinicalTrials.gov Identifier:
    NCT00549848
    Other Study ID Numbers:
    • TOTXVI
    • R01CA140729
    • F32CA141762
    • R37CA036401
    • R01CA090246
    • Aspar PK-PD-T16
    • NCI-2011-01254
    • P50GM115279
    First Posted:
    Oct 26, 2007
    Last Update Posted:
    Aug 23, 2022
    Last Verified:
    Jul 1, 2022