Improved outcome for children with acute lymphoblastic leukemia: results of Total Therapy Study XIIIB at St Jude Children's Research Hospital.
St Jude Total Therapy Study XIIIB for childhood acute lymphoblastic leukemia (ALL) incorporated more stringent risk classification, early intensification of intrathecal chemotherapy, reinduction treatment, and the addition of dexamethasone to postremission therapy to increase the proportion of event-free survivors without jeopardizing their quality of life. Cranial irradiation was reserved for the 12% of patients who had T-cell ALL and a presenting leukocyte count of 100 x 10(9)/L or more, or CNS-3 (5 or more leukocytes/microL with identifiable blast cells in an atraumatic sample or the presence of cranial nerve palsy) status. Among the 247 consecutive patients enrolled in the study, 117 were classified as having lower-risk leukemia and received mainly antimetabolite-based continuation therapy; the 130 cases with higher-risk leukemia received more intensive continuation chemotherapy with multiple drug pairs administered in weekly rotation. The 5-year event-free survival estimate was 80.8% +/- 2.6% (SE); the 8-year rate was 78.6% +/- 5.8%. The 5-year cumulative risk of an isolated central nervous system (CNS) relapse was 1.7% +/- 0.8%, and that of isolated plus combined CNS relapse was 3.0% +/- 1.1%. The 5-year cumulative risks of etoposide-related myeloid malignancies were 1.8% +/- 1.3% in the lower-risk patients who received a cumulative dose of 1.2 g/m(2) and 5.0% +/- 2.0% in the higher-risk patients who received a cumulative dose of up to 14.4 g/m(2) (P = .18). Independent adverse prognostic features included the presence of MLL-AF4 or BCR-ABL fusion gene and minimal residual leukemia of 0.01% or more at the end of the 6-week remission induction phase. Our results suggest the efficacy of early intensification of intrathecal chemotherapy and provide the basis for studies omitting cranial irradiation altogether.
Pui
Ching-Hon
CH
Department of Hematology/Oncology, St Jude Children's Research Hospital, Memphis, TN 38105-2794, USA. ching-hon.pui@stjude.org
Sandlund
John T
JT
Pei
Deqing
D
Campana
Dario
D
Rivera
Gaston K
GK
Ribeiro
Raul C
RC
Rubnitz
Jeffrey E
JE
Razzouk
Bassem I
BI
Howard
Scott C
SC
Hudson
Melissa M
MM
Cheng
Cheng
C
Kun
Larry E
LE
Raimondi
Susana C
SC
Behm
Frederick G
FG
Downing
James R
JR
Relling
Mary V
MV
Evans
William E
WE
D000293:Adolescent; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000008:administration & dosage; D002648:Child; D002675:Child, Preschool; D016371:Cranial Irradiation; D003907:Dexamethasone / Q000008:administration & dosage; D018572:Disease-Free Survival; D005047:Etoposide / Q000009:adverse effects; D005260:Female; D006801:Humans; D007223:Infant; D007278:Injections, Spinal; D007951:Leukemia, Myeloid / Q000139:chemically induced; D008297:Male; D054198:Precursor Cell Lymphoblastic Leukemia-Lymphoma / Q000150:complications / Q000473:pathology / Q000628:therapy*; D011379:Prognosis; D012008:Recurrence; D018570:Risk Assessment; D016896:Treatment Outcome
D005047:Etoposide; D003907:Dexamethasone