SeluDex: an international trial of selumetinib in combination with dexamethasone for the treatment of acute lymphoblastic leukaemia
ISRCTN | ISRCTN92323261 |
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DOI | https://doi.org/10.1186/ISRCTN92323261 |
EudraCT/CTIS number | 2016-003904-29 |
ClinicalTrials.gov number | NCT03705507 |
Secondary identifying numbers | 33990, RG_16-186 |
- Submission date
- 22/01/2018
- Registration date
- 23/05/2018
- Last edited
- 28/04/2025
- Recruitment status
- No longer recruiting
- Overall study status
- Completed
- Condition category
- Cancer
Plain English summary of protocol
Contact information
Public
Cancer Research UK Clinical Trials Unit (CRCTU)
Robert Aitken Clinical Research Building
Institute of Cancer and Genomic Sciences
The University of Birmingham
Vincent Drive
Edgbaston
Birmingham
B15 2TT
United Kingdom
Phone | +44 (0)121 414 6754 |
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seludex@trials.bham.ac.uk |
Study information
Study design | Non-randomized; Interventional; Design type: Treatment, Screening, Drug |
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Primary study design | Interventional |
Secondary study design | Non randomised study |
Study setting(s) | Hospital |
Study type | Treatment |
Participant information sheet | Not available in web format, please use the contact details to request a patient information sheet |
Scientific title | International phase I/II expansion trial of the MEK inhibitor selumetinib in combination with dexamethasone for the treatment of relapsed/refractory RAS-pathway mutated paediatric and adult acute lymphoblastic leukaemia |
Study acronym | SeluDex |
Study objectives | The purpose of this trial is to test a new drug called selumetinib in combination with another drug called dexamethasone. The trial specifically targets those patients who have relapsed or refractory acute lymphoblastic leukaemia (ALL) and who have an identified mutation in a particular gene in their cancer’s DNA (in the RAS pathway). The trialists would like to see what effect combining these two drugs has on the patient's leukaemia. This will include looking at how well this treatment works, finding out more information about how it affects the disease, and to see how safe the drugs are in participants taking the trial medication. During Phase I the trial will look at establishing what is the most suitable dose level of selumetinib in combination with dexamethasone that can be safely given to participants. The Phase II part of the trial will look at the dose level of selumetinib which has already been established in Phase I as being the most effective in combination with dexamethasone to see what effects the combination of these medications will have on participants' leukaemia. |
Ethics approval(s) | Yorkshire & The Humber - Leeds West Research Ethics Committee, 12/07/2017, ref: 17/YH/0123 |
Health condition(s) or problem(s) studied | Acute lymphoblastic leukaemia |
Intervention | Current intervention as of 15/11/2019: Patients will receive selumetinib on cycle 1 day 1, then continuously from cycle 1 day 4 onwards. Combined with pulsed doses of dexamethasone on days 2-4, 8-11, 15-18 and 22-25 during cycle 1, then on days 1-4 of cycle two, then on days 1-5 during subsequent cycles. Dose levels will be determined throughout phase I using a statistical model, observation of dose limiting toxicities, and pharmacokinetic analysis. Phase II patients will be administered the recommended phase II dose determined from the phase I part of the trial using the same schedule. The aim is to recruit patients to both phases into both arms of the trial over a 2-year period. It is anticipated that patients will be on treatment for approximately 6 months and will be followed up for a further month after completion of treatment. Previous intervention: Patients will receive selumetinib on cycle 1 day 1, then continuously from cycle 1 day 4 onwards, combined with dexamethasone from days 2-28 during cycle 1, then tapered dosing for the first week of cycle two, with full doses on days 1-5 during subsequent cycles. Dose levels will be determined throughout phase I using a statistical model, observation of dose limiting toxicities, and pharmacokinetic analysis. Phase II patients will be administered the recommended phase II dose determined from the phase I part of the trial using the same schedule. The aim is to recruit patients to both phases into both arms of the trial over a two-year period. It is anticipated that patients will be on treatment for approximately six months and will be followed up for a further month after completion of treatment. |
Intervention type | Drug |
Pharmaceutical study type(s) | |
Phase | Phase I/II |
Drug / device / biological / vaccine name(s) | Selumetinib |
Primary outcome measure | Phase I: Selection of the Recommended Phase II Dose using occurrence/non-occurrence of dose-limiting toxicities and pharmacokinetic results during cycle 1 day 1-28 Phase II: Response to treatment is measured using morphological response and for patients with CNS involvement only clearance of CSF blasts at cycle 1 day 28 |
Secondary outcome measures | Phase I: 1. The occurrence of adverse events (AEs) is measured using Common Terminology Criteria for Adverse Events (CTCAE) version 4 and causality assessment from cycle 1 day 1 until 28-day follow-up 2. Pharmacokinetic variables of selumetinib in combination with dexamethasone are measured using the concentration time profile (area under the curve (AUC), Cmax, Tmax, t1/2) at cycle 1 day 1, cycle 1 day 4 and cycle 2 day 1 3. Response to treatment is measured by complete remission rate using morphological and minimal residual disease (MRD) response in bone marrow (BM) and for patients with CNS involvement only clearance of Cerebrospinal Fluid (CSF) blasts at cycle 1 day 28 4. Difference in pharmacokinetics of selumetinib measured by the area under the curve (AUC) when selumetinib is administered as a single agent and in combination with dexamethasone at cycle 1 day 1, cycle 1 day 4 and cycle 2 day 1 Phase II: 1. The occurrence of adverse events (AEs) measured using Common Terminology Criteria for Adverse Events (CTCAE) version 4 and causality assessment from cycle 1 day 1 until 28-day follow-up 2. The occurrence/non-occurrence of DLTs measured by assessment of the DLTs defined in the trial protocol during cycle 1 day 1-28 3. Pharmacokinetic variables of selumetinib in combination with dexamethasone measured using the concentration time profile (area under the curve (AUC), Cmax, Tmax, t1/2) at cycle 1 day 1, cycle 1 day 4 and cycle 2 day 1 4. Difference in pharmacokinetics of selumetinib measured by the area under the curve (AUC) when selumetinib is administered as a single agent and in combination with dexamethasone at cycle 1 day 1, cycle 1 day 4 and cycle 2 day 1 5. MRD response in BM is measured using the MRD level at cycle 1 day 28 |
Overall study start date | 09/10/2014 |
Completion date | 01/08/2023 |
Eligibility
Participant type(s) | Patient |
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Age group | Adult |
Lower age limit | 18 Years |
Sex | Both |
Target number of participants | Planned Sample Size: 42; UK Sample Size: 31; International Sample Size: 11 |
Key inclusion criteria | Current inclusion criteria as of 23/12/2021: 1. Morphologically proven relapsed/refractory (M2 or M3 marrow; ≥1st relapse for adults, ≥2nd relapse in paediatric group) or progressive B cell precursor or T-Acute Lymphoblastic Leukaemia (ALL) with demonstrated RAS pathway activating mutations (NRAS, KRAS, FLT3, PTPN11, cCBL, NF1, BRAF, IKZF2, IKZF3, IL7Rα or JAK1) identified during the trial screening process 2. B cell precursor patients must either: 2.1 Have received CAR-T cell therapy, or 2.2. Be awaiting CAR-T cell therapy, or 2.3. Be considered ineligible for CAR-T cell therapy 3. Group P (paediatric): <18 years of age; Group A (adult): ≥18 years of age 4. Adequate renal function: 4.1. Group A: Serum creatinine <1.5 x upper limit of normal (ULN) 4.2. Group P as follows: 4.2.1. ≤5 years: Serum creatinine <0.8 mg/dL or 70 μmol/L 4.2.2. >5 years but ≤ 10 years: Serum creatinine <1 mg/dL or 88 μmol/L 4.2.3. >10 years but ≤ 15 years: Serum creatinine <1.2 mg/dL or 106 μmol/L 4.2.4. >15 years: Serum creatinine <1.5 mg/dL or 132 μmol/L 5. Patient is able to swallow selumetinib capsules whole 6. Performance status (PS): Group A - Eastern Cooperative Oncology Group (ECOG) ≤2; Group P - Lansky play scale ≥60% or Karnofsky scale ≥60% 7. Women of childbearing potential must have a negative pregnancy test 8. Patients who are women of childbearing potential and male patients with partners who are women of childbearing potential must agree to use appropriate contraception whilst on trial 9. Written informed consent 10. Absence of any psychological, familial, sociological or geographical factors potentially hampering compliance with the trial protocol and follow-up schedule; those conditions should be discussed with the patient before registration in the trial 11. Patients who relapse or progress after HSCT need to be at least at day +100, with no signs of Graft versus Host Disease and off immunosuppressive therapy for at least one week 12. Patients who relapse or progress after CAR T cell therapy should be at least 4 weeks after infusion of CAR T cells. 13. Patients must have a body surface area (BSA) ≥ 0.55 m² _____ Previous inclusion criteria: 1. Morphologically proven relapsed/refractory (M2 or M3 marrow; ≥1st relapse for adults, ≥2nd relapse in paediatric group) or progressive B cell precursor or T-Acute Lymphoblastic Leukaemia (ALL) with demonstrated RAS pathway activating mutations (NRAS, KRAS, FLT3, PTPN11, cCBL) identified during the trial screening process 2. Group P (paediatric): <18 years of age; Group A (adult): ≥18 years of age 3. Adequate renal function: 3.1. Group A: Serum creatinine <1.5 x upper limit of normal (ULN) 3.2. Group P as follows: 3.2.1. ≤ 5 years: Serum creatinine <0.8 mg/dL or 70 μmol/L 3.2.2. > 5 years but ≤ 10 years: Serum creatinine <1 mg/dL or 88 μmol/L 3.2.3. > 10 years but ≤ 15 years: Serum creatinine <1.2 mg/dL or 106 μmol/L 3.2.4. > 15 years: Serum creatinine <1.5 mg/dL or 132 μmol/L 4. Patient is able to swallow selumetinib capsules whole 5. Performance status (PS): Group A - Eastern Cooperative Oncology Group (ECOG) ≤2 (Appendix 6); Group P - Lansky play scale ≥60% or Karnofsky scale ≥60% 6. Women of childbearing potential must have a negative pregnancy test 7. Patients who are women of childbearing potential and male patients with partners who are women of childbearing potential must agree to use appropriate contraception whilst on trial 8. Written informed consent 9. Absence of any psychological, familial, sociological or geographical factors potentially hampering compliance with the trial protocol and follow-up schedule; those conditions should be discussed with the patient before registration in the trial 10. Patients who relapse or progress after HSCT need to be at least at day +100, with no signs of Graft versus Host Disease and off immunosuppressive therapy for at least one week 11. Patients who relapse or progress after CAR T cell therapy should be at least 4 weeks after infusion of CAR T cells. 12. Patients must have a body surface area (BSA) ≥ 0.55 m2 |
Key exclusion criteria | Current exclusion criteria as of 23/12/2021: 1. ALL without presence of RAS-pathway activating mutations 2. Mature B-cell leukaemia and Philadelphia positive ALL 3. Prior exposure to MEK, RAS or RAF inhibitors 4. Any unresolved toxicity > = CTCAE Grade 2 from previous anti-cancer therapy, except for alopecia 5. Cardiac conditions as follows: Group A and P 5.1. Prior or current cardiomyopathy including but not limited to the following: 5.1.1. Known hypertrophic cardiomyopathy 5.1.2. Known arrhythmogenic right ventricular cardiomyopathy 5.2. Even if full recovery has occurred, previous moderate or severe impairment of left ventricular systolic function (LVEF < 45% on ECHO in Group A; SF < 29% in Group P but excluding transient impairments due to e.g. anaemia/sepsis or results not thought to represent a true reflection of cardiac function) 5.3. Severe valvular heart disease 5.4. Severe congential heart disease 5.5. Uncontrolled hypertension: Group A: BP > = 150/95 mmHg despite medical therapy; Group P: BP > = 95th percentile for age, height and gender (please refer to Blood Pressure by Age and Height Percentiles tables Group A 5.6. Baseline (LVEF) below the lower limit of normal (LLN) or < 55% measured by ECHO 5.7. Acute coronary syndrome within 6 months prior to trial registration 5.8. Uncontrolled Angina - Canadian Cardiovascular Society grade II-IV despite medical therapy 5.9. Symptomatic heart failure New York Heart Association (NYHA) Class II-IV, prior or current cardiomyopathy, or severe valvular heart disease 5.10. Prior or current cardiomyopathy including but not limited to the following: 5.10.1. Known hypertrophic cardiomyopathy 5.10.2. Known arrhythmogenic right ventricular cardiomyopathy 5.11. Atrial fibrillation with a ventricular rate > 100 bpm on Electrocardiogram (ECG) at rest 5.12. QTcF > 450ms in male patients or > = 460ms in female patients, or other factors that increase the risk of QT prolongation Group P 5.13. Baseline SF < 29% 5.14. Atrial fibrillation with a ventricular rate > 130 bpm on Electrocardiogram (ECG) at rest 5.15. QTcF > 450ms in patients < 12 years or > = 460ms in patients > = 12 but < 18 years 6. Ophthalmological conditions as follows: 6.1. Current or past history of retinal pigment epithelial detachment (RPED)/central serous retinopathy (CSR) or retinal vein occlusion (RVO) 6.2. Intraocular pressure (IOP) > 21 mmHg or uncontrolled glaucoma (irrespective of IOP) 7. Pregnant and breast feeding females 8. Known severe hypersensitivity to selumetinib, dexamethasone or combination medications or any excipient of these medicinal products, or history of allergic reactions attributed to compounds of similar chemical or biologic composition to selumetinib 9. Have received or are receiving an IMP or other systemic anti-cancer treatment (not including dexamethasone, prednisilone, or hydroxycarbamide) within 4 weeks (6 weeks for nitrosoureas, mitomycin, and suramin) prior to trial registration, or within a period during which the IMP or systemic anticancer treatment has not been cleared from the body (e.g. a period of 5 ‘half-lives’), whichever is the most appropriate and as judged by the investigator 10. Have had recent major surgery within a minimum 4 weeks prior to trial registration, with the exception of surgical placement of vascular access 11. Have received radiation therapy within 4 weeks prior to trial registration, or limited field of radiation for palliation within 7 days of the first dose of trial treatment 12. Laboratory values as listed below (SI units): 12.1. Serum bilirubin > 1.5 x ULN (unless due to Gilbert’s syndrome) 13. Have evidence of any other significant clinical disorder or laboratory finding that, as judged by the investigator, makes it undesirable for the patient to participate in the trial 14. Have any evidence of a severe or uncontrolled systemic disease (e.g. unstable or uncompensated respiratory, cardiac, hepatic, or renal disease, active infection (including hepatitis B, hepatitis C, HIV), active bleeding diatheses, or renal transplant) 15. Have refractory nausea and vomiting, chronic gastrointestinal diseases (e.g., inflammatory bowel disease), or significant bowel resection that would adversely affect the absorption/bioavailability of the orally administered trial medication 16. Any other active malignancy which, in the opinion of the investigator would limit the ability of the patient to complete the study _____ Previous exclusion criteria: 1. ALL without presence of RAS-pathway activating mutations 2. Mature B-cell leukaemia and Philadelphia positive ALL 3. Prior exposure to MEK, RAS or RAF inhibitors 4. Any unresolved toxicity > = CTCAE Grade 2 from previous anti-cancer therapy, except for alopecia 5. Cardiac conditions as follows: Group A and P 5.1. Prior or current cardiomyopathy including but not limited to the following: 5.1.1. Known hypertrophic cardiomyopathy 5.1.2. Known arrhythmogenic right ventricular cardiomyopathy 5.2. Even if full recovery has occurred, previous moderate or severe impairment of left ventricular systolic function (LVEF < 45% on ECHO in Group A; SF < 29% in Group P but excluding transient impairments due to e.g. anaemia/sepsis or results not thought to represent a true reflection of cardiac function) 5.3. Severe valvular heart disease 5.4. Severe congential heart disease 5.5. Uncontrolled hypertension: Group A: BP > = 150/95 mmHg despite medical therapy; Group P: BP > = 95th percentile for age, height and gender (please refer to Blood Pressure by Age and Height Percentiles tables Group A 5.6. Baseline (LVEF) below the lower limit of normal (LLN) or < 55% measured by ECHO 5.7. Acute coronary syndrome within 6 months prior to trial registration 5.8. Uncontrolled Angina - Canadian Cardiovascular Society grade II-IV despite medical therapy 5.9. Symptomatic heart failure New York Heart Association (NYHA) Class II-IV, prior or current cardiomyopathy, or severe valvular heart disease 5.10. Prior or current cardiomyopathy including but not limited to the following: 5.10.1. Known hypertrophic cardiomyopathy 5.10.2. Known arrhythmogenic right ventricular cardiomyopathy 5.11. Atrial fibrillation with a ventricular rate > 100 bpm on Electrocardiogram (ECG) at rest 5.12. QTcF > 450ms in male patients or > = 460ms in female patients, or other factors that increase the risk of QT prolongation Group P 5.13. Baseline SF < 29% 5.14. Atrial fibrillation with a ventricular rate > 130 bpm on Electrocardiogram (ECG) at rest 5.15. QTcF > 450ms in patients < 12 years or > = 460ms in patients > = 12 but < 18 years 6. Ophthalmological conditions as follows: 6.1. Current or past history of retinal pigment epithelial detachment (RPED)/central serous retinopathy (CSR) or retinal vein occlusion 6.2. Intraocular pressure (IOP) > 21 mmHg or uncontrolled glaucoma (irrespective of IOP) 7. Pregnant and breast feeding females 8. Known severe hypersensitivity to selumetinib, dexamethasone or combination medications or any excipient of these medicinal products, or history of allergic reactions attributed to compounds of similar chemical or biologic composition to selumetinib 9. Have received or are receiving an IMP or other systemic anti-cancer treatment (not including dexamethasone or hydroxycarbamide) within 4 weeks (6 weeks for nitrosoureas, mitomycin, and suramin) prior to trial registration, or within a period during which the IMP or systemic anticancer treatment has not been cleared from the body (e.g. a period of 5 ‘half-lives’), whichever is the most appropriate and as judged by the investigator 10. Have had recent major surgery within a minimum 4 weeks prior to trial registration, with the exception of surgical placement of vascular access 11. Have received radiation therapy within 4 weeks prior to trial registration, or limited field of radiation for palliation within 7 days of the first dose of trial treatment 12. Laboratory values as listed below (SI units): 12.1. Serum bilirubin > 1.5 x ULN (unless due to Gilbert’s syndrome) 13. Have evidence of any other significant clinical disorder or laboratory finding that, as judged by the investigator, makes it undesirable for the patient to participate in the trial 14. Have any evidence of a severe or uncontrolled systemic disease (e.g. unstable or uncompensated respiratory, cardiac, hepatic, or renal disease, active infection (including hepatitis B, hepatitis C, HIV), active bleeding diatheses, or renal transplant) 15. Have refractory nausea and vomiting, chronic gastrointestinal diseases (e.g., inflammatory bowel disease), or significant bowel resection that would adversely affect the absorption/bioavailability of the orally administered trial medication 16. Any other active malignancy which, in the opinion of the investigator would limit the ability of the patient to complete the study |
Date of first enrolment | 18/05/2018 |
Date of final enrolment | 31/01/2023 |
Locations
Countries of recruitment
- Denmark
- England
- Netherlands
- Scotland
- United Kingdom
Study participating centres
High Heaton
Newcastle upon Tyne
NE7 7DN
United Kingdom
Queen Victoria Rd
Newcastle upon Tyne
NE1 4LP
United Kingdom
Birmingham
B4 6NH
United Kingdom
Birmingham
B15 2TH
United Kingdom
Liverpool
L14 5AB
United Kingdom
Sutton
SM2 5PT
United Kingdom
Bloomsbury
London
WC1E 6BT
United Kingdom
Manchester
M20 4BX
United Kingdom
Sheffield
S10 2JF
United Kingdom
Holborn
London
WC1N 3JH
United Kingdom
White City
London
W12 0HS
United Kingdom
Camberwell
London
SE5 9RS
United Kingdom
Glasgow
G12 0YN
United Kingdom
Utrecht
3584 CS
Netherlands
Copenhagen
DK-2100
Denmark
Sponsor information
University/education
-
Birmingham
-
England
United Kingdom
Phone | +44 (0)121 414 6754 |
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seludex@trials.bham.ac.uk | |
https://ror.org/03angcq70 |
Funders
Funder type
Industry
Government organisation / For-profit companies (industry)
- Alternative name(s)
- AstraZeneca PLC, Pearl Therapeutics
- Location
- United Kingdom
Private sector organisation / Other non-profit organizations
- Alternative name(s)
- CR_UK, Cancer Research UK - London, CRUK
- Location
- United Kingdom
Results and Publications
Intention to publish date | 31/12/2024 |
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Individual participant data (IPD) Intention to share | Yes |
IPD sharing plan summary | Available on request |
Publication and dissemination plan | Planned publication in a peer reviewed journal. |
IPD sharing plan | Current individual participant data (IPD) sharing statement as of 27/01/2022: The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request. The CRCTU is committed to responsible and controlled sharing of anonymised clinical trial data with the wider research community to maximise potential patient benefit while protecting the privacy and confidentiality of trial participants. Data anonymised in compliance with the Information Commissioners Office requirements, using a procedure based on guidelines from the MRC Methodology Hubs, will be available for sharing with researchers outside of the trials team within 6 months of the primary publication. More detailed information on the CRCTU’s Data Sharing Policy and the mechanism for obtaining data can be found on the CRCTU website: https://www.birmingham.ac.uk/research/activity/mds/trials/crctu/index.aspx. Previous individual participant data (IPD) sharing statement: The datasets generated during and/or analysed during the current study will be stored in a non-publically available repository (https://www.cancertrials.bham.ac.uk/SeluDexLive). Type of data that will be shared: case report form data. When the data will become available and for how long: from trial entry registration until the end of the trial. Access to the eRDC system will be granted to authorised individuals via the UK Coordinating Centre, for analysis of outcome measures, Phase I dose escalation continual reassessment method, Phase II Bayesian design. Consent from participants was obtained prior to trial entry, |
Study outputs
Output type | Details | Date created | Date added | Peer reviewed? | Patient-facing? |
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Protocol article | 04/03/2022 | 07/03/2022 | Yes | No | |
HRA research summary | 28/06/2023 | No | No | ||
Basic results | version 1.0 | 17/04/2025 | 28/04/2025 | No | No |
Statistical Analysis Plan | version 2.0 | 09/09/2019 | 28/04/2025 | No | No |
Additional files
Editorial Notes
28/04/2025: Basic results and statistical analysis plan uploaded.
07/03/2022: Publication reference added.
27/01/2022: The individual participant data (IPD) sharing statement has been updated and the IPD sharing summary has been changed from "Stored in repository" to. "Available on request"
21/01/2022: The following changes have been made:
1. The recruitment end date has been changed from 17/04/2018 to 18/05/2018.
2. The country of recruitment "Denmark" has been added.
3. The trial participating centre "University Hospital Rigshospitalet" has been added.
23/12/2021: The following changes were made to the trial record:
1. The contact name was changed.
2. The inclusion criteria were changed.
3. The exclusion criteria were changed.
4. The trial participating centre Prinses Máxima Centrum was added.
5. The recruitment end date was changed from 01/11/2021 to 31/01/2023.
6. The overall end date was changed from 01/08/2022 to 01/08/2023.
7. The intention to publish date was changed from 01/08/2023 to 31/12/2024.
8. The plain English summary was updated to reflect these changes.
20/09/2021: Internal review.
31/07/2020: The following changes have been made:
1. The recruitment end date has been changed from 17/05/2020 to 01/11/2021.
2. The overall trial end date has been changed from 17/12/2020 to 01/08/2022 .
3. The intention to publish date has been changed from 31/12/2021 to 01/08/2023.
15/11/2019: The following changes have been made:
1. The intervention has been changed.
2. The overall trial end date has been changed from 17/03/2021 to 17/12/2020.
3. The intention to publish date has been changed from 17/03/2022 to 31/12/2021.
4. Beatson West of Scotland Cancer Centre and King’s College Hospital have been added to the trial participating centres.
21/08/2019: Trial website and trial participating centres added.
22/03/2019: The condition was updated from "Specialty: Cancer, Primary sub-specialty: Haematological Oncology; UKCRC code/ Disease: Cancer/ Malignant neoplasms, stated or presumed to be primary, of lymphoid, haematopoietic and related tissu" to "Acute lymphoblastic leukaemia".
15/01/2019: The following changes have been made to the clinical trial record:
1. The trial participating centres have been updated, the following centres have been removed; Belfast City Hospital; Bristol Royal Hospital for Children; Bristol Royal Infirmary; University Hospital of Wales; St James University Hospital; Leicester Royal Infirmary; The Royal Liverpool University Hospital; Great Ormond Street Hospital; King's College Hospital; Nottingham City Hospital.
2. The ClinicalTrials.gov number has been added.
3. The protocol number, RG_16-186, has been added.