title: Delayed craniospinal irradiation for a first isolated central nervous relapse of acute lymphoblastic leukemia: report on 14 cases.
abstract: BACKGROUND
  Children developing an isolated central nervous system (CNS) relapse as first recurrence of their acute lymphoblastic leukemia (ALL) are considered to have a systemic relapse as well. They are mostly treated with intensive chemotherapy and craniospinal irradiation. In most treatment schedules, irradiation is given early after induction treatment. Because craniospinal irradiation affects a large portion of hematopoietic bone marrow systemically, treatment is often delayed owing to aplasias. Also, dose reductions are frequently needed. Children receiving simultaneously irradiation and chemotherapy are prone to (often severe) neurotoxicity. This study reports on children with a first isolated CNS relapse of their ALL receiving chemotherapy for 40 weeks. Treatment ends with the administration of irradiation given after cessation of chemotherapy.
  
  
  METHODS
  Fourteen children, with blasts and >5 cells/mm(3) in two consecutive samples of cerebrospinal fluid and a blast percentage <5% in their bone marrow were treated according to an intensive systemic and site-specific chemotherapy. Craniospinal irradiation was administered after cessation chemotherapy.
  
  
  RESULTS
  Event-free-survival was 57% (confidence interval 35-89%), freedom from relapse was 61.5%; follow-up ranges from 2.0 to 15.1 years (median 11.7 years). One child died from septicemia during induction. Five children experienced a second relapse and died from their malignancy. Two children [with a t(9;22) or a rearranged MLL gene] relapsed prior to radiotherapy. Outcome was related to duration of first remission, age at relapse, and identification as a high-risk patient at initial diagnosis. No neurologic complications were noted during and after treatment.
  
  
  CONCLUSIONS
  Delayed irradiation for isolated CNS relapse in children with ALL gives favorable survival rates, without significant toxicity. Neurotoxicity was absent.
authors.affiliation: Department of Pediatric Oncology, Emma Children Hospital AMC, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands. h.vandenberg@amc.uva.nl
authors.forename: H
authors.initials: H
authors.lastname: van den Berg
authors.forename: A E
authors.initials: AE
authors.lastname: Odink
authors.forename: H
authors.initials: H
authors.lastname: Behrendt
mesh_terms: D001932:Brain Neoplasms / Q000188:drug therapy / Q000532:radiotherapy; D016543:Central Nervous System Neoplasms / Q000188:drug therapy* / Q000532:radiotherapy*; D017024:Chemotherapy, Adjuvant; D002648:Child; D002675:Child, Preschool; D016371:Cranial Irradiation / Q000379:methods*; D005260:Female; D006801:Humans; D007223:Infant; D008297:Male; D054198:Precursor Cell Lymphoblastic Leukemia-Lymphoma / Q000188:drug therapy* / Q000532:radiotherapy*; D011832:Radiation Injuries / Q000209:etiology / Q000517:prevention & control*; D011878:Radiotherapy / Q000009:adverse effects; D018714:Radiotherapy, Adjuvant / Q000379:methods; D012008:Recurrence; D012074:Remission Induction; D012189:Retrospective Studies; D013120:Spinal Cord Neoplasms / Q000188:drug therapy / Q000532:radiotherapy; D016019:Survival Analysis; D013997:Time Factors; D016896:Treatment Outcome