title: Treatment of childhood acute lymphoblastic leukemia in central America: a lower-middle income countries experience.
abstract: BACKGROUND
  Five Asociación de Hemato-Oncología de Centroamérica (AHOPCA) countries have used an adapted BFM-based protocol for childhood acute lymphoblastic leukemia (ALL).
  
  
  METHODS
  In the AHOPCA-ALL 2008 protocol, patients were stratified by age, white blood cell count, immunophenotype, central nervous system involvement, day 8 prednisone response, and morphologic bone marrow response to induction therapy. Patients at Standard Risk (SR) received a three-drug induction regimen, a reinduction phase, and maintenance with protracted intrathecal therapy. Those at Intermediate (IR) and High Risk (HR) received, in addition, daunorubicin during induction therapy, a consolidation phase and two or three reinduction phases respectively.
  
  
  RESULTS
  From August 2008 through July 2012, 1,313 patients were enrolled: 353 in SR, 548 in IR, 412 in HR. During induction therapy, 3.0% of patients died, 2.7% abandoned treatment, 1.1% had resistant ALL, and 93.2% achieved morphological complete remission (CR). Deaths and abandonment in first CR occurred in 2.7% and in 7.0% of patients, respectively. The relapse rate at a median observation time of 2.1 years was 15.0%. At 3 years, the event-free survival (EFS) and overall survival (OS), with abandonment considered as an event, were 59.4% (SE 1.7) and 68.2% (SE 1.6). Three-year EFS was 68.5% (SE 3.0), 62.1% (SE 2.6), and 47.8% (SE 3.2) for SR, IR, and HR groups. Adolescents had a significantly higher relapse rate (P = 0.001).
  
  
  CONCLUSIONS
  This experience shows that common international studies are feasible in lower-middle income countries. Toxic deaths, abandonment of treatment, and relapses remain major obstacles to the successful treatment. Alternative treatment strategies may be beneficial.
authors.affiliation: Department of Hematology, Hospital Nacional de Niños "Dr. Carlos Sáenz Herrera,", San José, Costa Rica.
authors.forename: M
authors.initials: M
authors.lastname: Navarrete
authors.forename: E
authors.initials: E
authors.lastname: Rossi
authors.forename: E
authors.initials: E
authors.lastname: Brivio
authors.forename: J M
authors.initials: JM
authors.lastname: Carrillo
authors.forename: M
authors.initials: M
authors.lastname: Bonilla
authors.forename: R
authors.initials: R
authors.lastname: Vasquez
authors.forename: A
authors.initials: A
authors.lastname: Peña
authors.forename: L
authors.initials: L
authors.lastname: Fu
authors.forename: R
authors.initials: R
authors.lastname: Martinez
authors.forename: C M Pacheco
authors.initials: CM
authors.lastname: Espinoza
authors.forename: L F Baez
authors.initials: LF
authors.lastname: Lacayo
authors.forename: H
authors.initials: H
authors.lastname: Rodriguez
authors.forename: R
authors.initials: R
authors.lastname: Batista
authors.forename: R
authors.initials: R
authors.lastname: Barr
authors.forename: S C
authors.initials: SC
authors.lastname: Howard
authors.forename: R C
authors.initials: RC
authors.lastname: Ribeiro
authors.forename: G
authors.initials: G
authors.lastname: Masera
authors.forename: A
authors.initials: A
authors.lastname: Biondi
authors.forename: V
authors.initials: V
authors.lastname: Conter
authors.forename: M G
authors.initials: MG
authors.lastname: Valsecchi
mesh_terms: D000293:Adolescent; D002489:Central America; D002648:Child; D002675:Child, Preschool; D003131:Combined Modality Therapy; D003906:Developing Countries; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D016130:Immunophenotyping; D007182:Income; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D009364:Neoplasm Recurrence, Local / Q000209:etiology / Q000401:mortality / Q000628:therapy*; D016609:Neoplasms, Second Primary / Q000209:etiology / Q000401:mortality / Q000628:therapy*; D011203:Poverty; D054198:Precursor Cell Lymphoblastic Leukemia-Lymphoma / Q000150:complications / Q000401:mortality / Q000628:therapy*; D011379:Prognosis; D012074:Remission Induction; D015996:Survival Rate; D028761:Withholding Treatment / Q000191:economics / Q000706:statistics & numerical data*
keywords: acute lymphoblastic leukemia; childhood; low-middle income countries