Adapting the Capizzi-Methotrexate Protocol for T-LBL in a Lower-Middle-Income Country: A Case Report: Adapted C-MTX for T-LBL in an LMIC

Charity Cesilia Tololiu (Department of Child Health, Sam Ratulangi University Medical School/Prof. Dr. R.D. Kandou Hospital, Manado, Indonesia)
Stefanus Gunawan (Department of Child Health, Sam Ratulangi University Medical School/Prof. Dr. R.D. Kandou Hospital, Manado, Indonesia)
Max F J Mantik (Department of Child Health, Sam Ratulangi University Medical School/Prof. Dr. R.D. Kandou Hospital, Manado, Indonesia)
M Rahimi Bahar (Department of Child Health, Sam Ratulangi University Medical School/Prof. Dr. R.D. Kandou Hospital, Manado, Indonesia)
Anjo J P Veerman (Department of Pediatrics, Amsterdam University Medical Center, Amsterdam, the Netherlands 3. Faculty of Medicine, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.)

Indonesian Journal of Cancer
Vol. 20 No. 3 (2026): September

Introduction: Treating pediatric T-cell lymphoblastic lymphoma (T-LBL) in lower-middle-income countries (LMICs) is challenging, as the standard high-dose methotrexate (HD-MTX) regimen is unsafe without therapeutic drug monitoring. This case report aims to describe the clinical implementation, feasibility, and safety outcomes of an adapted Capizzi-style methotrexate (C-MTX) protocol as a practical alternative in a resource-limited setting Case Presentation: We report a case in Indonesia with T-LBL who was treated with an adapted C-MTX-based regimen. The protocol was chosen due to the inability to perform serum methotrexate measurements. He achieved initial complete remission and tolerated the therapy well. However, he experienced a relapse shortly after treatment completion Conclusions: Our experience demonstrates that a modified Capizzi-style Methotrexate protocol is a valuable and effective therapeutic strategy for pediatric T-LBL in settings with limited resources. This approach offers a practical way to circumvent the risks of unmonitored HD-MTX and can improve the standard of care.