Improved outcome in childhood acute lymphoblastic leukemia despite reduced use of anthracyclines and cranial radiotherapy: results of trial ALL-BFM 90

Abstract

AbstractTrial ALL-BFM 90 was designed to improve outcome in patients with childhood acute lymphoblastic leukemia (ALL) by using a reduced treatment regimen. Patients were stratified into a standard-risk group (SRG), a medium-risk group (MRG), both defined by adequate early treatment response; and a high-risk group (HRG), defined by inadequate response to the cytoreductive prednisone prephase, induction failure, or Philadelphia-chromosome–positive ALL. Four treatment modifications were evaluated: dose intensification in induction by a more rapid drug sequence; administration of l-asparaginase during consolidation therapy in the MRG (randomized); enforced consolidation by rotational elements in the HRG; and reduction in the dose of anthracyclines and use of only 12-Gy preventive cranial radiotherapy in the MRG and HRG, with the aim of avoiding toxicity. Among all 2178 patients (≤ 18 years of age), the 6-year event-free survival (EFS) rate (± SE) was 78% ± 1%, with a median observation time of 4.8 years. EFS was 85% ± 2% in the SRG (n = 636) and 82% ± 1% in the MRG (n = 1299). l-asparaginase did not improve outcome in the MRG: the event-free interval was 83% ± 2% withl-asparaginase (n = 528) and 81% ± 2% without it (n = 557). Because there were more systemic relapses in the HRG (n = 243), EFS was 34% ± 3%, an outcome inferior to that in the HRG in a previous trial, ALL-BFM 86, in which EFS was 47% ± 5% (P = .04). The rates of isolated central nervous system relapse in the MRG and HRG were 0.8% and 1.6%, respectively; thus, the 12-Gy preventive cranial radiotherapy regimen apparently provided sufficient central nervous system prophylaxis. The overall improvement over the results in ALL-BFM 86 (6-year EFS, 72%; P = .001) was based on fewer recurrences among patients in the MRG with B-cell-precursor ALL, indicating an advantage of more condensed induction therapy. In multivariate analysis, inadequate in vivo response emerged as the strongest adverse prognostic variable.