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Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Figuras y tablas -
Figure 1

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Table 1. Chemotherapy regimens

Study ID

Common treatment

Intervention 1

Intervention 2

Anderson 1983

C: 1.2 g/m2 IV on day 1; O: 2.0 mg/m2 (max 2 mg) IV on days 3,10,17 and 24; MTX: 6.25 mg/m2 IT on days 5, 31, and 34; P: 15 mg/m2 (max 60 mg) orally qds on days 3 to 30 decreasing to zero on days 31 to 33.

Radiation therapy.

Tumour excision attempted in patients with localised disease. Laparotomy and biopsy in patients with non‐localised disease.

COMP
Induction: MTX 300 mg/m2 IV on day 12.

Maintenance: C: 1 g/m2 IV on day 1; O: 1.5 mg/m2 IV on days 1 and 4; MTX: 6.25 mg/m2 IT on day 1 (excluded from 1st maintenance cycle), then 300 mg/m2 IV on day 15. Repeat maintenance cycle every 28 days.

LSA2 L2 (modified).
Induction: DAU; 60 mg/m2 IV on days 12 and 13.

Consolidation: CYT; 100 mg/m2 IV 5 days on, 2 days off x 2 weeks; THIO; 50 mg/m2 orally 8 to 12 hrs post CYT injection; ASP; 6000 IU/m2 IM daily x 14 days post CYT and THIO; MTX; 6.25 mg/m2 IT x2 doses 3 days apart, 2 to 3 days after last dose of ASP; CAR; 60 mg/m2 IV single dose given 2 to 3 days after completion of MTX.

Maintenance: THIO: 300 mg/m2 orally on days 1 to 4, 600 mg/m2 IV on day 5; H: 2.4 g/m2 orally on days 1 to 4; DAU: 45 mg/m2 orally on day 5,;CYT: 150 mg/m2 IV days 1 to 5; O: 2.0 mg/m2 (max 2 mg) IV on day 5; MTX: 6.25 mg/m2 IT x 2 doses 3 days apart. Repeat maintenance cycles 1 to 5.

Brecher 1997

None.

A
Prespecified duration:
Induction: C: on day 1 (dose not specified); MTX: on days 24 and 31 (dose not specified); O: weekly (x 5 weeks dose not specified); P: daily x 4 weeks (dose not specified).

Consolidation (22 weeks): C: days 52 and 102; MTX: on days 74,81,124, and 131; O: I hour prior to each MTX.

Maintenance: (11 weeks): O and MTX on days 174 and 216.

CNS prophylaxis: Ara‐C, MTX and H.

B
Duration determined by clinical response.

Induction: fractionated C,O and DOX.

Infusion phase: sequential continuous infusion of MTX and Ara‐C (pending mucosal and bone marrow recovery).
Repeat induction and infusion x 4 with dose of Ara‐C being doubled with each course.

CNS prophylaxis: MTX and Ara‐C.

Cairo 2003

Prephase: C: 0.3 g/m2 IV; O: 1 mg/m2 IV on day1; P: 60 mg/m2 IV or orally in 2 fractions on days 1 to 7; MTX+HYD+Ara‐C: 30 mg IT on days 1,3 and 5.

Induction:
COPADM 1 (started 1 week after day 1 of prephase).
O: 2 mg/m2 (max 2 mg) IV;high‐dose MTX: 8 g/m2 IV x 4 hours on day1; CFR: 15 mg/m2 every 6 hours orally on days 2 to 4; MTX+HYD+Ara‐C: 30 mg IT on day 2,4 and 6; DOX: 60 mg/m2 IV on day 2; C: 0.5 g/m2 IV (in 2 fractions) on days 2 to 4; P: 60 mg/m2 IV or orally on days 1 to 6.

COPADM 2 similar to COPADM1 except for: 2nd O dose: 2 mg/m2 (max 2 mg) IV on day 6; C: 1 g/m2 IV (in 2 fractions) on days 2 to 4.

Reduced intensity
Similar to standard dose except for consolidation drugs are given at 2/3 the standard doses and deletion of M2 to 4 maintenance.

Standard dose
Consolidation: (x 2 courses).
Ara‐C: 50 mg/m2 CI x 12 hours on days 1 to 5 (8 pm to 8 am); high‐dose Ara‐C 3 g/m2 IV x 3 hours on days 2 to 5 (8 am to 11 am); VP‐16: 200 mg/m2 IV on days 2 to 5 (2 pm to 4 pm).

Maintenance (monthly alternating courses).
M1: O: 2 mg/m2 (max 2 mg) IV; high‐dose MTX: 8 g/m2 IV x 4 hours on day 1; CFR: 15 mg/m2 every 6 hours orally on days 2 to 4; P: 60 mg/m2 orally on days 1 to 5; MTX+HYD+Ara‐C: 30 mg IT on day 2; C: 0.5 g/m2 IV on days 1 and 2; DOX: 60 mg/m2 IV on day 2.

M2/M4: VP‐16: 150 mg/m2 IV on days 1 to 3; Ara‐C: 100 mg/m2 SC (in 2 fractions) on days 1 to 5.

M3: similar to M1 but without high‐dose MTX and IT.

Magrath 1973

IV C 40 mg/kg x 2 doses 2 weeks apart.

Lomustine (70 mg/m2) administered orally.

No treatment.

Magrath 1976

IV C 40 mg/kg x 2 doses (a third dose was given when complete remission was not achieved with the standard 2 doses).

0.5 ml of freshly constituted BCG suspension administered by scarification.

No treatment.

Olweny 1976

None.

C: 40 mg/kg IV on day 1,repeated after 2 weeks or as soon as toxicity is abated.

C: 30 mg/kg IV on day 1; O: 2 mg/m2 IV on day 1; MTX: 15 mg/m2 orally on days 1 to 3. This is repeated 12 to 14 days later.

Patte 1991

Reduction phase: C: 0.3 g/m2 IV; O: 1 mg/m2 IV on day 1; P: 2 mg/kg orally on days 1 to 7; MTX+HYD: 15 mg/m2 IT on day 1.

Induction:

COPADM 1 (started 1 week after day 1 of prephase).

O: 2 mg/m2 IV;high‐dose MTX: 3 g/m2 IV x 3 hours on day 1; CFR: 15 mg/m2 every 6 hours orally on days 2 to 4; MTX+HYD: 15 mg IT on days 2 and 6; DOX: 60 mg/m2 IV on day 2; C: 0.5 g/m2 IV (in 2 fractions) on days 2 to; P: 2 mg/kg IV or orally on days 1 to 6.

COPADM 2 similar to COPADM 1 except for: addition of 2nd O dose: 2 mg/m2 IV on day 6; C: 1 g/m2 IV (in 2 fractions) on days 2 to 4.

CYM: high‐dose MTX 3 g/m2 IV x 3 hours on day 1; CFR: 15 mg/m2 every 6 hrs orally on days 2 to 4; Ara‐C: 100 mg/m2 CI on days 2 to 6; Ara‐C+HYD: 30 mg/m2 IT on day 6.

Maintenance (monthly alternating courses)
M1: O: 2 mg/m2 IV; high‐dose MTX 3 g/m2 IV x 3hours on day 1; CFR: 15 mg every 6 hours orally on days 2 to 4; P: 2 mg/kg orally on days 1 to 5; MTX+HYD: 15 mg IT on day 2; C: 0.5 g/m2 IV on days 1 and 2; DOX: 60 mg/m2 IV on day 2.

M2: Lomustine: 60 mg/m2 orally on day 28,; Ara‐C: 100 mg/m2 SC (in 2 fractions) on days 28 to 31; Ara‐C+HYD: 30 mg/m2 IT on day 28; THIO: 150 mg/m2 orally on days 28 to 31.

Long arm:
CYM 1,

Mini‐BACT: Lomustine: 60 mg/m2 orally on day 1; Ara‐C: 100 mg/m2 CI on days 2 to 6; THIO: 150 mg/m2 orally on days 2 to 6; C: 0.5 g/m2 IV on days 2 to 4.

M1, M2, M1, M2.

Short arm:

CYM 1 and 2,

M1.

Patte 2007

Prephase COP + IT MTX.

Maintenance: O, P, AD, high‐dose MTX given if 20% response at day 7 after COP.

Leucovorin rescue treatment.

NB. There is a second stage which involves subgroup of main interventions to receive either M1 (C1g/m2, O, P, AD, high‐dose MTX, or not.

1A: COPADM1: (Cyclophosphamide 1.5mg/m2) on days 2 and 6; CYM: (CYT IV on days 2 to 6 and IT CYT on day 6): M1 C 1g/m2, O, P, AD, high‐dose MTX.

1B: COPADM2 (double dose of C is given, O, P, AD. high‐dose MTX) on days 2 and 6, CYM (CYT IV on days 2 to 6 and IT CYT on day 6).

Sullivan 1991

Induction: C: 1.2 g/m2 IV on day 1, repeat on day 1 of weeks 7 and 14; O: 2.0 mg/m2 (max 2.0mg) IV on days 2 or 3 weekly x 4 then 1.0 mg/m2 IV given 1 hour before MTX infusion; P: 60 mg/m2 (max 60 mg) orally daily from day 1 x 28 days; MTX: 2 6‐hour infusion starting from week 3, starting dose 50 mg/kg increasing to 100 mg/kg then to 200 mg/kg throughout the rest of the treatment, given as 2 doses every 7 weeks during induction and consolidation and every 6 weeks during maintenance; CFR: 15 mg IV 3 hourly x 9 doses then 15 mg 6 hourly x 8 doses after each MTX infusion.

CNS prophylaxis: CYT: 45 mg/m2 on D1 and 2, MTX 15 mg/m2 on day 3 starting on day 2 of induction, subsequently given as triple therapy (CYT 60 mg/m2, MTX 15 mg/m2 (max 15 mg, HYD 30 mg/m2) at week 6 and 14, then 24 hours before each pair of MTX infusions.

Maintenance: triple therapy, IV MTX, IV O.

Maintenance regimen for 2 months.

Maintenance regimen for 6 months.

Ziegler 1971

Unclear.unclear

MTX 25 mg/m2 IT alternating with Ara‐C 50 mg /m2 IT every 4 days. Two doses of each drug were given.

No intrathecal therapy.

Ziegler 1972a

None.

C: 40 mg/kg IV at 2‐weekly intervals for 6 doses.

TRIKE schedule
C: 40 mg/kg followed in two weeks by O: 1.4 mg/m2 IV on day 1 and MTX 15 mg/m2 orally on days 1 to 4; Ara‐C: two weeks later; 250 mg/m2 CI daily x 3 days.

AD: adriamycin (doxorubicin)
Ara‐C: cytosine arabinoside
ASP: asparaginase
BCG: Bacille‐Calmette‐Guerin
C: cyclophosphamide
CAR: carmustine
CFR: citrovorum factor rescue
CI: continuous infusion
CNS: central nervous system
COMP: cyclophosphamide, oncovin, methotrexate and prednisolone
COP: cyclophosphamide, oncovin and prednisolone
CYM: CYT plus high‐dose MTX
CYT: cytarabine
DAU: daunorubicin
DOX: doxorubicon
H: hydroxyurea
HYD: hydrocortisone
IM: intramuscular
IT: intrathecal
IV: intravenous
MTX: methotrexate
O: oncovin (vincristine)
P: prednisolone
qds: four times daily
THIO: thioguanine

Figuras y tablas -
Table 1. Chemotherapy regimens
Table 2. Percentage deaths (remission‐inducing studies)

Study

Comparison

Rx 1

Rx 2 /control

Brecher 1997

Prespecified duration (1) versus duration determined by clinical response (2).

29

21

Olweny 1976

C: 40 mg/kg IV on day 1,repeated after 2 weeks or as soon as toxicity is abated (1) versus C: 30 mg/kg IV on day 1; O: 2 mg/m2 IV on day 1; MTX: 15 mg/m2 orally on days 1 to 3. This is repeated 12 to 14 days later (2).

58

33

Patte 1991

Long‐duration chemotherapy (1) versus short‐duration chemotherapy (2).

10

12

Ziegler 1972a

C (1) versus TRIKE (2).

50

28

C: cyclophosphamide
IV: intravenous
MTX: methotrexate
O: oncovin (vincristine)

Figuras y tablas -
Table 2. Percentage deaths (remission‐inducing studies)
Table 3. Percentage event‐free survival (remission‐inducing studies)

Study

Comparison

Rx 1

Rx 2/control

Brecher 1997

Prespecified duration (1) versus duration determined by clinical response (2).

35

21

Patte 1991

Long‐duration chemotherapy (1) versus short‐duration chemotherapy (2).

11

13

Sullivan 1991

Two‐month (1) versus six‐month (2) duration of maintenance chemotherapy.

6

10

Ziegler 1971

IT chemotherapy versus no treatment.

50

40

IT: intrathecal

Figuras y tablas -
Table 3. Percentage event‐free survival (remission‐inducing studies)
Table 4. Percentage remission (remission‐inducing studies)

Study

Comparison

Rx 1

Rx 2/control

Brecher 1997

Prespecified duration (1) versus duration determined by clinical response (2).

81

89

Patte 1991

Long‐duration chemotherapy (1) versus short‐duration chemotherapy (2).

87

89

Olweny 1976

Irradiation (1) versus no treatment (2).

83

84

Figuras y tablas -
Table 4. Percentage remission (remission‐inducing studies)
Table 5. Percentage relapse (remission‐inducing studies)

Study

Comparison

Rx 1

Rx2/control

Brecher 1997

Prespecified duration (1) versus duration determined by clinical response (2).

15

15

Olweny 1976

C: 40 mg/kg IV on day 1, repeated after 2 weeks or as soon as toxicity is abated (1) versus C: 30 mg/kg IV on day 1; O: 2 mg/m2 IV on day 1; MTX: 15 mg/m2 orally on days 1 to 3. This is repeated 12 to 14 days later (2).

53

62

Patte 1991

Long‐duration chemotherapy (1) versus short‐duration chemotherapy (2).

11

10

Ziegler 1972a

C (1) versus TRIKE (2).

80

61

C: cyclophosphamide
IV: intravenous
MTX: methotrexate
O: oncovin (vincristine)

Figuras y tablas -
Table 5. Percentage relapse (remission‐inducing studies)
Table 6. Percentage toxicity (remission‐inducing studies)

Study

Comparisons

Rx1

Rx2/ control

Type of toxicity

Brecher 1997

Prespecified duration (1) versus duration determined by clinical response (2)

74

96

Grades 3 and 4 toxicity; haematologic, neurotoxic, infections.

Patte 1991

Long‐duration chemotherapy (1) versus short‐duration chemotherapy (2)

0

4

Haematologic, multi‐organ failure, infections.

Patte 2007

1A versus 1B and 2A versus 2B

Infections and stomatitis (graded 1 to 4).

Figuras y tablas -
Table 6. Percentage toxicity (remission‐inducing studies)
Table 7. Percentage deaths (remission‐maintaining studies)

Study

Comparison

Rx 1

Rx 2/control

Magrath 1976

BCG (1) versus no treatment (2)

29

26

Neequaye 1990

TF (1) versus no treatment (2)

14

31

Olweny 1977

Irradiation (1) versus no treatment (2)

27

9

BCG: Bacille‐Calmette‐Guerin
TF: transfer factor

Figuras y tablas -
Table 7. Percentage deaths (remission‐maintaining studies)
Table 8. Percentage relapse (remission‐maintaining studies)

Study

Comparison

Rx 1

Rx 2/control

Type of relapse

Neequaye 1990

TF (1) versus no treatment (2)

28

54

Not stated

Magrath 1976

BCG (1) versus no treatment (2)

52

58

CNS

Magrath 1973

Lomustine (1) versus no treatment (2)

38

38

CNS:

Olweny 1977

Irradiation (1) versus no treatment (2)

54

36

CNS:

Ziegler 1971

IT chemotherapy (MTX) (1) versus no treatment (2)

50

40

CNS:

BCG: Bacille‐Calmette‐Guerin
CNS: central nervous system
IT: intrathecal
MTX: methotrexate
TF: transfer factor

Figuras y tablas -
Table 8. Percentage relapse (remission‐maintaining studies)