Dose‑adjusted EPOCH chemotherapy with or without rituximab plus ponatinib for newly diagnosed Philadelphia chromosome–positive B‑cell ALL/lymphoblastic lymphoma

Phase II Study of Dose-Adjusted EPOCH ± Rituximab + Ponatinib for Adults With Newly-Diagnosed Philadelphia Chromosome Positive Acute Lymphoblastic Leukemia/Lymphoma

This treatment plan tests whether adding the BCR‑ABL inhibitor ponatinib to dose‑adjusted EPOCH chemotherapy, with rituximab for CD20‑positive disease, helps adults newly diagnosed with Philadelphia chromosome–positive B‑cell acute lymphoblastic leukemia or lymphoblastic lymphoma.

Quick facts

• Phase: PHASE2
• Study type: Interventional
• Enrollment: 33 (estimated)
• Ages: 18 Years and up
• Sex: All
• Sponsor: University of Washington (other)
• Drugs / interventions: rituximab, ponatinib, chemotherapy, cyclophosphamide, doxorubicin, prednisone
• Locations: 1 site (Seattle, Washington)
• Trial ID: NCT07224100 on ClinicalTrials.gov

What this trial studies

Patients receive dose‑adjusted EPOCH chemotherapy (etoposide, doxorubicin, vincristine over 96 hours on days 1–4, cyclophosphamide on day 5, and prednisone days 1–5) combined with daily oral ponatinib on days 1–21 of each 21‑day cycle, with filgrastim or pegfilgrastim for neutrophil support. CD20‑positive patients also receive rituximab on day 1 or 5 of each cycle. Treatment repeats for up to eight cycles in the absence of progression or unacceptable toxicity, with serial blood, bone marrow, and imaging assessments for response and safety. After treatment, patients are followed every three months for two years and then every six months for up to three additional years.

Who should consider this trial

Good fit: Adults aged 18 or older with newly diagnosed Philadelphia chromosome–positive B‑cell acute lymphoblastic leukemia or lymphoblastic lymphoma with measurable marrow or blood disease and acceptable organ function are the ideal candidates.

Not a fit: Patients who do not have Ph+ disease, who have significant organ dysfunction or uncontrolled cardiovascular disease, or who have already received prior definitive therapy for ALL are unlikely to benefit from this protocol.

Why it matters

Potential benefit: If successful, this regimen could increase deep molecular remissions and reduce relapse risk, potentially improving long‑term outcomes for adults with Ph+ B‑ALL/lymphoblastic lymphoma.

How similar studies have performed: Prior trials combining BCR‑ABL tyrosine kinase inhibitors with intensive chemotherapy have improved remission rates in Ph+ ALL, and ponatinib‑containing regimens have shown promising molecular remission rates in smaller series.

Eligibility criteria

Inclusion Criteria:

* Adults (age 18 years and older) with newly-diagnosed Ph+ B-ALL. Ph status will be determined by routine cytogenetics, fluorescence in situ hybridization (FISH), and/or reverse transcriptase-polymerase chain reaction (RT-PCR) for the BCR::ABL1 translocation
* Marrow or blood involvement by abnormal lymphoblasts detectable by multiparameter flow cytometry (MFC)
* Total bilirubin (TBili) ≤ 1.5 x upper limit of normal (ULN) (unless attributed to Gilbert's disease or other causes of inherited indirect hyperbilirubinemia, at which point TBili must be ≤ 4 x ULN)

  * (Note: Patients with liver test abnormalities attributable to hepatic involvement by ALL will be permitted if the TBili is ≤ 5 x ULN)
* Aspartate aminotransferase (AST)(serum glutamic oxaloacetic transaminase \[SGOT\])/alanine aminotransferase (ALT)(serum glutamic pyruvic transaminase \[SGPT\]) ≤ 2.5 x institutional ULN

  * (Note: Patients with liver test abnormalities attributable to hepatic involvement by ALL will be permitted if the ALT/AST are ≤ 8 x ULN)
* Calculated creatinine clearance of \> 30 ml/min/1.73m\^2, as measured by the Modification of Diet in Renal Disease (MDRD) equation, will be eligible
* As patients with ALL frequently have cytopenias, no hematologic parameters will be required for enrollment or to receive the first cycle of treatment. However, adequate recovery of blood counts will be required to receive subsequent cycles
* Eastern Cooperative Oncology Group (ECOG) performance status 0 to 2. (Performance status of 3 will be allowed if poor performance status is thought to be directly secondary to ALL)
* Ability to give informed consent and comply with the protocol
* Anticipated survival of at least 3 months, independent of ALL
* Female subjects of reproductive potential must agree to use an effective method of birth control from the time of signing the consent form until one of the following:

  * For subjects not expected to receive rituximab (i.e., CD20-negative): at least 3 weeks after the last dose of ponatinib, or
  * For subjects expected to receive rituximab (i.e., CD20-positive): at least 12 months after the last dose of rituximab
  * A subject does not have reproductive potential if they are (1) surgically sterilized, or (2) postmenopausal (i.e., a female who is \> 50 years old or who has not had menses for ≥ 1 year), or (3) not heterosexually active
* Male subjects must agree to use an effective method of birth control and to not donate sperm from the time of signing the consent form until at least 3 weeks after the last dose of ponatinib

Exclusion Criteria:

* Burkitt lymphoma/leukemia
* No prior systemic therapy for ALL except to control acute symptoms and/or hyperleukocytosis (e.g., corticosteroids, cytarabine, etc.)
* No isolated extramedullary or known parenchymal central nervous system (CNS) disease
* History of acute pancreatitis within 1 year of enrollment or known chronic pancreatitis
* Symptomatic atherosclerotic cardiovascular disease (e.g., myocardial infarction, cerebrovascular accident, peripheral arterial disease, etc.) within 1 year of enrollment
* Active resistant hypertension, defined as having an ambulatory blood pressure above goal despite use of 3 antihypertensive medications from different classes
* Venous thromboembolic event (e.g., deep venous thrombosis, pulmonary embolism) within 6 months of enrollment
* Known hypersensitivity or intolerance to any of the agents under investigation
* Other medical or psychiatric conditions that in the opinion of the investigator would preclude safe participation in the protocol
* May not be pregnant or nursing. Pregnancy test is only required in females, unless they do not have reproductive potential. For subjects not expected to receive rituximab (i.e., CD20-negative), nursing can occur 1 week after the last dose of ponatinib. For subjects expected to receive rituximab (i.e., CD20-positive), nursing can occur 6 months after the last dose of rituximab

Where this trial is running

Seattle, Washington

• Fred Hutch/University of Washington Cancer Consortium — Seattle, Washington, United States (RECRUITING)

Study contacts

• Principal investigator: Ryan Cassaday, MD — Fred Hutch/University of Washington Cancer Consortium
• Study coordinator: Ryan Cassaday, MD

Conditions: B Acute Lymphoblastic Leukemia With t(9, 22)(q34.1, q11.2), BCR-ABL1, B Lymphoblastic Leukemia/Lymphoma With t(9, Lymphoblastic Lymphoma