• Characterization of Adverse Events (CTCAE version 5) [ Time Frame: All adverse events occurring through 30 days following last dose of inotuzumab ozogamicin. ]
  A characterization of all adverse events experienced by patients receiving these drug combinations. Also, any SAEs deemed related to study treatment, including veno-occlusive disease, will be captured at any time while the participant is on-study.
• Dose-limiting toxicities [ Time Frame: From initiation of inotuzumab ozogamicin through 30 days following the last dose of inotuzumab ozogamicin ]
  The number of dose-limiting toxicities will be used to determine the maximum tolerated dose combination for these combinations of drugs
• Informative course of treatment [ Time Frame: For each participant, up to the 29 days of study treatment ]
  Percent of patients that receive enough treatment to be informative to the study

• Drug: Inotuzumab ozogamicin
  By IV, given on days 12 and 19 Inotuzumab ozogamicin is approved as a single-agent in this population (patients with B-ALL) but adding it to these drug combinations has not been tested in humans
  Other Name: Besponsa
• Drug: Prednisone Pill
  Taken daily days 1-28 by mouth
  Other Name: Deltasone
• Drug: Daunorubicin
  By IV, given on days 1, 8, 15, and 22
  Other Names:

  • Cerubidine
  • daunomycin
  • rubidomycin
• Drug: Vincristine
  By IV, given on days 1, 8, 15, and 22
  Other Names:

  • Oncovin
  • Vincasar
  • Leurocristine
• Drug: Cytarabine
  Intrathecal, administered on day 1 only
  Other Names:

  • Ara-C
  • Cytosar-U
• Drug: Methotrexate
  Intrathecal, administered on days 8 and 29
  Other Names:

  • Otrexup
  • Rasuvo
  • Rheumatrex
  • Trexall
  • MTX
  • Amethopterin
• Drug: Pegaspargase
  By IV, given on day 4
  Other Name: Oncospar

• Experimental: 3-drug re-induction regimen with inotuzumab

  One cycle of a 3-drug regimen comprised of standard doses of prednisone, vincristine, and daunorubicin with inotuzumab ozogamicin at a reduced dose.

  Intrathecal methotrexate (IT-methotrexate) and intrathecal cytarabine (IT-Ara-C) will be included for CNS prophylaxis.

  IV inotuzumab ozogamicin will be given at a reduced dose (may vary from a total cycle dose of 0.4 mg/m^2 to 0.9 mg/m^2)

  Interventions:

  • Drug: Inotuzumab ozogamicin
  • Drug: Prednisone Pill
  • Drug: Daunorubicin
  • Drug: Vincristine
  • Drug: Cytarabine
  • Drug: Methotrexate
• Experimental: 4-drug re-induction regimen with inotuzumab

  One cycle of a 4-drug regimen comprised of standard doses of prednisone, vincristine, daunorubicin, and pegaspargase with inotuzumab ozogamicin at a reduced dose.

  Intrathecal methotrexate (IT-methotrexate) and intrathecal cytarabine (IT-Ara-C) will be included for CNS prophylaxis.

  IV inotuzumab ozogamicin will be given at a reduced dose (may vary from a total cycle dose of 0.4 mg/m^2 to 0.9 mg/m^2)

  Interventions:

  • Drug: Inotuzumab ozogamicin
  • Drug: Prednisone Pill
  • Drug: Daunorubicin
  • Drug: Vincristine
  • Drug: Cytarabine
  • Drug: Methotrexate
  • Drug: Pegaspargase

Inclusion Criteria:

1. Provision of signed and dated informed consent form
2. Stated willingness to comply with all study procedures and availability for the duration of the study
3. Diagnosed with CD-22 positive* B-cell Acute Lymphoblastic Leukemia or B-cell Lymphoblastic Lymphoma (Philadelphia chromosome negative) * For the purposes of this study, CD-22 positive is defined as at least 60% positive by flow cytometry or immunohistochemistry.
4. Body mass index (BMI) < 35 (BMI = weight in kg/(height in meters)^2)
5. Male or female, aged 18-55 years
6. ECOG performance status of 0-2
7. Left ventricular ejection fraction > 45% measured by echocardiogram or MUGA
8. Either relapsed following remission after initial induction therapy or refractory to induction therapy
9. Adequate organ function, including serum creatinine ≤ 1.6 mg/dL or creatinine clearance < 50 ml/min by Cockgroft-Gault formula, bilirubin ≤ 1.5 mg/dL (except in patients with Gilbert's disease), AST, ALT and alkaline phosphatase ≤ 3 x upper limit of normal
10. For females of reproductive potential: negative pregnancy test
11. For females and males of reproductive potential: agreement to use adequate contraception during study participation and for an additional 1 year after the end of study treatment
12. Agreement to adhere to Lifestyle Considerations throughout study duration and for 1 year following last study treatment.

Exclusion Criteria:

1. Requires concomitant therapeutic anticoagulation (e.g. warfarin, low molecular weight heparin, direct oral anticoagulant) or any medication included in the restricted concomitant medications
2. Past receipt of a total of ≥ 300 mg/m^2 doxorubicin equivalents (600 mg/m^2 daunorubicin, 60 mg/m^2 idarubicin, 75 mg/m^2 mitoxantrone)
3. Current or past history of pancreatitis
4. QT interval on electrocardiogram (ECG) > 0.45 by Framingham formula
5. Known congestive heart failure
6. Known allergy to asparaginase (only an exclusion criteria for participants enrolling in part 2)
7. Presence of central nervous system (CNS) disease
8. Pregnancy or lactation
9. Chronic liver disease including chronic active hepatitis and/or cirrhosis
10. Active Hepatitis B virus (HBV) by core antibody, surface antigen (HBsAg) or viral load
11. Active Hepatitis C virus (HCV) (positive antibody test confirmed by viral load if antibody test is positive)
12. Known history of infection with Human Immunodeficiency Virus (HIV)
13. Active or uncontrolled infections
14. Abnormal baseline hepatic ultrasound (including Dopplers)
15. Prior allogeneic stem cell transplant
16. Prior use of inotuzumab ozogamicin
17. Known diagnosis of hemochromatosis with iron overload
18. Prior CAR-T cell therapy
19. Treatment with steroids or hydroxyurea for more than 7 days within the 2 weeks prior to registration
20. Gastrointestinal tract disease causing the inability to take oral medication, malabsorption syndrome, a requirement for intravenous (IV) alimentation, prior surgical procedures affecting absorption, uncontrolled inflammatory GI disease, or inability to swallow medications.
21. Philadelphia chromosome positive B-cell ALL

• Pfizer
• Vanderbilt University
• University of Wisconsin, Madison
• Virginia Commonwealth University