| Induction |
Hyper-CVAD (laminar air flow rooms if ≥ 60 yrs) |
Y (Y) |
Y (Y) |
Y (N) |
| Consolidation |
|
|
|
|
| Cycle 2 (intensification) |
Liposomal daunorubicin 150 mg/m2 IV days 1–2 |
N |
Y |
N |
| Cytarabine 1.5 g/m2 CI IV days 1–2 |
| Prednisone 200 mg days 1–5 |
| Cycles 2, 4, 6, 8 or Cycles 3, 5, 7, 9 |
Methotrexate 200 mg/m2, then 800 mg/m2 IV day 1 |
Y |
Y |
Y |
| Cytarabine 3 g/m2 IV q12h × 3 days 2–3 |
| Solu-Medrol 50 mg IV q12h × 6 days 1–3 |
| Cycles 1, 3, 5, 7 or Cycles 1, 4, 6, 8 |
Cyclophosphamide 300 mg/m2 IV q12h × 6 days 1–3 |
Y |
Y |
Y |
| Dexamethasone 40 mg days 1–4, 11–14 |
| Doxorubicin 50 mg/m2 CI IV day 4 |
| Vincristine 2 mg IV days 1, 11 |
|
IF CD20 ≥ 20%: 8 doses rituximab 375 mg/m2
|
|
|
|
| Cycles 1–4 |
|
|
|
|
|
Rituximab days 1, 11 (hyper-CVAD) |
Y |
Y |
N |
|
Rituximab days 1, 8 (LDNR- or MTX-cytarabine) |
| CNS prophylaxis (No. intrathecals) |
Risk adapted (LDH > 1400, S + G2M ≥ 14%) |
|
|
|
| High |
8 |
16 |
| Indeterminate |
8 |
8 |
| Low |
6 |
4 |
| Maintenance |
|
|
|
|
POMP (6-mercaptopurine, VCR, methotrexate, prednisone) |
Months 1–5, 8–17, 20–30 |
Months 1–6, 8–10, 12–24 |
| Intensification |
Hyper-CVAD |
Months 6, 18 |
N |
| Rituximab 375 mg/m2 days 1, 11 if CD20 ≥ 20% |
| Intensification |
Methotrexate 100 mg/m2 IV day 1 weekly × 4 |
Months 7, 19 |
Months 7, 11 |
| L-asparaginase 20,000 units IV day 2 weekly × 4 |
