Prognostic factors and therapy in acute lymphoblastic leukemia of childhood: CCG-141. A report from childrens cancer study group

Treatment of Pediatric Acute Lymphoblastic Leukemia: A Historical Perspective

Acute lymphoblastic leukemia (ALL) is the most common disease in pediatric oncology. The history of developmental therapeutics for ALL began in the 1960s with the repetition of "unreliable" medical interventions against this lethal disease. By the 1990s, the development of multi-agent chemotherapy and various types of supportive care rendered ALL treatable. Highly sophisticated, molecular, diagnostic techniques have enabled highly accurate prediction of the relapse risk, and the application of risk-adapted treatments has increased the survival rate in the standard-risk group to nearly 100% in most European nations and North America. Incorporation of state-of-the-art, molecularly targeted agents and novel treatments, including cell and immunotherapy, is further improving outcomes even in the high-risk group. On the other hand, the financial burden of treating children with ALL has increased, imperiling the availability of these diagnostic and treatment strategies to patients in low- and middle-income countries (LMICs). The fundamental treatment strategy, consisting of corticosteroid and classical cytotoxic therapy, has achieved fairly good outcomes and should be feasible in LMICs as well. The present review will discuss the history of developmental therapeutics for childhood ALL in various countries through an extensive literature review with the aim of proposing a model for a treatment backbone for pediatric ALL. The discussion will hopefully benefit LMICs and be useful as a base for future clinical trials of novel treatments.

Top Ten Contributions of Pediatric Hematology/Oncology to the Diagnosis and Treatment of Acute Lymphoblastic Leukemia

Monumental progress has occurred in the diagnosis and treatment of childhood acute lymphoblastic leukemia dating back to the classic paper of Farber and colleagues in 1948. This historical review from the perspective of an individual, familiar with many of the waystations on this superhighway, will offer an admittedly personal review of the top 10 major contributions to the field. Fortunately, there have been many more additional advances beyond these 10 as we have witnessed an impressive improvement in overall survival from a few months 75 years ago to a cure rate of 85% in the world's more advanced countries. Other workers in the field assuredly would create a different list and ranking of these advances but the takeaway summation of the make-up and order of these lists is that advances have yielded improved and prolonged responses, a rational understanding of factors, both clinical and biological, that predict response and prognosis, the application of those factors to tailor therapy's intensity and duration to those factors and to discover and design modalities and targets of therapy that target our much more complete understanding of this most common malignancy of infants and children. On a very personal note, I vividly recall an early, ill-advised decision to devote my academic career to hematology/oncology, with one glaring exception, acute lymphoblastic leukemia, and other malignancies. The stark realities of clinical practice and the harsh unmet needs and mostly unanswered challenges redirected my path that resulted in participation in many of these advances, making my own journey so gratifying and that of most of our patients so favorable.

Optimizing therapy in the modern age: differences in length of maintenance therapy in acute lymphoblastic leukemia

A majority of children and young adults with acute lymphoblastic leukemia (ALL) are cured with contemporary multiagent chemotherapy regimens. The high rate of survival is largely the result of 70 years of randomized clinical trials performed by international cooperative groups. Contemporary ALL therapy usually consists of cycles of multiagent chemotherapy administered over 2 to 3 years that includes central nervous system (CNS) prophylaxis, primarily consisting of CNS-penetrating systemic agents and intrathecal therapy. Although the treatment backbones vary among cooperative groups, the same agents are used, and the outcomes are comparable. ALL therapy typically begins with 5 to 9 months of more-intensive chemotherapy followed by a prolonged low-intensity maintenance phase. Historically, a few cooperative groups treated boys with 1 more year of maintenance therapy than girls; however, most groups treated boys and girls with equal therapy lengths. This practice arose because of inferior survival in boys with older less-intensive regimens. The extra year of therapy added significant burden to patients and families and involved short- and long-term risks that were potentially life threatening and debilitating. The Children's Oncology Group recently changed its approach as part of its current generation of trials in B-cell ALL and now treats boys and girls with the same duration of therapy. We discuss the rationale behind this change, review the data and differences in practice across cooperative groups, and provide our perspective regarding the length of maintenance therapy.

Predicting Complete Remission of Acute Myeloid Leukemia: Machine Learning Applied to Gene Expression

Machine learning (ML) is a useful tool for advancing our understanding of the patterns and significance of biomedical data. Given the growing trend on the application of ML techniques in precision medicine, here we present an ML technique which predicts the likelihood of complete remission (CR) in patients diagnosed with acute myeloid leukemia (AML). In this study, we explored the question of whether ML algorithms designed to analyze gene-expression patterns obtained through RNA sequencing (RNA-seq) can be used to accurately predict the likelihood of CR in pediatric AML patients who have received induction therapy. We employed tests of statistical significance to determine which genes were differentially expressed in the samples derived from patients who achieved CR after 2 courses of treatment and the samples taken from patients who did not benefit. We tuned classifier hyperparameters to optimize performance and used multiple methods to guide our feature selection as well as our assessment of algorithm performance. To identify the model which performed best within the context of this study, we plotted receiver operating characteristic (ROC) curves. Using the top 75 genes from the k-nearest neighbors algorithm (K-NN) model (K = 27) yielded the best area-under-the-curve (AUC) score that we obtained: 0.84. When we finally tested the previously unseen test data set, the top 50 genes yielded the best AUC = 0.81. Pathway enrichment analysis for these 50 genes showed that the guanosine diphosphate fucose (GDP-fucose) biosynthesis pathway is the most significant with an adjusted P value = .0092, which may suggest the vital role of N-glycosylation in AML.

Isolated late testicular relapse of B-cell acute lymphoblastic leukemia treated with intensive systemic chemotherapy and response-based testicular radiation: A Children's Oncology Group study

BACKGROUND

The incidence of isolated testicular relapse (ITR) of acute lymphoblastic leukemia (ALL) has decreased with contemporary treatment strategies, but outcomes are suboptimal with a 58% 5-year overall survival (OS). This study aimed to improve outcome in patients with ITR of B-cell ALL (B-ALL) occurring after 18 months of first clinical remission using intensive systemic chemotherapy and to decrease long-term sequelae by limiting use of testicular radiation.

PROCEDURE

Forty patients in first ITR of B-ALL were enrolled. Induction (dexamethasone, vincristine, daunorubicin, and intrathecal triple therapy) was preceded by one dose of high-dose methotrexate (MTX, 5 g/m² ). Following induction, 25 of 26 patients who had persistent testicular enlargement underwent testicular biopsy. Eleven had biopsy-proven disease and received bilateral testicular radiation (24 Gy), whereas twenty-nine did not.

RESULTS

Overall 5-year event-free survival (EFS)/OS was 65.0 ± 8.8%/73.1 ± 8.3%, with 5-year EFS 62.1 ± 11.0% vs. 72.7 ± 14.4% for patients who did not receive radiation therapy (XRT) (n = 29) compared with those who did (n = 11), respectively (P = 0.64). There were six second bone marrow relapses and six second ITRs. The proportion of second relapses was similar in the patients that received testicular radiation and those who did not. However, the 5-year OS was similar for patients who did not receive XRT (72.6 ± 10.2%) compared with those who did (72.7 ± 14.4%) (P = 0.85).

CONCLUSIONS

A 5-year OS rate of 73.1 ± 8.3% was obtained in children with first ITR of B-ALL occurring after 18 months of CR1 (length of first clinical remission) using intensive chemotherapy and limiting testicular radiation.

Predicting relapse risk in childhood acute lymphoblastic leukaemia

Intensive multi-agent chemotherapy regimens and the introduction of risk-stratified therapy have substantially improved cure rates for children with acute lymphoblastic leukaemia (ALL). Current risk allocation schemas are imperfect, as some children are classified as lower-risk and treated with less intensive therapy relapse, while others deemed higher-risk are probably over-treated. Most cooperative groups previously used morphological clearance of blasts in blood and marrow during the initial phases of chemotherapy as a primary factor for risk group allocation; however, this has largely been replaced by the detection of minimal residual disease (MRD). Other than age and white blood cell count (WBC) at presentation, many clinical variables previously used for risk group allocation are no longer prognostic, as MRD and the presence of sentinel genetic lesions are more reliable at predicting outcome. Currently, a number of sentinel genetic lesions are used by most cooperative groups for risk stratification; however, in the near future patients will probably be risk-stratified using genomic signatures and clustering algorithms, rather than individual genetic alterations. This review will describe the clinical, biological, and response-based features known to predict relapse risk in childhood ALL, including those currently used and those likely to be used in the near future to risk-stratify therapy.

Prediction of outcome by early bone marrow response in childhood acute lymphoblastic leukemia treated in the ALL-BFM 95 trial: differential effects in precursor B-cell and T-cell leukemia

BACKGROUND

In the ALL-BFM 95 trial for treatment of acute lymphoblastic leukemia, response to a prednisone pre-phase (prednisone response) was used for risk stratification in combination with age and white blood cell count at diagnosis, response to induction therapy and specific genetic high-risk features.

DESIGN AND METHODS

Cytomorphological marrow response was prospectively assessed on Day 15 during induction, and its prognostic value was analyzed in 1,431 patients treated on ALL-BFM 95.

RESULTS

The 8-year probabilities of event-free survival were 86.1%, 74.5%, and 46.4% for patients with M1, M2, and M3 Day 15 marrows, respectively. Compared to prednisone response, Day 15 marrow response was superior in outcome prediction in precursor B-cell and T-cell leukemia with, however, a differential effect depending on blast lineage. Outcome was poor in T-cell leukemia patients with prednisone poor-response independent of Day 15 marrow response, whereas among patients with prednisone good-response different risk groups could be identified by Day 15 marrow response. In contrast, prednisone response lost prognostic significance in precursor B-cell leukemia when stratified by Day 15 marrow response. Age and white blood cell count retained their independent prognostic effect.

CONCLUSIONS

Selective addition of Day 15 marrow response to conventional stratification criteria applied on ALL-BFM 95 (currently in use in several countries as regular chemotherapy protocol for childhood acute lymphoblastic leukemia) may significantly improve risk-adapted treatment delivery. Even though cutting-edge trial risk stratification is meanwhile dominated by minimal residual disease evaluation, an improved conventional risk assessment, as presented here, could be of great importance to countries that lack the technical and/or financial resources associated with the application of minimal residual disease analysis.

Isolated extramedullary relapse in childhood acute lymphocytic leukemia

Although the vast majority of children with acute lymphocytic leukemia attain remission with modern therapies, an unacceptably high number will suffer a disease relapse. Both the duration of remission and the site of relapse are important prognostic factors. This review focuses on leukemic relapse isolated to sites outside the bone marrow (extramedullary sites). Data from cooperative study groups as well as large single institutions are reviewed with respect to the incidence of isolated extramedullary relapse as well as the outcome following relapse. The unique anatomic and physiologic properties of the testes and the central nervous system-the two most common sites of isolated extramedullary relapse-are discussed. Finally, the evolution of leukemia therapy is reviewed, bringing into focus the goals and challenges of future therapeutic endeavors.

Long-term results of the children's cancer group studies for childhood acute lymphoblastic leukemia 1983-2002: a Children's Oncology Group Report

The Children's Cancer Group enrolled 13 298 young people age <21 years on 1 of 16 protocols between 1983 and 2002. Outcomes were examined in three time periods, 1983-1988, 1989-1995, 1996-2002. Over the three intervals, 10-year event-free survival (EFS) for Rome/National Cancer Institute standard risk (SR) and higher risk (HR) B-precursor patients was 68 and 58%, 77 and 63%, and 78 and 67%, respectively, whereas for SR and HR T-cell patients, EFS was 65 and 56%, 78 and 68%, and 70 and 72%, respectively. Five-year EFS for infants was 36, 38, and 43%, respectively. Seminal randomized studies led to a number of important findings. Stronger post-induction intensification improved outcome for both SR and HR patients. With improved systemic therapy, additional intrathecal (IT) methotrexate effectively replaced cranial radiation. For SR patients receiving three-drug induction, iso-toxic substitution of dexamethasone for prednisone improved EFS. Pegylated asparaginase safely and effectively replaced native asparaginase. Thus, rational therapy modifications yielded better outcomes for both SR and HR patients. These trials provide the platforms for current Children's Oncology Group trials.

Flow cytometric chemosensitivity assay as a predictive tool of early clinical response in acute lymphoblastic leukemia

BACKGROUND

Residual disease or rapidity of response to induction therapy is among the most powerful predictors of outcome in pediatric acute lymphoblastic leukemia (ALL).

METHOD

Utilizing a multiparameter flow cytometric chemosensitivity assay (FCCA), we studied the relationship between in vitro drug sensitivity of diagnostic leukemic blasts from 30 children with ALL and rapidity of response to induction therapy. We also analyzed the in vitro drug sensitivity of de novo leukemic blasts among various clinical subsets.

RESULTS

Compared to rapid early responders (RERs), slow early responders (SERs) had a significantly greater in vitro drug resistance to dexamethasone (DEX; P = 0.04) and prednisone (P = 0.05). The studies with all other drugs showed a non-significant trend with the SER having a higher in vitro drug resistance compared to the RER. Risk group stratified analyses indicated that in vitro resistance to asparaginase (ASP), DEX, and vincristine (VCR) were each significantly related to having very high risk ALL. Additionally, a significantly higher in vitro drug resistance to ASP and VCR was associated with unfavorable lymphoblast genetics and ultimate relapse.

CONCLUSION

Our data indicate that this FCCA is a potentially simple and rapid method to detect inherent resistance to initial ALL therapy very early in induction, thus allowing for treatment modification shortly thereafter.

Survival outcome in childhood ALL: experience from a tertiary care centre in North India

BACKGROUND

Survival of children with ALL, in developing nations has not kept pace with cure rates in developed countries. Our study was designed to assess survival data and identify risk factors.

PROCEDURE

Data of 762 patients with ALL were analyzed. Information regarding the clinical-demographic profile, therapy and course of illness were recorded. Status and duration at last follow-up were utilized to generate Kaplan-Meier survival curves.

RESULTS

The mean age was 5.7 +/- 0.23 years (M/F, 3.2:1). Parents of 230 (30.2%) patients opted for no therapy. There were 68 and 60 deaths in induction and remission phases respectively. Besides these, 111 children either defaulted therapy or were lost to follow up. Relapsed disease was documented in 125 cases. The 5-year OS and EFS was 46% and 43% respectively. Survival analysis, using the Cox multivariate regression, for gender (P = 0.659, CI: 0.852-1.161), age (P = 0.943, CI: 0.725-1.225), symptom-diagnosis interval (P = 0.002, CI: 1.116-1.668), WCC (P < 0.001, CI: 1.353-1.814) and platelet count (P = 0.001, CI: 0.546-0.849) was performed. Bulk disease (P = 0.049, CI: 0.428-0.986), mediastinal adenopathy (P = 0.045, CI: 1.040-3.697), WCC (P = 0.016, CI: 1.395-2.691), platelet count (P = 0.031, CI: 0.431-0.967) and administration of 2 intensification blocks (P = 0.012, CI: 0.624-0.940) were found to be significant predictors of outcome by multivariate analysis.

CONCLUSIONS

The management of ALL requires financial resources and access to quality supportive care. One third of our patients opted for no therapy. The other problem areas were a high proportion of therapy defaulters, lost to follow up and infection related deaths during induction and remission phases. The introduction of remedial measures for resolving the difficulties identified would hopefully improve cure rates in ALL in developing nations.

Prevalence and Correlates of Fatigue in Long-Term Survivors of Childhood Leukemia

Purpose

To estimate the prevalence of fatigue, identify the factors associated with fatigue, and to explore the relationship between fatigue and quality of life (QOL) in long-term survivors of childhood acute lymphoblastic leukemia (ALL).

Methods

One hundred sixty-one ALL survivors diagnosed at Childrens Hospital Los Angeles (Los Angeles, CA) before age 18 years and between January 1, 1975 and December 31, 1995, participated in a structured telephone interview. Participants were aged 18 to 41 years and off treatment for an average of 14 years. Four measures of fatigue, including the Revised–Piper Fatigue Scale, were used to assess fatigue; depression was assessed using the Center for Epidemiological Studies Depression Scale. Multivariate logistic regression models were developed to identify factors associated with fatigue and depression.

Results

Prevalence of fatigue (30%) fell within the general population normal limits. Fatigue and depression were highly correlated (Pearson r = 0.75). Fatigue was associated with marriage (OR = 0.11; 95% CI, 0.02 to 0.50), having children (OR = 5.80; 95% CI, 1.30 to 25.82), sleep disturbances (OR = 6.15; 95% CI, 2.33 to 16.22), pain (OR = 5.56; 95% CI, 2.13 to 14.48), obesity (OR = 3.80; 95% CI, 1.41 to 10.26), cognitive impairment (OR = 2.56; 95% CI, 1.02 to 6.38), and exercise-induced symptoms (OR = 2.98; 95% CI, 1.11 to 8.02). Four factors associated with fatigue were also associated with depression: sleep disturbances, pain, obesity, and cognitive impairment. Fatigue was inversely related to QOL.

Conclusion

Some survivors of childhood ALL experience fatigue many years after treatment. Fatigued survivors represent a high-risk subgroup as they report more depression and poorer QOL than nonfatigued survivors and their peers.

Comparison of multidimensional flow cytometry with standard morphology for evaluation of early marrow response in pediatric acute lymphoblastic leukemia

PURPOSE

We compared multidimensional flow cytometry (MDF) with morphology in evaluating early marrow response to induction chemotherapy in pediatric ALL.

METHODS

Chemotherapy response was determined by standard morphology or by MDF assessed by residual leukemic cell percentage remaining in the marrow on days 7, 14, and 28 of induction. Bone marrow response was classified as M3 (>25% leukemic blasts) or M1/M2 (< or = 25% leukemic blasts). Multidimensional flow cytometry evaluation was compared with that of standard morphology. Available day-7 and day-14 marrow slides were also reevaluated by a single pathologist without patients' clinical information.

RESULTS

Of 46 day-7 specimens, eight (17%) had discordant MDF and morphologic results (P < 0.001), including six classified as M3 by morphology but were M1/M2 by MDF, and two were classified as M3 by MDF but were M1/M2 by morphology. Of 24 day-14 bone marrow specimens, five (20.5%) were discordant (P < 0.001), including two classified as M3 by morphology but were M1/M2 by MDF, and three were classified as M3 by MDF but were M1/M2 by morphology. Reevaluation of the blinded day-7 and day-14 marrow slides yielded discordance between repeated pathology readings of 11% (P < 0.001) and 6% (P = 0.04), respectively.

CONCLUSION

Our data show significant discordance between the morphologic and MDF evaluation of early marrow response. Early response to therapy is a significant prognostic indicator in pediatric acute lymphoblastic leukemia and is used to alter subsequent treatment; thus, precise assessment of response is important. A larger comparison of MDF with morphology for the evaluation of early response, including correlation with clinical outcome, is warranted.

Early response to chemotherapy as a prognostic factor in childhood acute lymphoblastic leukaemia: a methodological review

Published studies of the prognostic value of the early response to induction treatment in childhood acute lymphoblastic leukaemia (ALL) were analysed. Three criteria were used to judge the early treatment response: persistence of peripheral blasts (PPB) or of bone marrow blasts (PBMB) during induction therapy and minimal residual disease (MRD) after completion of induction therapy. Studies with more than 50 patients, published between 1980 and 2000, were reviewed. Among 13 659 distinct articles published on ALL, we identified only 43 applicable studies. Within- and between-laboratory variations were evaluated in only one study. Treatment modalities differed among, and sometimes within, studies. The cut-off points used in the statistical analyses were never discussed, and in many studies appeared to be selected after multiple tests. The proportion of missing data was > 30% in almost all studies of MRD, as a result of technical difficulties and not missing samples. PPB and PBMB were associated with shorter survival in, respectively, 13 out of 14 and 15 out of 16 studies. Detection of MRD was associated with poor outcome in 12 of the 13 studies. Because none of the parameters used to measure the early response to induction therapy for childhood ALL have been properly assessed as prognostic factors, we conclude that they should be considered only as candidate prognostic indicators pending more thorough studies.

Use of recombinant human granulocyte colony-stimulating factor to increase chemotherapy dose-intensity: a randomized trial in very high-risk childhood acute lymphoblastic leukemia

PURPOSE

To determine whether the use of a recombinant human granulocyte colony-stimulating factor ([G-CSF] lenogastrim) can increase the chemotherapy dose-intensity (CDI) delivered during consolidation chemotherapy of childhood acute lymphoblastic leukemia (ALL).

PATIENTS AND METHODS

Sixty-seven children with very high-risk ALL were randomized (slow early response to therapy, 55 patients; translocation t(9;22) or t(4;11), 12 patients). Consolidation consisted of six courses of chemotherapy; the first, third, and fifth courses were a combination of high-dose cytarabine, etoposide, and dexamethasone (R3), whereas the second, fourth, and sixth courses included vincristine, prednisone, cyclophosphamide, doxorubicin, and methotrexate (COPADM). G-CSF was given after each course, and the next scheduled course was started as soon as neutrophil count was > 1 x 10(9)/L and platelet count was > 100 x 10(9)/L. CDI was calculated using the interval from day 1 of the first course to hematologic recovery after the fifth course (100% CDI = 105-day interval).

RESULTS

CDI was significantly increased in the G-CSF group compared with the non-G-CSF group (mean +/- 95% confidence interval, 105 +/- 5% v 91 +/- 4%; P <.001). This higher intensity was a result of shorter post-R3 intervals in the G-CSF group, whereas the post-COPADM intervals were not statistically reduced. After the R3 courses, the number of days with fever and intravenous antibiotics and duration of hospitalization were significantly decreased by G-CSF, whereas reductions observed after COPADM were not statistically significant. Duration of granulocytopenia was reduced in the G-CSF group, but thrombocytopenia was prolonged, and the number of platelet transfusions was increased. Finally, the 3-year probability of event-free survival was not different between the two groups.

CONCLUSION

G-CSF can increase CDI in high-risk childhood ALL. Its effects depend on the chemotherapy regimen given before G-CSF administration. In our study, a higher CDI did not improve disease control.

Clinical importance of speed of response to therapy in childhood lymphoblastic leukaemia

Speed of response to therapy predicts outcome in childhood lymphoblastic leukaemia. This observation has been made studying both blood and bone marrow in children on widely differing treatment regimens from the 1970s to the present day. It appears to be independent of other classical prognostic factors such as age and diagnostic white cell count. Currently some major collaborative groups are using the rate of initial disease clearance to risk-stratify subsequent therapy and this practice may increase. The best way to measure the rate of disease clearance remains to be defined. Watching disappearance of peripheral blood blasts is the least invasive method but possibly the least sensitive. Molecular quantitation of minimal residual disease (MRD) after achievement of conventional remission is much more sensitive but less specific. It cannot be applied to all patients and is costly and time consuming. The degree of marrow infiltration remaining after 7 or 14 days may fall between the two but is often difficult to estimate reliably and reproducibly due to technical limitations. The three techniques may reflect response to therapy in a way slightly different from each other and may not be direct correlates. The best compromise may be to use all three but to reserve MRD study only for those who clear their blood and bone marrow after 7 days.

Pharmacodynamic monitoring of cancer chemotherapy: childhood acute lymphoblastic leukemia as a model

Childhood acute lymphoblastic leukemia (ALL) has long served as a model of disseminated cancer that can be cured with chemotherapy. Although pharmacokinetic variability has been shown to influence the efficacy of ALL chemotherapy, the usefulness of conventional pharmacokinetic measures to predict responses to individual chemotherapeutic agents can be confounded in the context of multiagent chemotherapy. This has led to the concomitant use of pharmacodynamic endpoints to identify patients who exhibit a poor initial response to therapy or whose residual disease has a persistence that predicts a poor prognosis unless therapy is changed. To this end, the initial reduction of leukemia cells in peripheral blood or in bone marrow and the detection of minimal residual disease by immunologic or polymerase chain reaction-based methods have shown promise as pharmacodynamic endpoints to identify patients who are at high risk for relapse if therapy remains unchanged. Prospective clinical trials are needed to determine the clinical usefulness of pharmacodynamic monitoring and to define more precisely the integration of pharmacokinetic and pharmacodynamic monitoring to optimize the treatment of childhood ALL.

Critical study of prognostic factors in childhood acute lymphoblastic leukaemia: differences in outcome are poorly explained by the most significant prognostic variables. Fralle group. French Acute Lymphoblastic Leukaemia study group

We determined the proportion of survival variability explained by the usual prognostic factors in childhood acute lymphoblastic leukaemia (ALL) during a prognostic study of 1552 patients enrolled in three consecutive Fralle group protocols (Fralle 83, Fralle 87 and Fralle 89). The event-free survival rates at 5 years were 54.8% (SD 1.9), 43.1%) (SD 2.7) and 55.6% (SD 2.2), respectively. In the univariate analysis the following variables were predictive of poor outcome: male gender, elevated leucocytosis (> 50 x 10(9)/l), circulating blastosis. haemoglobin >12 g/dl, platelet count <100 x 10(9)/l, age under 1 year or over 9 years, enlarged mediastinum, nodes, spleen and liver, T phenotype, absence of CD10+ cells; testicular and meningeal involvement, poor response to induction therapy (CCSG M3), and LDH >400 U/l. Among the cytogenetic features, hyperdiploidy had a protective effect, whereas hypodiploidy, translocation and other structural abnormalities had a negative influence, particularly in cases of t(9;22) or t(4;11). Multivariate analysis summarized the prognostic information in terms of four variables: age, gender, leucocytosis and cytogenetic features. Missing data had little influence on the results. However, despite their significance in the multivariate analysis, these four variables each had very low predictive power (1.1% for gender, 2.0% for age, 3.5% for leucocytosis, and 1.6% for cytogenetic features). Thus, the most significant prognostic factors in childhood ALL each explain no more than 4% of the variability in prognosis. This may explain the disappointing practical value of these factors and underlines the need for prognostic tools in childhood ALL.

Augmented post-induction therapy for children with high-risk acute lymphoblastic leukemia and a slow response to initial therapy

BACKGROUND

Children with high-risk acute lymphoblastic leukemia (ALL) who have a slow response to initial chemotherapy (more than 25 percent blasts in the bone marrow on day 7) have a poor outcome despite intensive therapy. We conducted a randomized trial in which such patients were treated with either an augmented intensive regimen of post-induction chemotherapy or a standard regimen of intensive post-induction chemotherapy.

METHODS

Between January 1991 and June 1995, 311 children with newly diagnosed ALL who were either 1 to 9 years of age with white-cell counts of at least 50,000 per cubic millimeter or 10 years of age or older, had a slow response to initial therapy, and entered remission at the end of induction chemotherapy were randomly assigned to receive standard therapy (156 children) or augmented therapy (155). Those with lymphomatous features were excluded. Event-free survival and overall survival were assessed from the end of induction treatment.

RESULTS

The outcome at five years was significantly better in the augmented-therapy group than in the standard-therapy group (Kaplan-Meier estimate of event-free survival [+/-SD]: 75.0+/-3.8 vs. 55.0+/-4.5 percent, P<0.001; overall survival: 78.4+/-3.7 vs. 66.7+/-4.2 percent, P=0.02). The difference between treatments was most pronounced among patients one to nine years of age, all of whom had white-cell counts of at least 50,000 per cubic millimeter (P<0.001). Risk factors for an adverse event in the entire cohort included a white-cell count of 200,000 per cubic millimeter or higher (P=0.004), race other than black or white (P<0.001), and the presence of a t(9;22) translocation (P=0.007). The toxic effects of augmented therapy were considerable but manageable.

CONCLUSIONS

Augmented post-induction chemotherapy results in an excellent outcome for most patients with high-risk ALL and a slow response to initial therapy.

Early response to therapy and outcome in childhood acute lymphoblastic leukemia: a review

BACKGROUND

Early response to therapy is defined as the initial response prior to Day 28 of treatment, the conventional time of marrow evaluation. The number of reports linking early response to therapy with the ultimate outcome of childhood acute lymphoblastic leukemia is substantial and growing. When this study began, these experiences had yet to be comprehensively reviewed.

METHODS

A comprehensive search of the published literature yielded contributory reports of 14 trials conducted in the United States and Europe. In addition, unpublished data from one Children's Cancer Group trial were made available. Outcome measures were standardized by conversion to ratios of the incidence of adverse events among poorer and better responders.

RESULTS

Early response to therapy was an independent prognostic factor in each of the 15 trials, which together included more than 10,000 patients. The incidence of slower early response ranged from 2-33%, with various measures and criteria used in different trials. Patients with a slower early response were 1.5-6.1 times (median, 2.7) more likely to have an adverse event than patients with a more rapid early response, however defined. Early response maintained prognostic significance after the exclusion of induction failure and within risk strata defined by age, white blood cell count, and/or immunophenotype. Its significance was also maintained in multivariate analyses where performed.

CONCLUSIONS

Early response to therapy, whether determined by evaluation of bone marrow or peripheral blood, is a consistent, independent prognostic factor in childhood acute lymphoblastic leukemia. Slower early response may serve as a useful surrogate for outcome, a more complex end point, in investigations of the cellular and molecular determinants of resistance to therapy. It may also allow early identification of a patient subpopulation for whom current therapy is less effective and alternative strategies may be justified.

[Testicular biopsy at the stopping of the treatment in acute lymphoblastic leukemia: value of the immunohistochemical detection of residual blasts]

BACKGROUND

The prognostic value of clinical and histological detection of testicular leukemia after completion of therapy is still debated. Immunohistochemical study could improve the results of this detection.

PATIENTS AND METHODS

Between 1982 and 1992, 70 consecutive boys with acute lymphoblastic leukemia (ALL) and treated with the same therapeutic regimen were included in the study. Testicular biopsy (TB) was surgical and bilateral. One piece of tissue was fixed and analysed by conventional microscopy. An immunohistochemical study was performed on the other sample with a panel of anti-T and anti-B Mc Ab, including JCB 117 (anti-CD79a) which stains early pre B lymphoblasts.

RESULTS

Twenty-five children relapsed while on treatment and did not undergo TB. Among the 45 boys who underwent routine TB, one had a diffuse infiltration seen in conventional histology. Thirty-nine had normal morphological and immunohistochemical study: among them, six relapsed subsequently in bone marrow; in this group, event free survival (EFS) was 85 +/- 10% with a median follow-up of 80 months after the biopsy. In the five remaining boys, anti-CD79a was found positive on blasts in four cases and anti-CD3 in one case; four of those relapsed, including two in the testes during the year following the biopsy; EFS was 20 +/- 36% (P = 0.001).

CONCLUSIONS

New Mc Ab such as JCB 117 (anti-CD79a) might detect a minimal residual disease in the testes of children treated for ALL, particularly on routine histological material. These results, if confirmed in larger series, might influence further therapeutic strategy.

Craniospinal irradiation for acute lymphoblastic leukemia with central nervous system disease at diagnosis: a report from the Children's Cancer Group

PURPOSE

This study attempted to determine if central nervous system (CNS) disease at diagnosis is a poor prognostic factor in children with acute lymphoblastic leukemia (ALL) and whether 6 Gy of spinal irradiation is an adequate dose for these patients.

METHODS AND MATERIALS

Previously the Children's Cancer Group (CCG) treated patients with ALL and CNS disease at diagnosis with cranio (24 Gy)-spinal (12 Gy) irradiation, as well as systemic and intrathecal chemotherapy. In a series of CCG trials completed in 1989 the spinal dose was empirically reduced to 6 Gy for patients receiving systemic chemotherapy with an intensive consolidation phase to limit hematopoietic toxicity. The spinal dose was left at 12 Gy for patients treated with a less intensive consolidation phase.

RESULTS

With a median follow-up for surviving patients of 74 months, the 5-year event-free survival for 53 patients with CNS disease at diagnosis was 69 +/- 13% (+/- 2 standard deviations), similar to the value obtained for 3364 patients without CNS disease, 67 +/- 2%. Corresponding values for 5-year survival were 77 +/- 12% and 80 +/- 1%, and for freedom from isolated first CNS relapse, were 90 +/- 9% and 94 +/- 1%. Event-free survival, survival, and freedom from isolated first CNS relapse in the 6-Gy group were as good as in the 12-Gy group.

CONCLUSION

CNS disease at diagnosis is not a poor prognostic factor for children with ALL who are treated with intensive systemic chemotherapy, craniospinal irradiation, and intrathecal chemotherapy. Six Gy is an adequate dose of spinal irradiation for these patients.

Randomized comparison of moderate-dose methotrexate infusions to oral methotrexate in children with intermediate risk acute lymphoblastic leukemia: a Childrens Cancer Group study

Methotrexate (MTX) infusions of 500--1,000 mg/m2 over 24 hours may improve survival and prevent relapse in children with acute lymphoblastic leukemia (ALL). Childrens Cancer Group (CCG) Study 139 compared weekly oral methotrexate 20 mg/m2/week (oral MTX) to MTX 500 mg/m2 infused over 24 hours (IV MTX) three times during consolidation and every 6 weeks during maintenance in 164 children with intermediate-risk ALL, i.e., those patients over age 1 year with white blood cell count 10,000 to 49,999/ml and no bulky extramedullary disease. Median follow-up for CCG-139 exceeded 75 months. Thirty-four events occurred among 80 patients receiving IV and oral MTX and 36 events among 84 patients receiving oral MTX. Two children died during induction and one did not enter remission. Remission induction rate is 98%. There have been 26 marrow relapses, 11 combined marrow and extramedullary relapses, 24 CNS relapses, and five testicular or other relapses. The frequency and distribution of relapses does not differ between the two regimens. For the entire group, overall event-free survival (EFS) at 6 years is 57.9% (standard deviation=4.0%) and actuarial survival is 80.0% (standard deviation =3.3%). Of the 29 patients with isolated extramedullary relapse, 18 survive free of a second event, a median of 42 months from relapse. In contrast to other trials, this trial does not show that IV MTX in this dose and schedule offers an advantage over standard therapy for this group of children.

Prognostic variables and survival in pediatric acute lymphoblastic leukemias: cancer institute experience

This presentation is an analysis of front-end prognostic variables in achieving a complete response, a continuous complete remission, and disease-free survival in pediatric acute lymphoblastic leukemia at the Cancer Institute, Madras, India between 1983 and 1988. The clinical characteristics at presentation showed that virtually 100% of patients belong to the poor risk category, age < 3 years of > 6 years 72.2%, WBC > 10,000/mm3 59.8%, blast count > 50% 39.2%, organomegaly 91.8%, and L2 morphology 66.0%. All patients had more than one risk factor. Between 1983 and 1988, 97 children were treated on a pilot protocol designed in collaboration with the Lymphoma Biology Division of the Pediatric Oncology Branch of the National Cancer Institute, Bethesda, Maryland. The protocol was designed for a poor prognostic group. The significance of implicated poor prognostic factors was analyzed using the Cox proportional hazard model. Age at presentation was the only variable that emerged as an independent risk factor, and sex appeared to be a modifier. No other variables attained significance. Survival data were calculated by the Kaplan-Meier method. The relapse-free and event-free survivals up to 10 years were 50.7% and 38.1%, and compare reasonably well with results reported for similar groups elsewhere for the same period.

Prognostic value of early response to chemotherapy assessed by the day 15 bone marrow aspiration in adult acute lymphoblastic leukemia: a prospective analysis of 437 cases and its application for designing induction chemotherapy trials

The early response to induction chemotherapy assessed by the percentage of residual blast cells in the D15 bone marrow aspiration was prospectively evaluated in 437 patients included in the same multicentric trial of newly diagnosed adult acute lymphoblastic leukemia (LALA87). Among them, 286 patients (65.4%) had < or = 5% residual blasts and their complete remission (CR) rate at D28 was 91% while the CR rate at D28 was only 34% for the 151 patients (34.6%) with more than 5% blasts at D15 of the induction chemotherapy. The persistence of more than 5% of blasts was associated with a significantly worse overall survival (P < 0.0001) and worse disease-free survival (P = 0.02). These data are used as a support for simulating different strategies in order to improve CR rates in future clinical trials. Results are consistent with the fact that D15 marrow evaluation might be a relevant test allowing an early intensification of a subgroup of patients predicted to fail with conventional induction chemotherapy.

Trends in survival after childhood cancer in Denmark, 1943-87: a population-based study

Survival from cancer in childhood and adolescence was studied in a population-based series of 8312 cases in children aged 0-19 years notified to the Danish Cancer Registry during 1943-87. During the first period (1943-72), 5-year survival rates from all malignant neoplasms increased from 23% (1943-52) to 33% (1963-72). The greatest improvement was seen during the period 1973-87 when 5-year survival rates reached 64% (1983-87). Between 1973-77 and 1983-87, 5-year survival rates increased from 32% to 62% for leukaemia, from 40% to 70% for acute lymphoblastic leukaemia, from 35% to 54% for non-Hodgkin's lymphoma, from 50% to 66% for central nervous system neoplasms and from 25% to 49% for bone tumours. An improvement in 5-year survival rates from Wilms' tumour was seen between 1960 (19%) and 1980 (81%). Up to 1972, the 5-year survival rate from germ-cell neoplasms was approximately 40%; among patients diagnosed in 1983-87, 76% survived for 5-years. Annual lethality decreased by 2.5% for all malignant neoplasms in 1943-72 and by 4.4% in 1972-87. Lethality was similar for boys and girls during the period 1943-72, but was significantly lower for girls subsequently. A marked effect of age at diagnosis was seen in the early registration period, where lethality rate for the age group 0-9 years was substantially higher compared with that in the age group 10-19 years. This inequality persisted only for children less than 2 years of age at the time of diagnosis in the later period.

Gender and treatment outcome in childhood lymphoblastic leukaemia: report from the MRC UKALL trials

We have examined the factors influencing prognosis in over 4000 children with acute lymphoblastic leukaemia (ALL) aged 1-14 who have been treated on consecutive MRC UKALL trials from 1972 to 1990. During this time the results of treatment have improved steadily but are consistently superior in girls when compared with boys; the 5-year event-free survival in girls improving from 51% to 71% and in boys from 31% to 57%. These results were independent of age and presenting leucocyte count. Boys not only had a testicular relapse rate of 10% but an excess of bone marrow relapse, particularly evident after 2 years from diagnosis. Other prognostic factors included organomegaly and the morphology of leukaemic blast cells; immunophenotype of the leukaemia, however, had no independent significance after allowance for age, sex and leucocyte count. The influence of sex on prognosis was reaffirmed when we examined various methods of identifying children at highest risk of treatment failure for whom alternative therapy such as bone marrow transplantation might be justified. In MRC UKALL X children had been deemed 'high risk' on the basis of leucocyte count alone, but with further follow-up it has become apparent that girls with an initial leucocyte count of > 100 x 10(9)/l have a similar prognosis to boys with a lower count. We therefore derived a risk score based on sex, age and count which has given better discrimination between standard risk (66% 5-year survival) and poor risk (39%) survival than other methods. This group of worse-risk children includes 16% of boys but only 3% of all girls. Gender remains an important prognostic factor in UKALL trials and there are very few girls who are at highest risk of treatment failure. The reasons for this remain unclear, but the pattern of relapses suggests that boys more often get inadequate systemic therapy. We postulate that the reasons for treatment failure may relate to sensitivity to continuing (maintenance) chemotherapy.

Intensification of treatment and survival in all children with lymphoblastic leukaemia: results of UK Medical Research Council trial UKALL X. Medical Research Council Working Party on Childhood Leukaemia

The UK Medical Research Council trial MRC UKALL X was designed to investigate the benefit of one or two courses of additional intensification therapy in children with acute lymphoblastic leukaemia receiving standard treatment. From 1985 to 1990 1612 children, comprising more than 90% of eligible cases in the UK, were treated with intensive induction therapy, central nervous system directed therapy with cranial irradiation and intrathecal methotrexate, and continuing treatment for 2 years. 1171 children were randomised to receive additional intensification therapy at 5 weeks, 20 weeks, both, or neither. At follow-up of at least 3 years disease-free survival for all children at 5 years was 62% (95% confidence interval [Cl] 60.0-64.4), a significant improvement over the 56% (53.0-59.6) found in the preceding MRC UKALL trial. The 5-year disease-free survival was 71% (65.5-76.1) for children randomised to two blocks of intensification therapy, this being significantly better than the 62% (56.6-68.0), 61% (55.7-67.1), and 57% (50.9-62.7) rates for the groups randomised to one intensification block at 5 weeks, one at 20 weeks, and no intensification, respectively. The benefits of intensification therapy were seen irrespective of clinical factors known to influence outcome such as age, sex, and initial leucocyte count. We conclude that the addition of two courses of intensification therapy has produced a 14% improvement in disease-free survival and an 11% improvement in overall survival for the randomised patients. This additional treatment is of benefit to all children with acute lymphoblastic leukaemia, even those traditionally deemed at lower risk of relapse.

Early cytoreduction: a major prognostic factor in adult acute lymphoblastic leukemia

Prognostic factors in acute lymphoblastic leukemia (ALL) are used for treatment stratification of ALL. Definition of simple parameters such as the presence or absence of peripheral leukemic cells after one week of treatment could help for stratification. A retrospective study was conducted on 79 previously untreated adult patients with ALL followed in the Hematology department of Hotel Dieu from 1981 to 1991. 84% of patients achieved complete remission (CR), 7% were refractory to induction treatment, and 7 patients (9%) died during the first month after diagnosis. After multivariate analysis the only independent statistically significant factors for achieving CR were the absence of peripheral blast cells at day 7 (PBC D7) (p = 0.009) and age (< 50 years) (p = 0.03). For CR duration the same independent statistically significant factors were found (PBC D7 = 0 versus > 0, p = 0.008; and age < or > or = 30 years, p = 0.045). The PBC D7 value was more significant when circulating blast cells were present at diagnosis. In patients with more than 50,000 PBC at diagnosis, the 10- years event free disease was 62% +/- 20% when PBC were absent at day 7 versus 0% when PBC were present (p < 0.002). All 20 patients with prolonged DFS had PBC D7 = 0 achieving CR by 28 days. The persistence of PBC at Day 7 could be used as a factor to identify a subgroup of poor prognosis adults with ALL.

Treatment of overt isolated testicular relapse in children on therapy for acute lymphoblastic leukemia. A report from the Childrens Cancer Group

BACKGROUND

Fifty-seven children with acute lymphoblastic leukemia (ALL) receiving therapy who experienced overt isolated testicular relapse while in bone marrow remission were entered into a study that featured an intensive retreatment regimen.

METHODS

The objective was to determine whether a change in chemotherapy and local irradiation would prevent subsequent marrow relapse and increase the survival rate. The regimens used (modified Berlin-Frankfurt-Munster or modified New York) delivered acceptable therapy based on analyses of toxicity data.

RESULTS

Overall survival at 5 years from the time of testicular relapse was 47%, with an event-free survival of 43%. Events have been documented in 28 of 55 evaluable children. Analysis of these patients revealed that 23 children had bone marrow relapse, 4 children had central nervous system relapse, and 1 child had testicular relapse. In addition, two patients were removed from the study for toxicity, one child for infection (mucormycosis), and five children had a bone marrow transplantation while in remission and became ineligible to continue in the study. Two children were removed at the request of their parents, and nine children were lost to follow-up.

CONCLUSION

Because of their high risk of developing systemic relapse, boys with ALL who experience isolated overt testicular relapse during active therapy should be retreated with intensive treatment.

The role of radiation therapy in the treatment of acute lymphoblastic leukemia with lymphomatous presentation: a report from the Childrens Cancer Group

PURPOSE

Childrens Cancer Group 123 was a trial of intensive multidrug chemotherapy as well as cranial irradiation and bulk disease irradiation in children with acute lymphoblastic leukemia with lymphomatous presentation (bulk disease and either T-cell phenotype, high white blood count, or absence of anemia), a poor prognostic group with an increased risk of central nervous system (CNS) and other extramedullary recurrence.

METHODS AND MATERIALS

Three hundred eight patients without CNS disease were randomized among three regimens: A--BFM chemotherapy (designed for high risk ALL patients) with 1800 cGy cranial irradiation; B--LSA2L2 chemotherapy (designed for non-Hodgkins lymphoma patients) with 1800 cGy cranial irradiation and 1500 cGy to nonabdominal bulk disease; C--Reg B without cranial irradiation. All patients received intrathecal methotrexate throughout therapy. Radiation treatment records were reviewed.

RESULTS

With a minimum 52-month follow-up, Regimen B and C patients had 5-year actuarial CNS relapses of 7% and 17% (p = 0.01) and event-free survivals of 53% and 39% (p = 0.04). Patients with white blood count < 50,000/mm3 did not benefit from cranial irradiation. Regimen A patients had the same CNS relapse rate as Regimen B patients but an improved event-free survival. Regimen B and C patients with large mediastinal masses who received their assigned chest radiation had a lower event rate than those who did not (p = 0.06). Patients whose cranial fields did or did not encompass the entire meningeal surface had equivalent CNS relapse rates.

CONCLUSION

Patients treated with LSA2L2 chemotherapy, a less than optimal regimen, benefited from cranial and mediastinal irradiation. Compliance with radiation volume guidelines was not essential for patients to receive the benefit of cranial irradiation.

Final height after treatment for childhood acute lymphoblastic leukemia: comparison of no cranial irradiation with 1800 and 2400 centigrays of cranial irradiation

We analyzed growth and final heights in 127 patients (68 female patients) treated for childhood acute lymphoblastic leukemia. Central nervous system prophylaxis included either no cranial radiation therapy (CRT) (n = 38), irradiation with 1800 centigrays (cGy) (n = 36), or irradiation with 2400 cGy (n = 53). None of the patients received spinal irradiation. Mean (+/- SEM) age at diagnosis was 6.4 +/- 0.25 years, mean height standard deviation score (SDS) at diagnosis was 0.28 +/- 0.12, and mean age at final height was 18.26 +/- 0.19 years. The change in height SDS between diagnosis and achievement of final height was significant for all treatment groups: -0.49 +/- 0.14, no CRT; -0.65 +/- 0.15, 1800 cGy; and -1.38 +/- 0.16, 2400 cGy. Irradiated patients had a greater loss in height SDS compared with the nonirradiated patients (p < 0.01), and those treated with 2400 cGy CRT had a greater decrease in final height SDS than the patients treated with 1800 cGy (p < 0.01). Both younger age and female sex were significantly associated with a greater decrease in height SDS in the patients treated with CRT; girls < or = 4 years of age at diagnosis had a mean loss in height SDS that was more than twice that observed for others treated with the same dose of CRT. Thus, although modern regimens for acute lymphoblastic leukemia (no CRT or 1800 cGy CRT) appear overall to have only a modest impact on final height, patients, especially girls, treated with 1800 cGy CRT at a young age remain at risk for clinically significant growth failure.

Second neoplasms after acute lymphoblastic leukemia in childhood

BACKGROUND

Effective forms of treatment for acute lymphoblastic leukemia (ALL) in childhood now result in survival rates above 70 percent at five years, but the treatments are potentially carcinogenic. To determine the magnitude of this risk and identify possible risk factors for the development of second neoplasms, we studied a large cohort of children treated for ALL. METHODS AND RESULTS. We undertook a retrospective cohort study of 9720 children who had been given a diagnosis of ALL between June 1972 and August 1988 and had been treated according to the therapeutic protocols of the Children's Cancer Study Group. The median follow-up was 4.7 years (range, 2 months to 16 years). We found that 43 second neoplasms occurred among the children in the cohort, including 24 neoplasms of the central nervous system, 10 new leukemias and lymphomas, and 9 other neoplasms. This represented a 7-fold excess of all cancers and a 22-fold excess of neoplasms of the central nervous system. The estimated cumulative proportion of children in whom a second neoplasm developed was 2.53 percent 15 years after diagnosis (95 percent confidence limits, 1.74 percent and 3.38 percent). An even higher risk, particularly of central nervous system tumors, was evident in children five years of age or less at the time of the diagnosis of ALL (P = 0.012). All central nervous system neoplasms developed in children who had previously undergone irradiation. There was no association with exposure to cyclophosphamide or anthracyclines.

CONCLUSIONS

There is a substantial excess of second neoplasms, especially of the central nervous system, among children treated for ALL. Children five years old or younger and those receiving radiation are at higher risk, especially for second tumors arising in the central nervous system.

Cognitive function in children with leukemia. Effect of radiation dose and time since irradiation

The effect of two cranial radiation (CRTX) doses and the time since radiation therapy on cognitive functioning were studied in 35 children who completed therapy for acute lymphoblastic leukemia (ALL). The patients were grouped according to CRTX dose (2400 or 1800 cGy) and evaluated for general intelligence, academic achievement, and visual motor integration. Those who received 2400 cGy (n = 20) scored ten points below those treated with 1800 cGy (n = 15) on verbal intelligence quotient and achievement tests of reading, spelling, and arithmetic. The effect of time since radiation therapy on these measures of cognitive function was significant (P = 0.001 to 0.03); the effect of CRTX dose was not. Visual motor integration scores in both groups fell below the 33rd percentile. The effect of CRTX dose and time since radiation therapy on visual motor integration and performance intelligence quotient were not significant. Thus, the interval between treatment and the emergence of cognitive impairments may be longer after lower CRTX doses, and deficits in nonverbal areas such as visual motor integration may appear first. A larger study is needed to confirm these findings from a limited sample of long-term survivors of ALL.

Clinical importance of myeloid-antigen expression in acute lymphoblastic leukemia of childhood

BACKGROUND

Leukemic cells in 15 to 25 percent of patients with acute lymphoblastic leukemia (ALL) express myeloid antigens as well as lymphoid antigens (the latter reflecting B-cell or T-cell lineage). The relations of myeloid-antigen expression to other features of ALL and to prognosis have been controversial.

METHODS

We analyzed clinical and laboratory features present at diagnosis in 236 consecutive cases of ALL in children. Immunophenotyping, including single- and dual-fluorescence analyses, was used to classify leukemic cells as B or T lymphoblasts and also to identify myeloid-antigen expression--the simultaneous expression of lymphoid-associated antigens and at least one of three myeloid-associated antigens (CD33, CD13, and CD14) on cells classified as L1 or L2 according to the French-American-British system.

RESULTS

Forty-five of 185 patients with B-lineage ALL had myeloid-antigen expression, as did 8 of 41 patients with T-lineage ALL. In 10 patients, the lineage could not be determined. Myeloid-antigen expression was associated with L2 morphology (P less than 0.05), but it did not correlate with other prognostic features recognized previously. Multivariate analysis showed that myeloid-antigen expression was an important predictor of relapse in childhood ALL and the most significant prognostic factor statistically (P less than 0.0001). A white-cell count greater than or equal to 50 x 10(9) per liter at diagnosis was also an important and highly significant prognostic feature (P less than 0.001). After 40 months, the estimated disease-free survival for patients with ALL was 84 percent for those without myeloid-antigen expression and with a low white-cell count, 57 percent for those without myeloid-antigen expression and with a high white-cell count, 47 percent for those with myeloid-antigen expression and a low white-cell count, and 26 percent for those with myeloid-antigen expression and a high white-cell count (P less than 0.00001).

CONCLUSIONS

Myeloid-antigen expression is an important independent predictor of a poor response to chemotherapy in childhood ALL.

Initial electroencephalographic findings in children with acute lymphoblastic leukaemia

Electroencephalography (EEG) was performed on 66 children with acute lymphoblastic leukaemia, 45 before treatment and 21 during the first 5 days of chemotherapy. The patients, aged 7 months to 16 years, 33 boys and 33 girls, had been admitted to the Department of Paediatrics, University of Oulu, between March 1976 and January 1987. The EEG findings were compared with those in 66 age and sex-matched control children chosen at random from the local population. The patients had significantly more frequent and more severe disturbances in background activity (p less than 0.001) than the controls and increased slow waves in the occipital (p less than 0.001) and temporal regions (p less than 0.01). The patients who had received chemotherapy before the EEG recording had EEG disturbances significantly more frequently than the other patients (p less than 0.01), but the latter still had EEG abnormalities significantly more frequently than their matched controls, although they did not have severe changes (grade 3). The results suggest that chemotherapy increases EEG changes during the early days of induction therapy and possibly induces long-term disturbances in brain function. The associations between EEG changes and clinical findings were also analysed and the results show that a long duration of leukaemic symptoms or an aggressive disease may lead to EEG abnormalities.

The value of the immunological subtypes and individual markers compared to classical parameters in the prognosis of acute lymphoblastic leukemia

The value of the immunophenotypical subtypes and individual markers was compared with classical parameters in the prognosis of 150 patients with acute lymphoblastic leukemia (ALL). Regarding the immunophenotype, common-ALL had a better prognosis than T-ALL in the children's group. However, in adults the situation was different since both null and T-ALL patients had longer survival rates than the common pre-B group. Moreover, several individual markers add interesting prognostic information, either in ALL as a whole group or within the different immunophenotypes. Thus, the expression of CD10 and TdT had a significantly favourable influence in the outcome of the whole series of patients; within the T-ALL, those cases positive for CD10 also had a longer median survival (33 versus 17 months). In addition, in the common ALL patients group the expression of a relatively mature B marker--CD20--appeared to have a favourable prognosis (27 versus 13 months). Other non lineage specific markers, such as CD9 and CD38 did not seem to influence survival. Regarding the more conventional parameters, our data suggest that the classical age prognostic classification in children (less than 15 years) and adults can be improved using two cut-off points at 11 and 35 years. Moreover, the multivariate analysis showed that this variable, together with FAB morphology and WBC counts were the best combination of parameters for predicting survival. The present study shows that although the immunophenotype helps us in understanding the biological heterogeneity of ALL, having also prognostic implications, there are other clinical and hematological features that yield stronger prognostic information.

Trends in survival for childhood cancer in Britain diagnosed 1971-85

Survival rates were analysed for a population-based series of over 15,000 childhood cancers registered in Great Britain during 1971-85. There were highly significant improvements (P less than 0.001 for trend) in survival for many major diagnostic groups. Between 1971-73 and 1983-85 the actuarial 5-year survival rates increased from 37% to 70% for acute lymphoblastic leukaemia, from 4% to 26% for acute non-lymphoblastic leukaemia, from 76% to 88% for Hodgkin's disease, from 22% to 70% for non-Hodgkin's lymphoma, from 61% to 72% for astrocytoma, from 24% to 42% for medulloblastoma, from 15% to 43% for neuroblastoma, from 58% to 79% for Wilms' tumour, from 17% to 54% for osteosarcoma, from 26% to 61% for rhabdomyosarcoma, from 59% to 94% for malignant testicular germ-cell tumours and from 43% to 77% for malignant ovarian germ-cell tumours. These increases in population-based survival rates reflect the substantial advances in treatment of a wide range of childhood cancers since 1970. The two principal diagnostic groups for which there was no evidence of any trend were retinoblastoma, which already had an excellent prognosis with a 5-year survival rate of over 85%, and Ewing's sarcoma, for which the survival rate remained below 45%.

Acute lymphoblastic leukemia in children. Advances and prospectus

During the past decade, advances in the treatment of childhood acute lymphoblastic leukemia (ALL) have continued, largely due to improved disease-free survival of poor-prognosis subgroups, improved sanctuary therapy, shortening of therapy duration, and salvage of relapsed patients with better chemotherapy regimens and with bone marrow transplantation. Nonetheless, more children continue to die of ALL than of any other childhood cancer. This review outlines central issues in the staging and treatment of ALL that should be addressed if the cure rate in childhood ALL is to be significantly improved. Present dilemmas in the staging of ALL include the following: lack of standardization of staging systems; complicated algorithms; variable application and interpretation of multivariate analyses; dynamic interactions between prognostic front end variables and subsequent treatment; ambiguity of prognostic factors that are predictive of outcome but biologically inexplicable; unsuccessful attempts to define a good-prognosis subgroup for the purpose of streamlining therapy to a minimum; and the interface between ALL and non-Hodgkin's lymphoma and myeloid leukemias. The remaining therapeutic problems include a lack of reliable in vitro tests of chemosensitivity and chemoresistance, inability to quantitate residual leukemia after remission induction or to detect drug-resistant clones of cells before they are clinically manifest, and delivery of optimum therapy and supportive care to all children with ALL.

Prognosis of Down's syndrome with acute leukaemia

The outcome in children with acute leukaemia with (n = 90) and without Down's syndrome (n = 4377) was compared. Sixty three (70%) of those with Down's syndrome had acute lymphoblastic leukaemia and in comparison with 3664 (84%) controls had similar prognostic features except for a significant excess of the 'common' immunological subtype of acute lymphoblastic leukaemia. The outcome of the children with Down's syndrome was significantly worse with a five year overall actuarial survival of 28% compared with 59% in the control group. It appeared that both suboptimal chemotherapy and a high rate of infective problems contributed to the poor survival. Twenty six children with Down's syndrome had acute myeloblastic leukaemia and were significantly younger and had a higher percentage of the megakaryocytic and erythroid subtypes of acute myeloblastic leukaemia than the 713 controls. The outcome was similar in the two groups. It is concluded that the patients with Down's syndrome who develop acute leukaemia should receive standard protocols without modification, but aggressive supportive care is necessary to improve outcome.

Day 7 marrow response and outcome for children with acute lymphoblastic leukemia and unfavorable presenting features

The percent of marrow blasts on day 7 of therapy was determined for 128 children with previously untreated acute lymphoblastic leukemia and white blood count (WBC) greater than or equal to 50,000/microliters and/or lymphomatous features enrolled in the Childrens Cancer Study Group trial of the Berlin Frankfurt Munster 76/79 regimen (CCG-193P). Patients received four-drug induction therapy including vincristine, prednisone, l-asparaginase, and daunomycin. Ninety-seven patients had fewer than 25% marrow blasts on day 7. Of these, 94 survived and maintained remission through day 28 and were designated early responders. Thirty-one patients had greater than 25% marrow blasts on day 7. Of these, 28 survived and achieved remission on day 28 and were designated late responders. The outcome of patients who underwent a day 7 marrow aspiration was similar to those who did not. Early responders had a 77.4% +/- 4.5% (standard deviation) 3-year estimated disease free survival, while late responders had 47.3% +/- 9.8% (P less than 0.001). Early responders had a superior outcome both in the subset with an initial WBC less than 50,000/microliters (P = 0.025) and in the subset with a WBC greater than or equal to 50,000/microliters (P = 0.01). The day 7 marrow response had prognostic value in this population of children with unfavorable presenting features who received four-drug remission induction therapy.

Childhood acute lymphoblastic leukemia: results of the Austrian Cooperative Study Group with the ALL A 84 protocol

We prospectively treated 127 children with ALL with a risk-adapted regimen. All patients received the identical induction-consolidation therapy. The early maintenance included intermediate dose methotrexate in patients with standard risk (n = 79) and medium risk (n = 39). In addition patients with high risk (n = 6) received high dose ARA-C followed by L-asparaginase. Intensification treatment and prophylactic cranial irradiation was also tailored according to the risk group. Treatment duration was 2 years. Complete remission was achieved in 97.6% of all patients. Treatment-related toxicity accounted for one death in complete remission. The probability of event-free survival (pEFS) for the combined group was 72% at a median follow-up of 42 months. The pEFS was higher in patients with standard risk (SR) than in patients with medium risk (MR) (80% versus 65%; p less than 0.05) at 30 months, but attenuated in the follow-up evaluation at 42 months (76% versus 63%; p less than 0.1). The number of high-risk patients was too small for statistical evaluation. Relapse within the first 18 months after diagnosis indicated a poor prognosis and was more common in patients with MR than in patients with SR. The immunophenotype of the leukemic cells was not found to constitute an independent risk factor after treatment has been risk-adapted. Patients with an initial white blood cell count of more than 50 X 10(9)/l had a worse prognosis than patients with a lower white blood cell count (p less than 0.01).

Influence of age, sex, and concurrent intrathecal methotrexate therapy on intellectual function after cranial irradiation during childhood: a report from the Children's Cancer Study Group

Standard IQ tests were performed in 70 children and adolescents 3.5-10 years (median 5 yrs) after 24 Gy cranial irradiation, with or without concurrent intrathecal methotrexate, for central nervous system prophylaxis of acute lymphoblastic leukemia. Lower IQ scores correlated with younger age, female gender, and concomitant intrathecal methotrexate therapy. Multivariate analysis identified age as the most important determinant of the three factors. The lowest IQ scores were observed in girls who were less than 5 years old at the time of irradiation and who received concurrent intrathecal methotrexate. The observed adverse contribution of simultaneous intrathecal methotrexate therapy on IQ outcome may have significant implications for school performance, peer relationships, and occupational expectations.

Fibronectin concentration in cerebrospinal fluid reflects early central nervous system involvement in children with acute lymphoblastic leukemia

We measured concentrations of fibronectin (FN) in the cerebrospinal fluid (CSF) in long-term follow-up patients with acute lymphoblastic leukemia (ALL). In 11 patients with neuroleukemia the CSF-FN level was elevated already at the time of diagnosis of ALL, 3.8 +/- 0.6 mg/l, increased during therapy to 4.7 +/- 0.5 mg/l, and at the time of concurrent blast cell finding it was 5.5 +/- 1.0 mg/l. In 11 patients with no subsequent CNS leukemia, the mean CSF-FN level was 2.4 +/- 0.6 mg/l at the time of diagnosis of ALL and 2.8 +/- 0.6 mg/l during therapy, and increased to 3.2 +/- 0.8 mg/l. The neuroleukemia rate was 43% in patients with initial CSF-FN levels greater than 2 mg/l, compared with 5% in patients with CSF-FN levels less than or equal to 2 mg/l (p less than 0.005) in a group of 45 long-term follow-up patients with ALL. Regression analysis on the 21 clinical or laboratory parameters studied showed that the only variable independently associated with CSF-FN was the total protein concentration in the CSF; this, however, explained only 14% of the observed variation in the CSF-FN concentration and did not show any correlation with CNS involvement. We conclude that the CSF-FN test at diagnosis of ALL showed significant differences between groups of patients with and without CNS leukemia, and may prove to be a new early marker for neuroleukemia.