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2005 105: 948-958

Prepublished online October 14, 2004;
doi:10.1182/blood-2004-03-0973

The impact of the methotrexate administration schedule and dose in the

treatment of children and adolescents with B-cell neoplasms: a report of
the BFM Group Study NHL-BFM95
Wilhelm Woessmann, Kathrin Seidemann, Georg Mann, Martin Zimmermann, Birgit Burkhardt, Ilske
Oschlies, Wolf-Dieter Ludwig, Thomas Klingebiel, Norbert Graf, Bernd Gruhn, Heribert Juergens,
Felix Niggli, Reza Parwaresch, Helmut Gadner, Hansjoerg Riehm, Martin Schrappe and Alfred Reiter

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CLINICAL OBSERVATIONS, INTERVENTIONS, AND THERAPEUTIC TRIALS

The impact of the methotrexate administration schedule and dose in the treatment
of children and adolescents with B-cell neoplasms: a report of the BFM Group
Study NHL-BFM95
Wilhelm Woessmann, Kathrin Seidemann, Georg Mann, Martin Zimmermann, Birgit Burkhardt, Ilske Oschlies, Wolf-Dieter Ludwig,
Thomas Klingebiel, Norbert Graf, Bernd Gruhn, Heribert Juergens, Felix Niggli, Reza Parwaresch, Helmut Gadner, Hansjoerg Riehm,
Martin Schrappe, and Alfred Reiter, for the BFM Group

In the Non-Hodgkin Lymphoma–Berlin-
Frankfurt-Münster 95 (NHL-BFM95)
study, we tested by randomization
whether for patients with B-cell neo-
plasms methotrexate as intravenous in-
fusion over 4 hours (MTX-4h) is not infe-
rior to, but less toxic than, a 24-hour
intravenous infusion (MTX-24h). Second,
we investigated against the historical
control of study NHL-BFM90, whether for
patients with moderate tumor mass MTX
can be reduced from 5 g/m2 to 1 g/m2.
Patients received 2 5-day therapy
courses in risk group R1 (resected), 4 in
R2 (lactate dehydrogenase [LDH] < 500
U/L), 5 in R3 (LDH > 500 to < 1000 U/L)
and 6 in R4 (LDH > 1000 U/L and/or
central nervous system [CNS] disease).
Courses contained MTX 1 g/m2 in R1 ⴙ
R2 and 5 g/m2 in R3 ⴙ R4. Of 505 patients
(April 1996 to March 2001), 364 were ran-
domized to receive MTX-4h or MTX-24h.
Failure-free survival (pFFS, 1 year) for
arm MTX-4h versus MTX-24h, respec-
tively, was 95% ⴞ 5% (n ⴝ 20) versus
100% (n ⴝ 19) in R1, 94% ⴞ 2% (n ⴝ 88)
versus 96% ⴞ 2% (n ⴝ 95) in R2, and
77% ⴞ 5% (n ⴝ 62) versus 93% ⴞ 3%
(n ⴝ 69) in R3 ⴞ R4 (per-protocol anal-
ysis). Incidence of mucositis grade III/IV
was significantly lower with MTX-4h in all
risk groups. For patients in R2, event-free
survival (pEFS) was 95% ⴞ 2% (n ⴝ 222)
in NHL-BFM95 (MTX 1 g/m 2 ) and
97% ⴞ 1% (n ⴝ 154) in NHL-BFM90 (MTX
5 g/m2). In conclusion, MTX-4h was less
toxic than MTX-24h. MTX-4h was nonin-
ferior to MTX-24h for limited stage B-cell
non-Hodgkin lymphoma (B-NHL) but not
for advanced disease. For limited
disease, MTX 1 g/m2 is noninferior to 5
g/m2. (Blood. 2005;105:948-958)
© 2005 by The American Society of Hematology

Introduction
Favorable results were reported from previous studies on childhood
and adolescent B-cell non-Hodgkin lymphoma (B-NHL) and acute
B-cell leukemia (B-AL) with 2 to 8 short intensive therapy courses
depending on stage and tumor mass.1-8 The toxicity of these
protocols was considerable, however. Therefore, the Non-Hodgkin
Lymphoma–Berlin-Frankfurt-Münster 95 (NHL-BFM95) study
aimed at reducing treatment-related toxicity without jeopardizing
treatment outcome. In our previous trials, increasing the dose of
methotrexate (MTX) from 0.5 g/m2 to 5 g/m2 (administered over 24
hours) resulted in significant improvement of the probability of
event-free survival (pEFS) for patients with B-AL as well as for
patients with B-NHL stage III with higher tumor load.4,9 However,
high-dose MTX particularly contributed to the toxicity of the
treatment, namely orointestinal mucositis, which may increase the
risk of sepsis and toxic death.4
High-dose MTX combined with racemic tetrahydrofolic acid
(leucovorin) is a key component of the majority of treatment
regimens currently used for childhood and adolescent B-cell
neoplasms.1-6,8 However, dose and administration schedule of
MTX varies considerably between therapy protocols. Dosages of
MTX range from 0.5 g/m2 to 8.0 g/m2; duration of continuous
intravenous infusion of MTX ranges from 1 hour to 24 hours,
resulting in very different pharmacokinetic profiles. Furthermore,
time of application of the first dose of leucovorin varies between 24
hours6 and 42 hours4 after the start of MTX infusion, which
introduces potentially significant differences regarding the duration
of MTX exposure of healthy and malignant cells.
All mentioned parameters—dosage, administration schedule,
drug exposure time—may influence efficacy and toxicity of MTX
therapy.10-14 Controlled clinical trials investigating the impact of
these parameters on treatment efficacy and toxicity are still lacking.
Therefore, in order to optimize the MTX therapy in the treatment of
children and adolescents with B-cell neoplasms, we investigated 2
questions in study NHL-BFM95. First, we tested in a randomized

From the Department of Pediatric Hematology and Oncology, Justus-Liebig-
University, Giessen, Germany; the Department of Pediatric Hematology and On-
cology, Medizinische Hochschule, Hannover, Germany; St Anna Kinderspital, Vienna,
Austria; the Institute of Hematopathology and Lymph Node Registry, University
Hospital Schleswig-Holstein, Christian-Albrechts-University, Kiel, Germany; the De-
partment of Hematology, Oncology, and Tumor Immunology, HELIOS Clinic Berlin-
Buch, Charité, Campus Berlin-Buch, Berlin, Germany; the Department of Pediatric
Hematology and Oncology, Johann-Wolfgang-Goethe University, Frankfurt,
Germany; the Department of Pediatric Hematology and Oncology, University of
Saarland, Homburg, Germany; the Department of Pediatrics, Friedrich Schiller Uni-
versity, Jena, Germany; the Department of Pediatric Hematology and Oncology,
Westfaelische Wilhelms-University, Muenster, Germany; and the Department of Pe-
diatrics, University of Zurich, Zurich, Switzerland.
First Edition Paper, October 14, 2004; DOI 10.1182/blood-2004-03-0973.
Supported by the Deutsche Krebshilfe, Bonn, grant no. M 109/91/Re1.
Complete lists of the principal investigators and pathologists of the BFM Group
appear in “Appendix 3” and “Appendix 4,” respectively.
Reprints: Alfred Reiter, NHL-BFM Study Center, Department of Pediatric
Hematology and Oncology, Justus-Liebig-University, D-35385 Giessen,
Germany; e-mail: alfred.reiter@paediat.med.uni-giessen.de.
The publication costs of this article were defrayed in part by page charge
payment. Therefore, and solely to indicate this fact, this article is hereby
marked ‘‘advertisement’’ in accordance with 18 U.S.C. section 1734.

Submitted March 16, 2004; accepted August 6, 2004. Prepublished online as Blood © 2005 by The American Society of Hematology

948 BLOOD, 1 FEBRUARY 2005 䡠 VOLUME 105, NUMBER 3

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BLOOD, 1 FEBRUARY 2005 䡠 VOLUME 105, NUMBER 3 MTX DOSE AND SCHEDULE IN TREATMENT OF B-NHL/B-AL 949

trial whether the incidence of severe orointestinal mucositis can be

Figure 1. Treatment strategy. Patients were stratified into 4 risk groups: R1, R2, R3,
and R4. The composition of therapy courses is given in Table 1. V indicates
cytoreductive prephase.
reduced by shortening the duration of intravenous infusion of
high-dose MTX from 24 hours to 4 hours without impairment of
the probability of failure-free survival. Second, we tested whether
for patients with unresected B-NHL of moderate tumor mass
(lactate dehydrogenase [LDH] ⬍ 500 U/L), representing approxi-
mately 45% of B-NHL patients, the dose of MTX can be reduced to
1 g/m2 without lowering the probability of EFS of 95% or higher
that the patients achieved in our previous study NHL-BFM90, with
therapy courses including MTX 5 g/m2.4

Table 1. Therapy courses

Day
Drug Dose 1 2 3 4 5

Prephase V
Dexamethasone orally/IV mg/m2¶ 5 5 10 10 10
Cyclophosphamide IV 1 h 200 mg/m2 x x
Methotrexate* IT 12 mg x
Cytarabine* IT 30 mg x
Prednisolone* IT 10 mg x
Course A
Dexamethasone orally/IV 10 mg/m2¶ x x x x x
Vincristine IV 1.5 mg/m2㛳 x
Ifosfamide IV 1 h 800 mg/m2 x x x x x
Cytarabine IV 1 h 150 mg/m2 x ⫺ x** x ⫺ x**
Etoposide IV 1 h 100 mg/m2 x x
Methotrexate IV† 1 g/m2 x
Methotrexate* IT 12 mg x
Cytarabine* IT 30 mg x
Prednisolone* IT 10 mg x
Course B
Dexamethasone orally/IV 10 mg/m2¶ x x x x x
Vincristine IV 1.5 mg/m2㛳 x
Cyclophosphamide IV 1 h 200 mg/m2 x x x x x
Doxorubicin IV 1 h 25 mg/m2 x x
Methotrexate IV† 1 g/m2 x
Methotrexate* IT 12 mg x
Cytarabine* IT 30 mg x
Prednisolone* IT 10 mg x
Courses AA‡§ and BB‡§
Methotrexate IV† 5 g/m2 x
Methotrexate* IT 6 mg x x
Cytarabine* IT 15 mg x x
Prednisolone* IT 5 mg x x
Course CC‡
Dexamethasone orally/IV 20 mg/m2¶ x x x x x
Vindesine IV 3 mg/m2†† x
Cytarabine IV 3 h 3 g/m2 x ⫺ x** x ⫺ x**
Etoposide IV 2 h 100 mg/m2 x ⫺ x** x ⫺ x** x**
Methotrexate* IT 12 mg x
Cytarabine* IT 30 mg x
Prednisolone* IT 10 mg x

IV indicates intravenously; h, hour; IT, intrathecally.

*Doses were adjusted for children younger than 3 years. In courses A, B, AA, and BB, intrathecal therapy was administered 24 hours after beginning of MTX intravenous
infusion.
†Patients were randomized to receive MTX as continuous intravenous infusion either over 24 hours or over 4 hours. In the 24-hour arm, 10% of the MTX dose was given
within 0.5 hours, 90% of dose intravenously over 23.5 hours. Racemic folinic acid (leucovorin) intravenously 15 mg/m2 at hours 42, 48, and 54 after beginning of MTX. In
courses AA and BB, the dose of leucovorin at hour 42 was 30 mg/m2 intravenously. Adjustment of leucovorin dose in case of impaired MTX excretion as previously described.4
‡For CNS-positive patients, chemotherapy was applied intraventricularly as described in “Chemotherapy.”
§Courses AA and BB are the same as A and B, respectively, with the exceptions listed.
¶Subdivided in 3 doses.
㛳Maximum dose was 2 mg; vincristine was not given in patients of branch R1.
**Doses are 12 hours apart.
††Maximum dose was 5 mg.
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950 WOESSMANN et al BLOOD, 1 FEBRUARY 2005 䡠 VOLUME 105, NUMBER 3

Table 2. Diagnosis, treatment results

Site of tumor failure (any involvement*)
Patients suffering
Diagnosis No. of patients (%) pEFS, 3 y, % from tumor failure Local BM CNS Testes New site

Burkitt lymphoma 283 (56) 93 ⫾ 2 14 8 6 6 2 5

B-AL 79 (16) 77 ⫾ 5 12 2 9 4 0 2
Diffuse large B-cell lymphoma
Centroblastic 81 (16) 93 ⫾ 3 4 3 0 0 0 2
Immunoblastic 7 NA 1 1 0 0 0 1
T-cell rich B-cell lymphoma 9 NA 1 1 0 0 0 0
Primary mediastinal large B-cell lymphoma 15 (3) 53 ⫾ 13† 7 7 0 0 0 3
B-NHL, not further specified 31 (6) 100 0 0 0 0 0 0
All 505 (100) 89 ⫾ 1 39 22 15 10 2 13

*Note: multiple sites can be involved in one patient.

†P ⬍ .05 (log-rank test) for all comparisons.

Patients, materials, and methods
Patients
Children and adolescents up to 18 years of age newly diagnosed with
mature B-cell NHL or B-AL were eligible for trial NHL-BFM95. From
April 1996 to March 2001, 566 patients were registered from 84 clinics in
Austria, Germany, and Switzerland after informed consent according to the
Declaration of Helsinki. Approval of the study was obtained from the
ethical committee of the principal investigator (A.R.) and the participating
investigators. Due to the following criteria, 61 patients were excluded:
previous treatment (n ⫽ 4), no therapy (n ⫽ 3), NHL as a second malig-
nancy (n ⫽ 4), severe immunodeficiency (n ⫽ 14, 4 failures), preexisting
disease prohibiting protocol therapy (n ⫽ 1), AIDS-related NHL (n ⫽ 1, 1
failure), posttransplantation NHL (n ⫽ 11, 3 failures), treatment according
to a different protocol due to decision of 2 participating clinics (n ⫽ 21, one
failure), or erroneous diagnosis (n ⫽ 2). There were 505 patients eligible
for the trial.
Diagnosis
NHL subtypes originally diagnosed according to the updated Kiel classifi-
cation for non-Hodgkin lymphomas15 were reclassified on the basis of the
WHO Classification of Hematological Malignancies.16 In 466 of 505 cases,
the diagnosis was centrally reviewed by one of the reference laboratories.
Staging
The St Jude staging system was used.17 Staging included physical
examination, peripheral blood and bone marrow (BM) aspiration smears,
cerebrospinal fluid (CSF) analyses, ultrasonography, X-ray, computed
tomography (CT) and/or magnetic resonance imaging (MRI), and skeletal
scintigraphy. Initial central nervous system (CNS) disease was diagnosed if
one of the following was present: lymphoma cells in the CSF, cerebral
infiltrates on cranial CT or MRI, or cranial nerve palsy that was not caused
by an extradural mass. The total serum LDH activity was measured as a
parameter for the tumor mass.
Stratification of treatment intensity
Patients were stratified into 4 risk groups according to stage, resection
status, pretherapeutic serum LDH, and presence of CNS disease (Figure 1).
Chemotherapy
The treatment strategy is depicted in Figure 1. The composition of therapy
courses is given in Table 1. Patients in risk groups R2, R3, and R4 received
a 5-day cytoreductive prephase before the first course A (AA) was
administered. By November 15, 1997, an amendment was introduced. All
patients in R3 ⫹ R4 had to receive urate oxidase 3 ⫻ 50 U/kg per day
intravenously during the first days of cytoreductive chemotherapy.18-20
Conditions for starting the second and subsequent courses were as follows:
platelet levels higher than 50 ⫻ 109/L and neutrophil counts higher than
0.5 ⫻ 109/L after the nadir of postchemotherapeutic cytopenia. For patients
of risk groups R3 and R4, granulocyte colony-stimulating factor 5 ␮g/kg
per day subcutaneously was recommended after the first 2 therapy courses.
In CNS-positive patients, a device for intraventricular application of
chemotherapy was implanted before the second course. MTX 3 mg and
prednisolone 2.5 mg were administered intraventricularly on days 2, 3, 4,
and 5, and cytarabine 30 mg was given on day 6 of courses AA and BB. In
course CC, MTX 3 mg and prednisolone 2.5 mg were administered on days
3, 4, 5, and 6; cytarabine 30 mg was given on day 7.
For patients in risk groups R3 ⫹ R4 who had residual tumor after the
fifth course of therapy, a second-look operation was performed. If viable
lymphoma tissue was detected, megadose chemotherapy with autologous
stem cell rescue (autologous stem cell transplantation [ASCT]) was
performed as previously described.4 If no viable lymphoma tissue was
found, therapy was continued with the last course CC in risk group R4,
while patients in risk group R3 did not receive any further therapy. For
patients in risk group R2, no intervention was foreseen in case of a
persistent tumor remnant during or after therapy.
Randomization of MTX infusion schedule
Patients were randomized to receive MTX as continuous intravenous
infusion either over 24 hours (MTX-24h) or over 4 hours (MTX-4h). The
dose of MTX was 1 g/m2 in courses A and B, (risk groups R1 ⫹ R2) and
was 5 g/m2 in courses AA and BB (risk groups R3 ⫹ R4). Intrathecal
therapy was given at hour 24 after the beginning of the MTX infusion in
both randomized arms. The MTX serum concentration was measured at
hours 24, 42, and 48 from the start of the MTX infusion. In both randomized
arms, leucovorin 15 mg/m2 was given intravenously at hours 42, 48, and 54
after the beginning of MTX. In courses AA and BB, the dose of leucovorin
at hour 42 was 30 mg/m2 intravenously. In case of impaired MTX excretion,
intensified leucovorin rescue was carried out as previously described.4

Table 3. Risk groups and stages

Stage, no. patients (%)
Risk group No. patients (%) I II III IV CNSⴚ IV CNSⴙ B-AL CNSⴚ B-AL CNSⴙ

R1 48 (10) 18 30 0 0 0 0 0
R2 233 (46) 35 89 109 0 0 0 0
R3 82 (16) 0 0 65 8 0 9 0
R4 142 (28) 0 0 47 8 17 47 23
All 505 (100) 53 (10) 119 (24) 221 (44) 16 (3) 17 (3) 56 (11) 23 (5)
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BLOOD, 1 FEBRUARY 2005 䡠 VOLUME 105, NUMBER 3
Response criteria
The response to the treatment was evaluated after each course of therapy.
Follow-up studies were performed at 4- to 6-week intervals during the first
1.5 years. In patients with BM and/or CNS involvement, follow-up
punctures of BM and/or CSF were performed only until the BM or the CNS,
respectively, was cleared from blasts. Tumor failure was defined as a
recurrence of lymphoma proven by biopsy, or regrowth of an incompletely
resolved tumor, or persistence of BM blasts after the second course of
therapy. Isolated BM relapse was based on 25% or more blasts in the BM.
Isolated CNS relapse was based on the appearance of blasts in the CSF.
Study design and statistical analysis
Event-free survival (EFS) was calculated from the day of diagnosis to an
event (tumor failure, death for any reason, second malignancy) or to the
date of last follow-up contact. Failure-free survival (FFS) was calculated
from the day of diagnosis to treatment failure (tumor failure, death due to
therapy) or to the date of last follow-up contact, while patients who
experienced second malignancy were censored at the time of that event.
Analyses of EFS and FFS were performed using the Kaplan and Meier
method with differences compared by the log-rank test.21,22 The 95%
confidence interval (CI) for the Kaplan-Meier estimate of EFS and FFS was
calculated using standard errors according to Greenwood.23 In order to take
into account prognostic factors when comparing FFS of patient subgroups,
Cox regression analysis was used.24 The statistical analysis was carried out
using the SAS statistical program (SAS-PC, Version 6.12; SAS Institute,
Cary, NC). Follow-up data were updated as of June 1, 2003. Trial
NHL-BFM95 was supervised by an external data safety and monitoring
committee (DMC).
The first aim of study NHL-BFM95 was to test whether the incidence of
orointestinal mucositis grades III or IV can be reduced by shortening the
duration of intravenous infusion of high-dose MTX from 24 hours to 4
hours, without impairment of the probability of FFS (pFFS). Patients were
randomized to receive either MTX-24h or MTX-4h. Randomization was
stratified by risk group. For safety reasons, the first question to be answered
was: Is MTX-4h noninferior to MTX-24h? The end point of that analysis
was the one-sided 95% CI for the difference of a one-year pFFS between
the 2 arms. This test was planned as a per-protocol analysis; that is, only
randomized patients who received therapy according to their randomized
arm were analyzed.25 Analysis was performed separately for branch R1, R2,
and the combined branches R3 ⫹ R4. MTX-4h was accepted to be
noninferior to MTX-24h if the lower limit of the one-sided 95% CI for the
difference of pFFS between randomized patients treated with MTX-4h and
those treated with MTX-24h did not exceed ⫺11% in risk group R2 and
⫺17% in the combined risk groups R3 ⫹ R4. The expected total number of
randomized patients was 405 with a risk group distribution of 17%, 43%,
13%, and 27% for risk groups R1, R2, R3, and R4, respectively. With these
expected numbers of patients for risk group R2, the power to prove
noninferiority of MTX-4h was estimated to be 0.80 if the pFFS is 0.95 for
the MTX-24h arm (type I error ⫽ 5%, n ⫽ 87 per arm). For the combined
risk groups R3 ⫹ R4, the test power was estimated to be 0.80 if the pFFS is
0.80 for the MTX-24h arm (type I error ⫽ 5%, n ⫽ 81 per arm). There was
no planned test for risk group R1 because of the small number of patients
Figure 2. Kaplan-Meier estimate (P) of EFS at 3 years for the total group. SE
indicates standard error.
MTX DOSE AND SCHEDULE IN TREATMENT OF B-NHL/B-AL 951
Figure 3. Kaplan-Meier estimate (P) of EFS at 3 years according to risk groups
R1, R2, R3, and R4. SE indicates standard error.
and the extremely low number of expected events.4 After the test for
noninferiority, the second part of the study question was addressed: Is it
possible to significantly reduce orointestinal toxicity by reducing the MTX
infusion time from 24 hours to 4 hours? The end point of this analysis was
the incidence of the maximum grade of mucositis per randomized arm. The
analysis (Wilcoxon rank-sum test) was performed separately for risk group
R1 (2 MTX-containing courses with MTX 1 g/m2), risk group R2 (4 courses
with MTX 1 g/m2), and together for risk groups R3 ⫹ R4 (4 MTX-
containing courses with MTX 5 g/m2) with type I error equal to 5% for each
test. For patients receiving courses including MTX 5 g/m2 as intravenous
infusion over 24 hours, an incidence of mucositis grade III or IV of 72%
was expected based on observations in the preceding study NHL-BFM90.
There were 2 interim analyses and a final analysis planned when 33%, 66%,
and 100% of the expected total number of randomized patients would have
a potential follow-up of at least one year. The overall alpha 0.05 was
corrected according to O’Brien and Fleming for the first interim (P ⫽ .0005),
the second interim (P ⫽ .014), and the final analysis (P ⫽ .045).26
The second aim of study NHL-BFM95 was to investigate, against the
historical control of study NHL-BFM90, whether for patients in risk group
R2 the dose of MTX can be reduced from 5 g/m2 in study NHL-BFM90 to 1
g/m2 in study NHL-BFM95 without impairment of pEFS. The end point of
that analysis was the one-sided 95% CI for the difference of a 3-year pEFS
between patients in risk group R2 in studies NHL-BFM90 and NHL-
BFM95. Treatment with MTX 1 g/m2 was accepted to be noninferior to the
therapy with MTX 5 g/m2 if the lower limit of the one-sided 95% CI for the
difference in pEFS of patients in risk group R2 in study NHL-BFM95 and
study NHL-BFM90 did not exceed ⫺7%. This test was planned as a
per-protocol analysis; that is, only patients allocated to risk group R2 who
received R2 therapy were included in that analysis.25
Results
Patient characteristics
Of the 505 eligible patients, 119 were girls and 386 were boys. The
median age was 9.3 years (range, 1.4-19.7 years). The diagnoses of
patients are given in Table 2. Table 3 lists the distribution of
Figure 4. Kaplan-Meier estimate (P) of EFS at 3 years according to stage. SE
indicates standard error.
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952 WOESSMANN et al BLOOD, 1 FEBRUARY 2005 䡠 VOLUME 105, NUMBER 3

Table 4. Adverse events according to risk groups and stages

Risk group, no. Stage, no.
All R1 R2 R3 R4 I II III IV CNSⴚ IV CNSⴙ B-AL CNSⴚ B-AL CNSⴙ

No. patients 505 48 233 82 142 53 119 221 16 17 56 23

Early death of tumor lysis syndrome, 1 0 0 0 1 0 0 0 0 0 1 0
Death unrelated to tumor 10 0 1 2 7 0 0 4 1 0 4 1
Tumor failure 39 1§ 10 9 19 16 0 22 0 4 5 7
Late event* 1 0 0 1 0 0 0 0 1 0 0 0
Second malignancy† 3 1 2 0 0 0 1 2 0 0 0 0
Lost to follow-up‡ 14 0 11 2 1 2 3 8 0 0 0 1

*Not possible to perform a successful molecular study on clonal differences between the first and the second malignant growths.
†Secondary NHL in 2 cases, malignant melanoma in 1 patient.
‡After event-free follow-up duration of 0.4 to 5.4 years (median, 2.75 years).
§Primary in parailiac nodes, combined local and bone marrow relapse 3 months after completion of front-line therapy. The patient is in complete second remission for 34
months following salvage therapy including megadose chemotherapy with autologous stem cell rescue.

patients according to risk groups and stages: 48, 233, 82, and 142 Second-look surgery and autologous blood stem cell
patients were assigned to risk group R1, R2, R3, and R4, transplantation
respectively. Of the 40 patients with CNS disease, 27 had CSF
Of the patients, 15 in risk group R3 and 16 in R4 received
blasts, 9 had an intraparenchymal mass, and 4 patients had a cranial
second-look surgery due to residual tumor after the fifth course.
nerve palsy only. Of the boys, 11 had testicular disease. The median
The histologic examination revealed viable residual tumor in only
pretreatment LDH was 371 U/L (range, 57-46 340 U/L). one patient of R4. This patient underwent ASCT and remained free
Event-free survival of relapse (follow-up, 42 months). Another 4 patients (1 in R3, 3 in
R4) underwent ASCT after completion of chemotherapy without
At a median follow-up of 3.3 years (range, 0.4-6.3 years), the undergoing second-look surgery. Although not foreseen in the
3-year pEFS was 89% ⫾ 1% (SE) for the total group (Figure 2). protocol, 17 patients in risk group R2 underwent second-look
The 3-year pEFS was 94% ⫾ 4%, 94% ⫾ 2%, 85% ⫾ 4%, and surgery or biopsy after the fourth course of therapy due to a
81% ⫾ 3% for patients in risk groups R1, R2, R3, and R4, persistent tumor remnant. In 2 of these 17 cases, vital residual
respectively (Figure 3). pEFS according to stage is depicted in tumor was found. ASCT was performed in both patients, but one
Figure 4. There was no statistically significant difference patient died of progressive disease thereafter.
between pEFS of patients with Burkitt lymphoma (BL) and
Randomized trial of methotrexate as intravenous infusion over
diffuse large B-cell lymphoma (DLBCL). Patients with primary 4 hours versus 24 hours
mediastinal large B-cell lymphoma had an inferior outcome,
however (Table 2). Of the 505 patients, 364 were randomized to receive either
MTX-4h (n ⫽ 180) or MTX-24h (n ⫽ 184) (Table 5). Of the
Events
patients randomized to receive MTX-4h, 10 chose to receive
Table 4 summarizes adverse events according to risk group and MTX-24h. One patient randomized to receive MTX-24h chose to
according to stage. One child in risk group R4 died early of tumor
lysis syndrome. A total of 10 children died of sepsis (n ⫽ 6), Table 5. Randomization
invasive mycosis (n ⫽ 3), or meningitis (n ⫽ 1) after the first Risk group, no.
(n ⫽ 6), the third (n ⫽ 1), and the fourth (n ⫽ 3) course of therapy. R1 R2 R3 R4 Total
There were 39 children who suffered from tumor failure. Local
No. of patients 48 233 82 142 505
manifestations were the most frequent site of tumor failure Early death before randomization 0 0 0 1 1
followed by BM and new sites (Table 2). While on therapy, 11 No. patients randomized in arm MTX-4h 21 93 26 40 180
patients suffered from tumor failure; 1 of them had persistent blasts Refused, MTX-24h given 1 5 1 3 10
after the second course of therapy. In 27 patients, tumor failure No. patients randomized in arm MTX-24h 19 96 31 38 184
occurred after completion of chemotherapy within one year from Refused, MTX-4h given 0 1 0 0 1
Not randomized*
diagnosis. There was one relapse 1.3 years after diagnosis. There
MTX-4h chosen 2 7 1 3 13
were 3 patients who developed a second malignancy. There were 2
MTX-24h chosen 3 33 4 10 50
patients with BL who developed a second BL of different clonality Randomization halted† 3 4 3 10 20
2.9 and 3.4 years after the first disease. One patient with DLBCL Randomization stopped in R3 ⴙ R4
suffered a malignant melanoma. One BL patient suffered from a MTX-24h given‡ NA NA 17 40 57
late recurrence 3.3 years after the first diagnosis. There was no
NA indicates not applicable.
material available for analysis regarding clonal identity or differ- *Not randomized due to patients/guardians refusal or by physicians in charge.
ence between the first and second malignant growths. †Because there was a trend for inferior results in the randomized arm MTX-4h,
after the first and second interim analysis randomization was halted in blinded fashion
CNS disease for the time period until approval and recommendation of the external data safety and
monitoring committee and the study committee regarding continuation or stopping of
The 3-year pEFS for the 40 CNS-positive patients was 69% ⫾ 7%. the trial. During this period, all requests for randomization of patients were answered
with the allocation MTX-24 h.
One patient died of infection (Table 4). Of the remaining 39 ‡In risk groups R3 and R4, randomization was stopped after the second interim
patients, 11 suffered from progression, 7 of them within the CNS. analysis.
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BLOOD, 1 FEBRUARY 2005 䡠 VOLUME 105, NUMBER 3 MTX DOSE AND SCHEDULE IN TREATMENT OF B-NHL/B-AL 953

Table 6. Characteristics of randomized patients

R1 R2 R3 ⴙ R4 All
MTX-4h MTX-24h MTX-4h MTX-24h MTX-4h MTX-24h MTX-4h MTX-24h

No. patients 21 19 93 96 66 69 180 184

No. male 18 13 68 72 54 52 140 137
No. female 3 6 25 24 12 17 40 47
Median age, y 10.9 9.8 9.0 9.3 8.6 7.7 8.7 8.8
Age 10 years or older, no. 12 8 40 43 24 19 76 70
Burkitt, no. 16 12 53 67 53 55 122 134
DLBL, no. 4 6 27 23 5 6 36 35
Other, no. 1 1 13 6 8 8 22 15
Stage, no.
I 9 6 12 12 0 0 21 18
II 12 13 36 40 0 0 48 53
III 0 0 45 44 39 32 84 76
IV, CNS⫺ 0 0 0 0 5 8 5 8
IV, CNS⫹ 0 0 0 0 2 9 2 9
B-AL, CNS⫺ 0 0 0 0 13 17 13 17
B-AL, CNS⫹ 0 0 0 0 7 3 7 3
Median LDH, U/L 206 212 248 234 1,036 883 348 308
LDH 1000 U/L or more, no. 0 0 0 0 34 31 34 31
Vital tumor at SL-OP, no. NA NA 1* 1† 1‡ 0 2 1
Risk group R4 patients, no. NA NA NA NA 40 38 40 38

NA indicates not applicable; SL-OP, second look–operation.

*Alive disease-free after autologous stem cell transplantation.
†Died of progressive disease after autologous stem cell transplantation.
‡Alive disease-free after autologous stem cell transplantation.

receive MTX-4h. In 63 cases (12%), patients/guardians did not
give consent for randomization, preferring instead to choose the
treatment arm. For the following reason, 20 patients were not
randomized: In the first and second interim analysis, there was a
trend toward inferior results in the randomized arm MTX-4h in risk
groups R3 ⫹ R4. Therefore, randomization was temporarily halted
in a blinded fashion, pending approval and recommendation
whether to stop or to continue the trial. In these periods, all requests
of the participating clinics for randomization of patients were
answered with the allocation MTX-24h.
In the second interim analysis in the combined risk groups R3 ⫹
R4, the incidence of tumor failure was 5 times higher in the
randomized arm MTX-4h than in the randomized arm MTX-24h,
while in both arms 2 patients had died of toxicity. Because of this
unexpected and alarming observation, in accordance with the DMC
we changed from a test for noninferiority in pFFS to a log-rank test
for difference. Because for a test of difference, an intent-to-treat
analysis is the most conservative approach (not a per-protocol
analysis), we also changed from the per-protocol analysis set of
patients to an intent-to-treat set.25 pFFS at one year was 91% ⫾ 4%
for 56 patients with a minimal potential follow-up of one year and
randomized to receive MTX-24h. In contrast, the one-year pFFS
was 75% ⫾ 6% for 49 patients with a minimal potential follow-up
of one year and randomized to receive MTX-4h (P ⫽ .03).
Therefore, after consultation with the DMC, the randomization was
stopped for patients in risk groups R3 ⫹ R4 after the second interim
analysis. The 57 patients thereafter enrolled in risk group R3
(n ⫽ 17) and risk group R4 (n ⫽ 40) and received MTX-24h. For
patients in risk groups R1 and R2, however, randomization was
continued until the end of the planned accrual period.
The final analysis was performed after a median follow-up of
3.3 years (range, 0.4-6.3 years). Table 6 shows the distribution of
patient characteristics per randomized arm and according to risk
group. The MTX serum concentrations at 24, 42, and 48 hours after
the start of the MTX intravenous infusion were higher in patients
receiving MTX-24h compared with those receiving MTX-4h
(Table 7). There was no statistically significant difference of
intervals between 2 subsequent courses in either randomization
group (Table 8).
Intent-to-treat analysis
Results of the intent-to-treat analysis are given in Table 9 and in
Figure 5A-C. The one-year pFFS for patients randomized to
receive MTX-4h versus MTX-24h was as follows: in the total
group, 88% ⫾ 2% (n ⫽ 180) versus 95% ⫾ 2% (n ⫽ 184)

Table 7. Serum methotrexate concentrations of randomized patients

R1 ⴙ R2 R3 ⴙ R4
1 g/m2 MTX 5 g/m2 MTX
4 h* 24 h* 4 h* 24 h*

No. MTX courses given 305 318 199 235

MTX serum concentration at hour 24,† ␮M, median (range) 0.32 (0.1-75.9) 8.17 (0.1-107.0) 0.88 (0.1-31.0) 46.40 (0.3-344.9)
MTX serum concentration at hour 42,† ␮M, median (range) 0.09 (0-2.6) 0.18 (0-1.0) 0.18 (0-13.0) 0.43 (0-6.5)
MTX serum concentration at hour 48,† ␮M, median (range) 0.06 (0-1.2) 0.1 (0-0.7) 0.13 (0-4.9) 0.24 (0-5.0)

*Indicates the number of hours over which the infusion was given.
†After the beginning of MTX intravenous infusion.
 From bloodjournal.hematologylibrary.org by guest on July 22, 2011. For personal use only.
954 WOESSMANN et al BLOOD, 1 FEBRUARY 2005 䡠 VOLUME 105, NUMBER 3

Table 8. Number of days between beginning of 2 subsequent courses in randomized patients (MTX intravenous infusion as given)
R1 R2 R3/R4
MTX-4h MTX-24h MTX-4h MTX-24h MTX-4h MTX-24h
Median d No. Median d No. Median d No. Median d No. Median d No. Median d No.
(range) patients (range) patients (range) patients (range) patients (range) patients (range) patients

Interval course*
1 to 2 22 (19-34) 20 22 (18-26) 20 22 (15-49) 86 22 (14-31) 95 21 (16-32) 58 21 (15-41) 69
2 to 3 NA NA NA NA 22 (15-42) 86 22 (17-43) 95 21 (14-29) 57 22 (17-51) 68
3 to 4 NA NA NA NA 23 (16-43) 84 23 (18-36) 94 22 (16-38) 56 22 (17-36) 68
4 to 5 NA NA NA NA NA NA NA NA 23 (15-43) 55 22 (18-43) 64
5 to 6 NA NA NA NA NA NA NA NA 22 (17-43) 27† 23 (18-41) 37†

NA indicates not applicable.

The difference of the interval of the beginning of 2 subsequent courses was statistically not significant between randomized arms in either risk group.
*Interval between day one of 2 subsequent courses.
†Patients of risk group R3 received only 5 courses.

(P ⫽ .015; Figure 5A); in risk group R1, 95% ⫾ 5% (n ⫽ 21)
versus 100% (n ⫽ 19) (P ⫽ 0.34); in risk group R2, 95% ⫾ 2%
(n ⫽ 93) versus 96% ⫾ 2% (n ⫽ 96) (P ⫽ .71) (hazard ratio,
1.28; 95% CI, 0.34-4.78) (Figure 5B); and in the combined risk
groups R3 ⫹ R4 77% ⫾ 5% (n ⫽ 66) versus 93% ⫾ 3% (n ⫽ 69)
(P ⫽ .0077; hazard ratio, 3.58; 95% CI, 1.31-9.79) (Figure 5C).
In univariate analysis of patients of the combined risk groups R3 ⫹
R4, female sex (P ⫽ .03) and age older than 10 years (P ⫽ .01) were
associated with inferior pFFS. In a Cox regression model with the
covariables sex, age younger than 10 years versus 10 years or older, and
risk group R3 versus R4, the hazard ratio of the randomized arm
MTX-4h was 3.59 (95% CI, 1.30-9.93; P ⫽ .014; Table 10). This result
is very close to the univariate analysis.
Per-protocol analysis to test for noninferiority of the
randomized arm MTX-4h
Excluded from the per-protocol analysis were 11 patients who
rejected the randomized arm but instead chose to receive the
alternative MTX schedule (Table 5). In risk group R2 (MTX dose,
1 g/m2), the one-year pFFS was 94% ⫾ 2% for 88 randomized
patients who received MTX-4h compared with 96% ⫾ 2% for 95
randomized patients who received MTX-24h (hazard ratio, 1.34;
95% CI, 0.36-4.99). The lower limit of the one-sided 95.5% CI for
the difference (pFFS MTX-4h ⫺ pFFS MTX-24h, alpha corrected
for multiple testing) was ⫺6.8%. This was above the predeter-
mined loss of ⫺11%, which was considered still to be acceptable.
In the combined risk groups R3 ⫹ R4 (MTX dose, 5 g/m2), the
one-year pFFS was 77% ⫾ 5% for 62 randomized patients who
received MTX-4h (12 tumor failures) compared with 93% ⫾ 3%
for 69 randomized patients who received MTX-24h (2 tumor
failures). In both arms, 3 patients each died of toxicity. The hazard
ratio was 3.56 (95% CI, 1.29-9.82). The lower limit of the
one-sided 95% CI for the difference (pFFS MTX-4h ⫺ pFFS
MTX-24h) was ⫺25%, which was far lower than the predeter-
mined level of ⫺17%. This means that the possible loss in the
efficacy is too high.
Toxicities with MTX-4h or MTX-24h
In all risk groups, the incidence of the maximum grade of mucositis
was significantly lower in randomized patients who received
MTX-4h compared with randomized patients who received MTX-
24h (Table 11). The frequencies of main toxicities grades III/IV per
total number of courses administered are given as a descriptive
analysis in Table 12.
Comparison of pEFS for patients in risk group R2 against the
historical control group in study NHL-BFM90
The proportion of patients in risk group R2 was 40% in study
NHL-BFM90 and 46% in study NHL-BFM95 (Table 13). In
studies BFM90 and BFM95, 13 and 11 patients, respectively,
received treatment differing from risk group R2. Thus, 154 and 222
R2 patients of studies NHL-BFM90 and NHL-BFM95, respec-
tively, were evaluable for comparison. In study BFM90, the 3-year
pEFS was 97% ⫾ 1% for the 154 patients of risk group R2 who
received R2 therapy and was 95 ⫾ 2% for the 222 patients in study
BFM95 (Figure 6). The lower limit of the one-sided 95% CI for the
difference in pEFS of risk group R2 in study NHL-BFM95 (MTX
dose, 1 g/m2) minus pEFS of risk group R2 in study NHL-BFM95
(MTX dose, 5 g/m2) was ⫺4.5%. The distribution of patient
characteristics was comparable in studies NHL-BFM90 and NHL-
BFM95 with one exception. In study NHL-BFM95, the percentage
of BL patients was lower than in study NHL-BFM90, while the
proportion of patients with DLBCL was higher. The 3-year pEFS
for patients with BL or DLBCL was comparable in both studies,
however (Table 13).

Table 9. Treatment results of randomized patients

R1 R2 R3 ⴙ R4 All
MTX-4h MTX-24h MTX-4h MTX-24h MTX-4h MTX-24h MTX-4h MTX-24h

No. patients 21 19 93 96 66 69 180 184

Toxic death, no. 0 0 1 0 3 3 4 3
Tumor failure, no. (no. alive after rescue) 1 (1) 0 4 (2) 4 (0) 12 (2) 2 (0) 17 (5) 6 (0)
Second malignancy, no. 0 1 2 0 0 0 2 1
Late event, no. 0 0 0 0 1 0 1 0
pFFS at 1 y, ⫾ SE, % 95 ⫾ 5 100 95 ⫾ 2 96 ⫾ 2 77 ⫾ 5 93 ⫾ 3 88 ⫾ 2 95 ⫾ 2

Intent-to-treat analysis. Log-rank P ⫽ .34 for R1, .72 for R2, .0077 for R3 ⫹ R4, and .015 for all.
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BLOOD, 1 FEBRUARY 2005 䡠 VOLUME 105, NUMBER 3 MTX DOSE AND SCHEDULE IN TREATMENT OF B-NHL/B-AL 955

Table 11. Incidence of the maximum grade of mucositis according

to patients receiving MTX as 4-hour intravenous infusion compared
with patients receiving MTX as 24-hour intravenous infusion
R1 R2 R3 ⴙ R4
1 g/m2 MTX 1 g/m2 MTX 5 g/m2 MTX
4 h* 24 h* 4 h* 24 h* 4 h* 24 h*

No. MTX-containing courses 2 2 4 4 4 4

No. of patients evaluable 20 20 86 94 60 71
% patients with maximal
mucositis grade
0 35 30 26 15 8 1
I 45 15 27 13 15 4
II 15 15 26 28 20 16
III 5 25 16 22 32 36
IV 0 15 6 22 25 43

Per protocol analysis as MTX given. Wilcoxon test P ⫽ .06 for R1, .0002 for R2,
and .0027 for R3 ⫹ R4.
*Indicates the number of hours over which the infusion was given.

lymphoma, which may need a specifically adapted treatment (eg,

Figure 5. Kaplan-Meier estimate (P) of a one-year failure-free survival of
patients randomized to receive MTX as intravenous infusion either over 4
hours or over 24 hours. Intent-to-treat analysis. (A) For the whole group; (B) for
patients in risk group R2; and (C) for patients in combined risk groups R3 ⫹ R4. SE
indicates standard error.
Discussion
Favorable results have been reported from previous studies on
childhood and adolescent B-cell neoplasms.1-8 The toxicity of these
protocols was considerable, however. Therefore, study NHL-
BFM95 aimed at reducing treatment-related toxicity without
jeopardizing treatment outcome. The 3-year pEFS for the 505
eligible patients was 89% ⫾ 1% and thus comparable with the
results of previous studies.1-8 The treatment proved equally effica-
cious for all subtypes of childhood and adolescent B-NHL, with the
possible exception of primary mediastinal large B-cell lymphoma.
Recent reports support the unique nature of this large cell
Table 10. Cox regression analysis for randomized patients of risk
groups R3 ⴙ R4
Hazard ratio (95% CI)
Randomization arm MTX 4 hours 3.59 (1.30-9.93)
Female 2.84 (1.16-6.92)
Age 10 years or older 2.62 (1.09-6.29)
Risk group R4 1.32 (0.54-3.20)
the high local failure rate [Table 2] may ask for a role of local
radiotherapy).27
High-dose MTX is a key component of most protocols for
childhood and adolescent B-cell neoplasms. However, the dose of
MTX, the administration schedule, as well as the leucovorin rescue
vary considerably between these protocols. All these parameters,
especially the duration of the continuous intravenous infusion of
MTX, may have a substantial influence on efficacy and toxicity.10-14
In our previous trials, orointestinal toxicity appeared to be the
most important therapy-associated toxicity, mainly attributable to
high-dose MTX given as continuous intravenous infusion over 24
hours.4 Therefore, the first aim of study NHL-BFM95 was to test in
a randomized trial whether the incidence of orointestinal mucositis
grade III/IV can be reduced by shortening the time of intravenous
infusion of high-dose MTX from 24 hours to 4 hours, without
impairment of the probability of FFS. Indeed, the present study
showed an impressive reduction of severe orointestinal mucositis
in patients having received MTX-4h compared with MTX-24h in
all therapy branches.
However, in terms of efficacy, significant differences were
observed regarding outcome and MTX infusion regimen in differ-
ent risk groups. Regarding pFFS, the 4-hour infusion of high-dose
MTX was noninferior to the 24-hour infusion for patients in risk
groups R1 and R2 (55% of the total patient population). In risk
groups R3 ⫹ R4, however, pFFS was significantly worse for
patients having received MTX as a 4-hour infusion. The second
interim analysis of the trial showed a 5-fold excess of tumor failure
if MTX was administered over 4 hours compared with a 24-hour
infusion. As a consequence of this alarming finding, randomization
was omitted for patients in risk groups R3 ⫹ R4 after the second
interim analysis. In the final analysis, pFFS of patients randomized
to receive MTX 5 g/m2 as infusion over 4 hours was significantly
(P ⫽ .008) lower compared with patients randomized to receive
MTX 5 g/m2 as infusion over 24 hours. This difference in pFFS was
not attributable to differences in patient characteristics between the
2 randomized arms. In a multivariate Cox regression analysis
(including the covariables risk group, age, and sex), randomization
in therapy arm MTX-4h was a significant risk factor for tumor
P. chi
failure. The leucovorin rescue as well as the application of all other
.014 chemotherapeutic agents were identical in both randomized arms.
.022 We conclude, therefore, that the difference in treatment efficacy
.031
between the 2 randomized arms for patients in risk groups R3 ⫹ R4
.545
can be attributed to the different schedule of intravenous MTX infusion.
 From bloodjournal.hematologylibrary.org by guest on July 22, 2011. For personal use only.
956 WOESSMANN et al BLOOD, 1 FEBRUARY 2005 䡠 VOLUME 105, NUMBER 3

Table 12. Percent courses with toxicity grade III/IV (NCI-CTC) of randomized patients (MTX IV infusion as given)
R1 ⴙ R2 R3 ⴙ R4
Courses A/B Courses AA/BB
1 g/m2 MTX 5 g/m2 MTX
4 h*† 24 h*‡ 4 h*§ 24 h*㥋 CC¶
Grade III Grade IV Grade III Grade IV Grade III Grade IV Grade III Grade IV Grade III Grade IV
toxicity % toxicity % toxicity % toxicity % toxicity % toxicity % toxicity % toxicity % toxicity % toxicity %

Performance status 3 1 8 1 11 5 23 6 10 2
Hemoglobin 21 8 28 9 40 13 39 24 56 17
WBC 36 37 25 49 26 48 17 69 9 87
Platelets 21 10 18 12 20 28 18 44 12 75
Infection 2 0 3 0 3 1 9 2 9 1
Mucositis 5 1 11 7 16 9 25 19 7 4
Diarrhea 1 1 0 0 2 3 5 3 3 2
Bilirubin 1 0 1 0 3 1 3 1 3 1
Central neurotoxicity 0 0 0 0 0 1 1 0 0 0

NCI-CTC indicates National Cancer Institute-Common Toxicity Criteria.

Hepatotoxicity grade III/IV was 0% for all courses.
*Indicates the number of hours over which the infusion was given.
†374 courses recorded.
‡409 courses recorded.
§235 courses recorded.
㛳286 courses recorded.
¶165 courses recorded.

The observed difference of the impact of MTX administration evidence for the efficacy of MTX as such in the treatment of B-cell
schedules on efficacy for patients in risk groups R3 ⫹ R4 compared neoplasms of childhood and adolescents. According to the Goldie
with those in risk groups R1 and R2 is intriguing. Patients in risk Coldman postulation,28 the lower tumor mass of the patients in risk
groups R3 ⫹ R4 differ from those in risk groups R1 and R2 groups R1 and R2 might be associated with a lower proportion of
primarily with respect to the higher tumor mass, which, in turn, multiple resistant cells within the tumor cell population. Hence,
might be associated with a higher proportion of multiple resistant these cells might be eradicated with a less efficacious schedule of
cells within the tumor cell population.28 Because cytotoxicity of MTX. On the other hand, the noninferiority of the short MTX
MTX is time dependent,12 longer exposure times of these resistant infusion regimen compared with the long infusion regimen in terms
cells during a 24-hour infusion of MTX might be associated with of pFFS for patients in risk groups R1 and R2 may reflect that the
improved clearance of these cells and, thus, might explain the impact of MTX on the overall therapeutic success may be of lesser
higher pFFS of patients with high tumor load and long MTX importance in patients with lower tumor load compared with those
infusion. In fact, this observation may be interpreted as strong with higher tumor masses.
Comparison of treatment outcome of patients in risk group R2
Table 13. Characteristics and treatment results of patients of risk in the present trial NHL-BFM95 versus the previous study
group R2 in studies NHL-BFM90 and NHL-BFM95 NHL-BFM90 supports the following hypothesis: pEFS for patients
NHL-BFM90 patients NHL-BFM95 patients in risk group R2 did not differ between trials NHL-BFM90 and
No. patients in risk group R2 167 233 NHL-BFM95 despite a reduction of the dose of MTX to 1 g/m2 in
% of study population 40 46 study NHL-BFM95 compared with 5 g/m2 in the preceding trial
No. patients receiving R2 therapy 154 222 NHL-BFM90. Furthermore, for this patient subgroup, intensifica-
Male, % 75 75 tion of chemotherapy in case of incomplete tumor regression after 2
Female, % 25 25
therapy courses as performed in study NHL-BFM90 seems to be
Age, y, median (range) 9.6 (1.9-17.9) 9.6 (2.5-19.7)
dispensable with the exception of single cases with very poor
Burkitt, % 69 62
DLBCL, % 17 28
response to treatment.4
PMLBL, % 4 2
Other, % 10 7
Stage, %
I 14 16
II 44 40
III 42 45
Mediastinal tumor, no. patients 13 12
LDH, U/L, median (range) 238 (80-3583) 229 (57-654)
Events, no.
Death unrelated to tumor 3 1
Tumor failure 2 10
Second malignancy 3 2
pEFS, 3 years, % 97 ⫾ 1 95 ⫾ 2
Figure 6. Kaplan-Meier estimate (P) of EFS at 3 years for patients of risk group
DLBCL indicates diffuse large B-cell lymphoma; and PMLBL, primary mediastinal R2 in study NHL-BFM95 and in the preceding trial NHL-BFM90. SE indicates
(thymic) large B-cell lymphoma. standard error.
 From bloodjournal.hematologylibrary.org by guest on July 22, 2011. For personal use only.
BLOOD, 1 FEBRUARY 2005 䡠 VOLUME 105, NUMBER 3
Our data suggest that a favorable balance of efficacy and
toxicity is possible for patients with B-NHL stage I, II, and III
(LDH ⬍ 500 U/L) (55% of all cases of B-cell neoplasms of
childhood and adolescence). They have a pFFS of 95% with only 2
(R1) or 4 (R2) 5-day courses of chemotherapy including MTX 1
g/m2 as intravenous infusion over 4 hours. Mucositis grade III/IV
was observed after only 6% of 374 courses, while infections grade
III were observed after only 2% of 374 courses. However, further
reduction of therapy in this patient subgroup may be crucial as long
as no proven salvage regimen for relapsed patients is available.
Surprisingly all 3 second malignancies occurred in risk groups R1
and R2 with less intense chemotherapy.
For patients with advanced disease, however, FFS rates
comparable with the excellent results in the French study LMB
896 were obtained only with the courses including MTX 5 g/m2
as intravenous infusion over 24 hours. In study LMB 89,
however, high-dose MTX was given as intravenous infusion
over only 3 or 4 hours depending on treatment branch. Although
almost the same drugs were used in the LMB and the BFM
strategy, the weight of some drugs such as anthracyclines,
etoposide, and alkylating agents differed considerably. This may
have outweighed the effect of the short infusion time of MTX in
the LMB regimen. This assumption is supported by the observa-
tion that the acute toxicity profiles of the COPADM courses used
in study LMB 89, including MTX 3 g/m2 and 8 g/m2 as infusion
over 3 and 4 hours, respectively, are similar to those of the
courses AA and BB in study NHL-BFM95, including MTX 5
g/m2 as infusion over 24 hours.6
Interestingly, in study NHL-BFM95, the pFFS of patients in the
combined risk groups R3 ⫹ R4 who received MTX 5 g/m2 as
intravenous infusion over 24 hours was higher compared with the
corresponding patients in study NHL-BFM90 (risk group R3 of
study NHL-BFM90 was subdivided into risk groups R3 ⫹ R4 by
LDH ⬍ or ⬎ 1000 U/L in study NHL-BFM95).4 In trial NHL-
BFM95, all patients in risk groups R3 ⫹ R4 received course CC
including high-dose cytarabine and etoposide. High-dose cytarabine/
etoposide was described as effective even in relapsed B-NHL
patients.29 For comparison, in our preceding study NHL-BFM90
only 30% of the corresponding patients received course CC.
Moreover, the dose of cytarabine and etoposide was increased in
course CC of study NHL-BFM95.
To our knowledge, study NHL-BFM95 is the first randomized
controlled trial describing the impact of different MTX administra-
tion regimens on patient outcome and toxicity in the therapy of
NHL. The results and conclusions from this trial may help to
further optimize treatment not only for children and adolescents
with B-cell NHL/AL, but also for adults suffering from highly
aggressive B-cell neoplasms. Furthermore, experience from this
trial shows that changes in administration schedules of well-
established drugs may have profound and unexpected impact on
both efficacy and side effects of chemotherapy.
Acknowledgments
This work is dedicated to our colleague Stephan Mueller-Weihrich,
MD, who died too early.
We acknowledge the expert work of Edelgard Odenwald,
Beatrice Puttkammer (cytomorphology), Ulrike Meyer, and U.
Regelsberger (data management).
We wish to thank the members of the external data safety and
monitoring committee for their most valuable work: Catherine
MTX DOSE AND SCHEDULE IN TREATMENT OF B-NHL/B-AL 957
Patte, MD, Villejuif/France; Maria-Gracia Valsecchi, PhD, Milano/
Italy; Ian Magrath, MD, PhD, Bethesda/USA; and Joerg Michaelis,
MD, Mainz/Germany.
Appendix 1: Study committee of trial
NHL-BFM95
W. Dörffel, Berlin; W. Ebell, Berlin; N. Graf; Homburg; H. Gadner, Vienna;
G. Henze, Berlin; G. Janka-Schaub, Hamburg; T. Klingebiel, Frankfurt; St
Müller-Weihrich, Munich; I. Mutz, Leoben; H. J. R. Parwaresch, Kiel; A.
Reiter, Giessen; H. Riehm, Hannover; G. Schellong, Münster; M. Schrappe,
Hannover; F. Zintl, Jena.
Appendix 2: Reference laboratories
Histopathology and immunohistochemistry: R. Parwaresch, Lymph Node
Registry founded by the Society of German Pathologists, Institute of
Hematopathology, University Kiel; A. Feller, Institute of Pathology,
University Luebeck; M. L. Hansmann, Institute of Pathology, University of
Frankfurt; P. Möller, Institute of Pathology, University of Ulm; H. K.
Müller-Hermelink, Institute of Pathology, University Wuerzburg; H. Stein,
Institute of Pathology, Free University Berlin; I. Simonitsch, Institute of
Pathology, University Vienna, Austria.
Immunophenotyping: W.-D. Ludwig, Berlin; W. Knapp, Vienna; F.
Niggli, Zürich.
Cytomorphology: A. Reiter, Giessen; W. Haas, Wien; F. Niggli, Zürich.
Appendix 3: Principal investigators
R. Mertens (Aachen); R. Angst (Aarau); A. Gnekow (Augsburg); R.
Dickerhoff (St Augustin); P. Imbach (Basel); G. F. Wuendisch (Bayreuth);
W. Dörffel (Berlin-Buch); G. Henze (Berlin, Charité); U. Bode (Bonn); W.
Eberl (Braunschweig); H. J. Spaar (Bremen); I. Krause (Chemnitz); J.-D.
Thaben (Coburg); D. Möbius (Cottbus); W. Wiesel (Datteln); B. Ausserer
(Dornbirn); H. Breu (Dortmund); G. Weißbach (Dresden, University); W.
Kotte (Dresden); U. Göbel (Düsseldorf); W. Weinmann (Erfurt): J. D. Beck
(Erlangen); W. Havers (Essen); G. Müller (Feldkirch); B. Kornhuber
(Frankfurt); C. Niemeyer (Freiburg); F. Lampert (Gießen); M. Lakomek
(Göttingen); C. Urban (Graz); H. Reddemann (Greifswald); S. Burdach
(Halle); G. Janka-Schaub (Hamburg); H. Riehm/K. Welte (Hannover); B.
Selle/A. Kulozik (Heidelberg); N. Graf (Homburg); C. Tautz (Herdecke);
F. M. Fink (Innsbruck); F. Zintl (Jena); G. Nessler (Karlsruhe); H. Wehinger
(Kassel); R. Schneppenheim (Kiel); H. Meßner (Klagenfurt); M. Rister
(Koblenz); F. Berthold (Köln); W. Sternschulte (Köln); C. Schulte-
Wissermann (Krefeld); M. Domula (Leipzig); I. Mutz (Leoben); G. Schmitt
(Linz); O. Stoellinger (Linz); L. Nobile (Locarno); P. Bucsky (Lübeck); H.
Ruetschle (Ludwigshafen); U. Caflisch (Luzern); U. Mittler (Magdeburg);
P. Gutjahr (Mainz); O. Sauer (Mannheim); C. Eschenbach (Marburg); W.
Tillmann (Minden); S. Müller-Weihrich (Muenchen, Technical University);
C. Bender-Götze (Muenchen); R. J. Haas (Muenchen); H. Jürgens (Mün-
ster); O. Schofer (Neunkirchen); A. Jobke (Nürnberg); U. Schwarzer
(Nürnberg); G. Eggers (Rostock); R. Geib-König (Saarbrücken); H. Grien-
berger (Salzburg); H. Haas (Schwarzach); F. J. Göbel (Siegen); R. Ploier
(Steyr); J. Treuner (Stuttgart); R. Schumacher (Schwerin); A. Feldges (St
Gallen); H. Rau (Trier); D. Niethammer (Tübingen); K. M. Debatin (Ulm);
D. Franke (Vechta); H. Gadner (Wien, St Anna Kinderspital); F. Haschke
(Wien); J. Weber (Wiesbaden); A. Dohrn (Wuppertal); J. Kühl (Würzburg);
F. Niggli (Zurich).
Appendix 4: Pathologists
H. Mittermeyer (Aachen); B. Stamm (Aarau); R. Backmann (Augsburg); H.
Ohnacker (Basel); M. Stolte (Bayreuth); H. Stein (Berlin); W. Schneider
 From bloodjournal.hematologylibrary.org by guest on July 22, 2011. For personal use only.
958 WOESSMANN et al BLOOD, 1 FEBRUARY 2005 䡠 VOLUME 105, NUMBER 3

(Berlin); H. J. Foedisch, (Bonn); R. Donhuisen (Braunschweig); F. K.
Koessling (Bremen); J. O. Habeck (Chemnitz); P. Stosiek (Cottbus); E. W.
Schwarze (Dortmund); M. Müller (Dresden); H. E. Gabbert (Düsseldorf);
V. Becker (Erlangen); L. D. Leder (Essen); M. L. Hansmann (Frankfurt);
H. E. Schäfer (Freiburg); W. Schultz (Gießen); E. Kunze (Göttingen); C.
Schmid (Graz); G. Lorenz (Greifswald); F. W. Rath (Halle); U. Helmchen
(Hamburg); F. Kreipe (Hannover); F. Otto (Heidelberg); K. Remberger
(Homburg); G. Mikuz (Innsbruck); D. Katenkamp (Jena); R. Wagner
(Kaiserslautern); W. Gusek (Karlsruhe); O. Klinge (Kassel); R. Parwaresch
(Kiel); W. Wagner (Klagenfurt); F. deLeon (Koblenz); H. P. Dienes (Köln);
O. M. Gokel (Krefeld); C. Wittekind (Leipzig); G. Leitner (Leoben); M.
Weber (Linz); E. Pedrinis (Locarno); K. Wegener (Ludwigshafen); A. Feller
(Lübeck); J. O. Grebbers (Luzern); A. Roesser (Magdeburg); W. Thoenes
(Mainz); U. Bleyl (Mannheim); C. Thomas (Marburg); E. Jehn (Minden);
K. Wurster (Muenchen, Technical University); U. Löhrs (Muenchen); W.
Böcker (Münster); P. H. Wünsch (Nürnberg); F. Hofstädter (Regensburg);
H. Nizze (Rostock); H. Mitschke (Saarbrücken); O. Dietze (Salzburg); A.
Hittmair (Schwarzach); G. Wittstock (Schwerin); D. Kunde (Siegen); A.
Diener (St Gallen); J. Feichtinger (Steyr); A. Bosse (Stuttgart); H. Maeusle
(Trier); P. Kaiserling (Tübingen); O. Haferkamp (Ulm); M. Respondek (Vechta);
T. Radasckiewicz (Wien); W. Remmle (Wiesbaden); G. Fischer (Wilhelms-
haven); H. K. Müller-Hermelink (Würzburg); T. Stallmach (Zurich).

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