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Brown PA, Shah B, Advani A, Aoun P, Boyer MW, Burke PW, DeAngelo DJ, Dinner S, Fathi AT, Gauthier J, Jain N, Kirby S, Liedtke M, Litzow M, Logan A, Luger S, Maness LJ, Massaro S, Mattison RJ, May W, Oluwole O, Park J, Przespolewski A, Rangaraju S, Rubnitz JE, Uy GL, Vusirikala M, Wieduwilt M, Lynn B, Berardi RA, Freedman-Cass DA, Campbell M. Acute Lymphoblastic Leukemia, Version 2.2021, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2021; 19:1079-1109. [PMID: 34551384 DOI: 10.6004/jnccn.2021.0042] [Citation(s) in RCA: 95] [Impact Index Per Article: 31.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The NCCN Guidelines for Acute Lymphoblastic Leukemia (ALL) focus on the classification of ALL subtypes based on immunophenotype and cytogenetic/molecular markers; risk assessment and stratification for risk-adapted therapy; treatment strategies for Philadelphia chromosome (Ph)-positive and Ph-negative ALL for both adolescent and young adult and adult patients; and supportive care considerations. Given the complexity of ALL treatment regimens and the required supportive care measures, the NCCN ALL Panel recommends that patients be treated at a specialized cancer center with expertise in the management of ALL This portion of the Guidelines focuses on the management of Ph-positive and Ph-negative ALL in adolescents and young adults, and management in relapsed settings.
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Affiliation(s)
- Patrick A Brown
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
| | | | - Anjali Advani
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | | | | | | | | | - Shira Dinner
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | - Jordan Gauthier
- Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance
| | - Nitin Jain
- The University of Texas MD Anderson Cancer Center
| | | | | | | | - Aaron Logan
- UCSF Helen Diller Family Comprehensive Cancer Center
| | - Selina Luger
- Abramson Cancer Center at the University of Pennsylvania
| | | | | | | | | | | | - Jae Park
- Memorial Sloan Kettering Cancer Center
| | | | | | - Jeffrey E Rubnitz
- St. Jude Children's Research Hospital/The University of Tennessee Health Science Center
| | - Geoffrey L Uy
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | | | | | - Beth Lynn
- National Comprehensive Cancer Network
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Brown P, Inaba H, Annesley C, Beck J, Colace S, Dallas M, DeSantes K, Kelly K, Kitko C, Lacayo N, Larrier N, Maese L, Mahadeo K, Nanda R, Nardi V, Rodriguez V, Rossoff J, Schuettpelz L, Silverman L, Sun J, Sun W, Teachey D, Wong V, Yanik G, Johnson-Chilla A, Ogba N. Pediatric Acute Lymphoblastic Leukemia, Version 2.2020, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2021; 18:81-112. [PMID: 31910389 DOI: 10.6004/jnccn.2020.0001] [Citation(s) in RCA: 85] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Acute lymphoblastic leukemia (ALL) is the most common pediatric malignancy. Advancements in technology that enhance our understanding of the biology of the disease, risk-adapted therapy, and enhanced supportive care have contributed to improved survival rates. However, additional clinical management is needed to improve outcomes for patients classified as high risk at presentation (eg, T-ALL, infant ALL) and who experience relapse. The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for pediatric ALL provide recommendations on the workup, diagnostic evaluation, and treatment of the disease, including guidance on supportive care, hematopoietic stem cell transplantation, and pharmacogenomics. This portion of the NCCN Guidelines focuses on the frontline and relapsed/refractory management of pediatric ALL.
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Affiliation(s)
- Patrick Brown
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
| | - Hiroto Inaba
- St. Jude Children's Research Hospital/The University of Tennessee Health Science Center
| | - Colleen Annesley
- Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance
| | | | - Susan Colace
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | - Mari Dallas
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | | | - Kara Kelly
- Roswell Park Comprehensive Cancer Center
| | | | | | | | - Luke Maese
- Huntsman Cancer Institute at the University of Utah
| | - Kris Mahadeo
- The University of Texas MD Anderson Cancer Center
| | | | | | | | - Jenna Rossoff
- Ann & Robert H. Lurie Children's Hospital of Chicago
| | - Laura Schuettpelz
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | | | | | - Weili Sun
- City of Hope National Medical Center
| | - David Teachey
- Abramson Cancer Center at the University of Pennsylvania
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Lymphohematopoietic cancers induced by chemicals and other agents and their implications for risk evaluation: An overview. MUTATION RESEARCH-REVIEWS IN MUTATION RESEARCH 2014; 761:40-64. [PMID: 24731989 DOI: 10.1016/j.mrrev.2014.04.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Revised: 04/02/2014] [Accepted: 04/03/2014] [Indexed: 12/13/2022]
Abstract
Lymphohematopoietic neoplasia are one of the most common types of cancer induced by therapeutic and environmental agents. Of the more than 100 human carcinogens identified by the International Agency for Research on Cancer, approximately 25% induce leukemias or lymphomas. The objective of this review is to provide an introduction into the origins and mechanisms underlying lymphohematopoietic cancers induced by xenobiotics in humans with an emphasis on acute myeloid leukemia, and discuss the implications of this information for risk assessment. Among the agents causing lymphohematopoietic cancers, a number of patterns were observed. Most physical and chemical leukemia-inducing agents such as the therapeutic alkylating agents, topoisomerase II inhibitors, and ionizing radiation induce mainly acute myeloid leukemia through DNA-damaging mechanisms that result in either gene or chromosomal mutations. In contrast, biological agents and a few immunosuppressive chemicals induce primarily lymphoid neoplasms through mechanisms that involve alterations in immune response. Among the environmental agents examined, benzene was clearly associated with acute myeloid leukemia in humans, with increasing but still limited evidence for an association with lymphoid neoplasms. Ethylene oxide and 1,3-butadiene were linked primarily to lymphoid cancers. Although the association between formaldehyde and leukemia remains controversial, several recent evaluations have indicated a potential link between formaldehyde and acute myeloid leukemia. The four environmental agents examined in detail were all genotoxic, inducing gene mutations, chromosomal alterations, and/or micronuclei in vivo. Although it is clear that rapid progress has been made in recent years in our understanding of leukemogenesis, many questions remain for future research regarding chemically induced leukemias and lymphomas, including the mechanisms by which the environmental agents reviewed here induce these diseases and the risks associated with exposures to such agents.
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Pottier N, Cheok M, Kager L. Antileukemic drug effects in childhood acute lymphoblastic leukemia. Expert Rev Clin Pharmacol 2014; 1:401-13. [DOI: 10.1586/17512433.1.3.401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Benoit Y, Suciu S, Cavé H, Ferster A, Dastugue N, Lutz P, Mazingue F, Robert A, Uyttebroeck A, Norton L, Sirvent N, Rohrlich P, Karrasch M, Bertrand Y. The EORTC Children's Leukemia Group: Preclinical and clinical research and resulting achievements. EJC Suppl 2012. [DOI: 10.1016/s1359-6349(12)70009-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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6
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Gaynon PS. A remembrance: James B. Nachman 1948-2011. Pediatr Blood Cancer 2011; 57:533-4. [PMID: 21826779 DOI: 10.1002/pbc.23276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Paul S Gaynon
- Division of Hematology/Oncology, University of Southern California, 4650 Sunset Boulevard, Los Angeles, California 90027, USA.
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James B. Nachman, 1948 to 2011: a remembrance. J Pediatr Hematol Oncol 2011; 33:403-5. [PMID: 21792033 DOI: 10.1097/mph.0b013e31822ad27e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Pieters R, Hunger SP, Boos J, Rizzari C, Silverman L, Baruchel A, Goekbuget N, Schrappe M, Pui CH. L-asparaginase treatment in acute lymphoblastic leukemia: a focus on Erwinia asparaginase. Cancer 2010; 117:238-49. [PMID: 20824725 DOI: 10.1002/cncr.25489] [Citation(s) in RCA: 407] [Impact Index Per Article: 29.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2010] [Revised: 05/20/2010] [Accepted: 05/20/2010] [Indexed: 01/19/2023]
Abstract
Asparaginases are a cornerstone of treatment protocols for acute lymphoblastic leukemia (ALL) and are used for remission induction and intensification treatment in all pediatric regimens and in the majority of adult treatment protocols. Extensive clinical data have shown that intensive asparaginase treatment improves clinical outcomes in childhood ALL. Three asparaginase preparations are available: the native asparaginase derived from Escherichia coli (E. coli asparaginase), a pegylated form of this enzyme (PEG-asparaginase), and a product isolated from Erwinia chrysanthemi, ie, Erwinia asparaginase. Clinical hypersensitivity reactions and silent inactivation due to antibodies against E. coli asparaginase, lead to inactivation of E. coli asparaginase in up to 60% of cases. Current treatment protocols include E. coli asparaginase or PEG-asparaginase for first-line treatment of ALL. Typically, patients exhibiting sensitivity to one formulation of asparaginase are switched to another to ensure they receive the most efficacious treatment regimen possible. Erwinia asparaginase is used as a second- or third-line treatment in European and US protocols. Despite the universal inclusion of asparaginase in such treatment protocols, debate on the optimal formulation and dosage of these agents continues. This article provides an overview of available evidence for optimal use of Erwinia asparaginase in the treatment of ALL.
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Affiliation(s)
- Rob Pieters
- Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands.
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Pombo de Oliveira MS, Koifman S, Vasconcelos GM, Emerenciano M, de Oliveira Novaes C. Development and perspective of current Brazilian studies on the epidemiology of childhood leukemia. Blood Cells Mol Dis 2009; 42:121-5. [DOI: 10.1016/j.bcmd.2008.10.012] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2008] [Accepted: 10/17/2008] [Indexed: 11/17/2022]
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Cheok MH, Pottier N, Kager L, Evans WE. Pharmacogenetics in acute lymphoblastic leukemia. Semin Hematol 2009; 46:39-51. [PMID: 19100367 DOI: 10.1053/j.seminhematol.2008.09.002] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Progress in the treatment of acute lymphoblastic leukemia (ALL) in children has been remarkable, from a disease being lethal four decades ago to current cure rates exceeding 80%. This exemplary progress is largely due to the optimization of existing treatment modalities rather than the discovery of new antileukemic agents. However, despite these high cure rates, the annual number of children whose leukemia relapses after their initial therapy remains greater than that of new cases of most types of childhood cancers. The aim of pharmacogenetics is to develop strategies to personalize treatment and tailor therapy to individual patients, with the goal of optimizing efficacy and safety through better understanding of human genome variability and its influence on drug response. In this review, we summarize recent pharmacogenomic studies related to the treatment of pediatric ALL. These studies illustrate the promise of pharmacogenomics to further advance the treatment of human cancers, with childhood leukemia serving as a paradigm.
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Affiliation(s)
- Meyling H Cheok
- Jean-Pierre Aubert Research Center, INSERM U837, Genomics Core IRCL-IMPRT, Lille, France.
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Monitoring treatment response of childhood precursor B-cell acute lymphoblastic leukemia in the AIEOP-BFM-ALL 2000 protocol with multiparameter flow cytometry: predictive impact of early blast reduction on the remission status after induction. Leukemia 2008; 23:528-34. [PMID: 19020543 DOI: 10.1038/leu.2008.324] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Treatment response is a strong outcome predictor for childhood acute lymphoblastic leukemia (ALL). Here, we evaluated the predictive impact of flow cytometric blast quantification assays (absolute blast count, BC, and blast reduction rate, BRR) in peripheral blood (pB) and/or bone marrow (BM) at early time points of induction therapy (days 0, 8 and 15) on the remission status in the AIEOP-BFM-ALL 2000 protocol. At the single parameter level (905 patients), the strongest predictive parameter for the remission status as a dichotomous minimal residual disease (MRD) parameter (positive/negative) has been provided by the BC at day 15 in BM (cutoff: 17 blasts/microl; 50 vs 15%; odds ratio: 5.6; 95% confidence interval: 4.1-7.6, P<0.001), followed by the BRR at day 15 in BM and by the BC at day 8 in pB (odds ratios: 3.8 and 2.6, respectively). In the multiple regression analysis (440 patients), BC in pB (d0 and d8) and in BM (d15) as well as BRR at day 8 in pB provided significantly contributing variables with an overall correct prediction rate of 74.8%. These data show that the quantitative assessment of early response parameters, especially absolute BCs at day 15 in BM, has a predictive impact on the remission status after induction therapy.
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Tang Y, Xu X, Song H, Yang S, Shi S, Wei J. Long-term outcome of childhood acute lymphoblastic leukemia treated in China. Pediatr Blood Cancer 2008; 51:380-6. [PMID: 18506765 DOI: 10.1002/pbc.21629] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND To retrospectively determine the treatment outcome and causes of treatment failure of ALL children treated in a single institution at East China. PROCEDURE Between January 1998 and October 2004, 346 newly diagnosed ALL patients <or=16 years were admitted to our hospital. Of these, 248 patients received modified National Protocol of Childhood ALL in China 1997 (NPCAC97) for at least 2 weeks of treatment and were eligible for protocol evaluation. RESULTS Among the 346 newly diagnosed patients, 167 (48.3%) stopped treatment either at diagnosis or during therapy. The abandonment rates for urban area group (UAG) and rural area group (RAG) were 25.3% and 57.3%, respectively (P < 0.0001). The 5-year event-free survival (EFS) rate for the entire cohort was 38.5 +/- 2.7%. For 248 evaluable patients, the remission rate was 97.2%. The 5-year EFS and overall survival (OS) rates were 70.7 +/- 3.6% and 82.1 +/- 3.0%, respectively. The 5-year EFS for standard-risk group (n = 196) was significantly higher than that of high-risk group (n = 52) (75.9 +/- 3.9% vs. 50.7 +/- 8.0%, P = 0.0002). Prognostic factor analysis showed that poor response to remission induction therapy and a poor socioeconomic status were predictive for an inferior outcome. CONCLUSION Abandonment of chemotherapy was the most common cause of treatment failure, which was strongly related to poor socioeconomic status and financial support. For patients who could adhere to the treatment protocol, a relatively good outcome was achieved.
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Affiliation(s)
- Yongmin Tang
- Division of Hematology-Oncology, Children's Hospital Zhejiang University School of Medicine, Hangzhou, PR China.
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Valsecchi MG, Silvestri D, Covezzoli A, De Lorenzo P. Web-based international studies in limited populations of pediatric leukemia. Pediatr Blood Cancer 2008; 50:270-3. [PMID: 17486643 DOI: 10.1002/pbc.21240] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Recent progress in cancer research leads to the characterization of small subgroups of patients by genetic/biological features. Clinical studies in this setting are frequently promoted by international networks of independent researchers and are limited by practical and methodological constraints, not least the regulations recently issued by national and international institutions (EU Directive 2001/20/EC). PROCEDURE We reviewed various methods in the design of international multicenter studies, with focus on randomized clinical trials. RESULTS This paper reports our experience in planning and conducting international studies in childhood leukemia. We applied a decentralized study conduct based on a two-level structure, comprising a national and an international coordinating level. For the more recent trials this structure was implemented as a web-based system. This approach accommodates major legal requirements (e.g., safety reporting) and ensures Good Clinical Practice principles by implementing risk-oriented monitoring procedures. CONCLUSIONS Setting up international non-commercial trials is increasingly complicated. Still, they are strongly needed for answering relevant questions in limited populations.
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Affiliation(s)
- Maria Grazia Valsecchi
- Unit of Medical Statistics, Department of Clinical Medicine and Prevention, University of Milano-Bicocca, Via Cadore, Monza (MI), Italy.
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Petra BG, Janez J, Vita D. Gene-gene interactions in the folate metabolic pathway influence the risk for acute lymphoblastic leukemia in children. Leuk Lymphoma 2007; 48:786-92. [PMID: 17454638 DOI: 10.1080/10428190601187711] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Acute lymphoblastic leukemia (ALL) is the most common pediatric cancer. Genetic polymorphisms in the folate metabolic pathway may contribute to the susceptibility to childhood ALL because they affect the DNA synthesis, methylation and repair. We analysed common genetic polymorphisms of 5,10-methylenetetrahydrofolate reductase (MTHFR), thymidylate synthase (TS), methionine synthase (MS) and methionine synthase reductase (MTRR) in 68 children with ALL and 258 healthy controls to investigate their influence on the risk for ALL. No significant differences in frequencies of separate polymorphisms were observed between both groups. Combined MTHFR 677CT/TT and MS 2756AG/GG genotypes showed a nonsignificant tendency to reduce the risk for ALL 2.24-fold (CI: 0.191 - 1.037, P: 0.061). The risk was significantly reduced in carriers of combined MTHFR 677CT/TT, MS 2756AG/GG and MTRR 66AG/GG genotypes (OR: 0.312; CI: 0.107 - 0.907; P: 0.032). Our results suggest that gene - gene interactions that may decrease the methylation capacity might have a protective effect on the risk for childhood ALL.
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Ribera JM, Ortega JJ, Oriol A, Bastida P, Calvo C, Pérez-Hurtado JM, González-Valentín ME, Martín-Reina V, Molinés A, Ortega-Rivas F, Moreno MJ, Rivas C, Egurbide I, Heras I, Poderós C, Martínez-Revuelta E, Guinea JM, del Potro E, Deben G. Comparison of intensive chemotherapy, allogeneic, or autologous stem-cell transplantation as postremission treatment for children with very high risk acute lymphoblastic leukemia: PETHEMA ALL-93 Trial. J Clin Oncol 2007; 25:16-24. [PMID: 17194902 DOI: 10.1200/jco.2006.06.8312] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The optimal postremission therapy for children with very high-risk (VHR) acute lymphoblastic leukemia (ALL) is not well established. This randomized trial compared three options of postremission therapy: chemotherapy and allogeneic or autologous stem-cell transplantation (SCT). PATIENTS AND METHODS All 106 VHR-ALL patients received induction with five drugs followed by intensification with three cycles of chemotherapy. Patients in complete remission (CR) with an HLA-identical family donor were assigned to allogeneic SCT (n = 24) and the remaining were randomly assigned to autologous SCT (n = 38) or to delayed intensification followed by maintenance chemotherapy up to 2 years in CR (n = 38). RESULTS Overall, 100 patients achieved CR (94%). With a median follow-up of 6.5 years, 5-year disease-free survival (DFS) and overall survival (OS) probabilities were 45% (95% CI, 37% to 54%) and 48% (95% CI, 40% to 57%), respectively. The three groups were comparable in the main pretreatment ALL characteristics. Intention-to-treat analysis showed no differences for donor versus no donor in DFS (45%; 95% CI, 27% to 65% v 45%; 95% CI, 37% to 55%) and OS (48%; 95% CI, 30% to 67% v 51%; 95% CI, 43% to 61%), as well as for autologous SCT versus chemotherapy comparisons (DFS: 44%; 95% CI, 29% to 60% v 46%; 95% CI, 32% to 62%; OS: 45%; 95% CI, 31% to 62% v 57%; 95% CI, 43% to 73%). No differences were found within the different subgroups of ALL and neither were differences observed when the analysis was made by treatment actually performed. CONCLUSION This study failed to prove that, when a family donor is available, allogeneic SCT produces a better outcome than autologous SCT or chemotherapy in children with VHR-ALL.
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Affiliation(s)
- Jose-Maria Ribera
- Servicio de Hematología Clínica, Institut Català d'Oncologia-Hospital Universitari Germans Trias i Pujol, Badalona, Spain.
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Schultz KR, Pullen DJ, Sather HN, Shuster JJ, Devidas M, Borowitz MJ, Carroll AJ, Heerema NA, Rubnitz JE, Loh ML, Raetz EA, Winick NJ, Hunger SP, Carroll WL, Gaynon PS, Camitta BM. Risk- and response-based classification of childhood B-precursor acute lymphoblastic leukemia: a combined analysis of prognostic markers from the Pediatric Oncology Group (POG) and Children's Cancer Group (CCG). Blood 2006; 109:926-35. [PMID: 17003380 PMCID: PMC1785141 DOI: 10.1182/blood-2006-01-024729] [Citation(s) in RCA: 305] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The Children's Cancer Group (CCG) and the Pediatric Oncology Group (POG) joined to form the Children's Oncology Group (COG) in 2000. This merger allowed analysis of clinical, biologic, and early response data predictive of event-free survival (EFS) in acute lymphoblastic leukemia (ALL) to develop a new classification system and treatment algorithm. From 11 779 children (age, 1 to 21.99 years) with newly diagnosed B-precursor ALL consecutively enrolled by the CCG (December 1988 to August 1995, n=4986) and POG (January 1986 to November 1999, n=6793), we retrospectively analyzed 6238 patients (CCG, 1182; POG, 5056) with informative cytogenetic data. Four risk groups were defined as very high risk (VHR; 5-year EFS, 45% or below), lower risk (5-year EFS, at least 85%), and standard and high risk (those remaining in the respective National Cancer Institute [NCI] risk groups). VHR criteria included extreme hypodiploidy (fewer than 44 chromosomes), t(9;22) and/or BCR/ABL, and induction failure. Lower-risk patients were NCI standard risk with either t(12;21) (TEL/AML1) or simultaneous trisomies of chromosomes 4, 10, and 17. Even with treatment differences, there was high concordance between the CCG and POG analyses. The COG risk classification scheme is being used for division of B-precursor ALL into lower- (27%), standard- (32%), high- (37%), and very-high- (4%) risk groups based on age, white blood cell (WBC) count, cytogenetics, day-14 marrow response, and end induction minimal residual disease (MRD) by flow cytometry in COG trials.
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Affiliation(s)
- Kirk R Schultz
- Children's Oncology Group, Department of Pediatrics, BC Children's Hospital, University of British Columbia, Vancouver, Canada.
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