Childhood Acute Lymphoblastic Leukemia Treatment (PDQ®) 5/5 —Health Professional Version - National Cancer Institute

Childhood Acute Lymphoblastic Leukemia Treatment (PDQ®)—Health Professional Version - National Cancer Institute

Childhood Acute Lymphoblastic Leukemia Treatment (PDQ®)–Health Professional Version

CNS-Directed Therapy for Childhood ALL

In This Section

• Intrathecal Chemotherapy
• CNS-Directed Systemic Chemotherapy
• Cranial Radiation
• CNS Therapy for Standard-risk Patients
• CNS Therapy for High-risk and Very High-risk Patients
• CNS Therapy for Patients With CNS Involvement (CNS3 Disease) at Diagnosis
• Presymptomatic CNS Therapy Options Under Clinical Evaluation
• Toxicity of CNS-Directed Therapy
  • Acute and subacute toxicities
  • Late-developing toxicities

At diagnosis, approximately 3% of patients have central nervous system 3 (CNS3) disease (defined as cerebrospinal fluid [CSF] specimen with ≥5 white blood cells [WBC]/μL with lymphoblasts and/or the presence of cranial nerve palsies). However, unless specific therapy is directed toward the CNS, most children will eventually develop overt CNS leukemia whether or not lymphoblasts were detected in the spinal fluid at initial diagnosis. Therefore, all children with acute lymphoblastic leukemia (ALL) should receive systemic combination chemotherapy together with some form of CNS prophylaxis.

Because the CNS is a sanctuary site (i.e., an anatomic space that is poorly penetrated by many of the systemically administered chemotherapy agents typically used to treat ALL), specific CNS-directed therapies must be instituted early in treatment to eliminate clinically evident CNS disease at diagnosis and to prevent CNS relapse in all patients. Historically, survival rates for children with ALL improved dramatically after CNS-directed therapies were added to treatment regimens.

Standard treatment options for CNS-directed therapy include the following:

1. Intrathecal chemotherapy.
2. CNS-directed systemic chemotherapy.
3. Cranial radiation.

All of these treatment modalities have a role in the treatment and prevention of CNS leukemia. The combination of intrathecal chemotherapy plus CNS-directed systemic chemotherapy is standard; cranial radiation is reserved for selective situations.[1]

The type of CNS-therapy that is used is based on a patient’s risk of CNS-relapse, with higher-risk patients receiving more intensive treatments. Data suggest that the following groups of patients are at increased risk of CNS relapse:

• Patients with 5 or more WBC/µL and blasts in the CSF (CNS3), obtained at diagnosis.
• Patients with blasts in the CSF but fewer than 5 WBC/µL (CNS2) may be at increased risk of CNS relapse,[2] although this risk appears to be nearly fully abrogated if they receive more doses of intrathecal chemotherapy, especially during the induction phase.[3]
• Patients with T-cell ALL, especially those with high presenting peripheral blood leukocyte counts.
• Patients who have a traumatic lumbar puncture showing blasts at the time of diagnosis may have an increased risk of CNS relapse. These patients receive more intensive CNS-directed therapy on some treatment protocols.[3,4]

CNS-directed treatment regimens for newly diagnosed childhood ALL are presented in Table 4:

Table 4. CNS-Directed Treatment Regimens for Newly Diagnosed Childhood ALL

Disease Status	Standard Treatment Options
ALL = acute lymphoblastic leukemia; CNS = central nervous system; CNS3 = cerebrospinal fluid with five or more white blood cells/µL, cytospin positive for blasts, or cranial nerve palsies.
aThe drug itself is not CNS-penetrant, but leads to cerebrospinal fluid asparagine depletion.
Standard-risk ALL	Intrathecal chemotherapy
		Methotrexate alone
		Methotrexate with cytarabine and hydrocortisone
	CNS-directed systemic chemotherapy
		Dexamethasone
		L-asparaginasea
		High-dose methotrexate with leucovorin rescue
		Escalating-dose intravenous methotrexate (no leucovorin rescue)
High-risk and very high-risk ALL	Intrathecal chemotherapy
		Methotrexate alone
		Methotrexate with cytarabine and hydrocortisone
	CNS-directed systemic chemotherapy
		Dexamethasone
		L-asparaginasea
		High-dose methotrexate with leucovorin rescue
	Cranial radiation

A major goal of current ALL clinical trials is to provide effective CNS therapy while minimizing neurologic toxic effects and other late effects.

Intrathecal Chemotherapy

All therapeutic regimens for childhood ALL include intrathecal chemotherapy. Intrathecal chemotherapy is usually started at the beginning of induction, intensified during consolidation and, in many protocols, continued throughout the maintenance phase.

Intrathecal chemotherapy typically consists of one of the following:[5]

1. Methotrexate alone.
2. Methotrexate with cytarabine and hydrocortisone (triple intrathecal chemotherapy).

Unlike intrathecal cytarabine, intrathecal methotrexate has a significant systemic effect, which may contribute to prevention of marrow relapse.[6]

CNS-Directed Systemic Chemotherapy

In addition to therapy delivered directly to the brain and spinal fluid, systemically administered agents are also an important component of effective CNS prophylaxis. The following systemically administered drugs provide some degree of CNS prophylaxis:

• Dexamethasone.
• L-asparaginase (does not penetrate into CSF itself, but leads to CSF asparagine depletion).
• High-dose methotrexate with leucovorin rescue.
• Escalating dose intravenous (IV) methotrexate without leucovorin rescue.

Evidence (CNS-directed systemic chemotherapy):

1. In a randomized Children's Cancer Group (CCG) study of standard-risk patients who all received the same dose and schedule of intrathecal methotrexate without cranial irradiation, oral dexamethasone was associated with a 50% decrease in the rate of CNS relapse compared with oral prednisone.[7]
2. In another standard-risk ALL trial (COG-1991), escalating dose IV methotrexate without leucovorin rescue significantly reduced the CNS relapse rate compared with standard, low-dose, oral methotrexate given during each of two interim maintenance phases.[8]
3. In a randomized clinical trial conducted by the former Pediatric Oncology Group, T-cell ALL patients who received high-dose methotrexate experienced a significantly lower CNS relapse rate than patients who did not receive high-dose methotrexate.[9]

Cranial Radiation

The proportion of patients receiving cranial radiation has decreased significantly over time. At present, most newly diagnosed children with ALL are treated without cranial radiation. Many groups administer cranial radiation only to those patients considered to be at highest risk of subsequent CNS relapse, such as those with documented CNS leukemia at diagnosis (as defined above) (≥5 WBC/μL with blasts; CNS3) and/or T-cell phenotype with high presenting WBC count.[10] In patients who do receive radiation, the cranial radiation dose has been significantly reduced and administration of spinal irradiation is not standard.

Ongoing trials seek to determine whether radiation can be eliminated from the treatment of all children with ALL without compromising survival or leading to increased rate of toxicities from upfront and salvage therapies.[11,12] A meta-analysis of randomized trials of CNS-directed therapy has confirmed that radiation therapy can be replaced by intrathecal chemotherapy in most patients with ALL. Additional systemic therapy may be required depending on the agents and intensity used.[13]; [1][Level of evidence: 1iDi]

CNS Therapy for Standard-risk Patients

Intrathecal chemotherapy without cranial radiation, given in the context of appropriate systemic chemotherapy, results in CNS relapse rates of less than 5% for children with standard-risk ALL.[11,12,14-17]

The use of cranial radiation is not a necessary component of CNS-directed therapy for these patients.[18,19] Some regimens use triple intrathecal chemotherapy (methotrexate, cytarabine, and hydrocortisone), while others use intrathecal methotrexate alone throughout therapy.

Evidence (triple intrathecal chemotherapy vs. intrathecal methotrexate):

1. The CCG-1952 study for National Cancer Institute (NCI) standard-risk patients compared the relative efficacy and toxicity of triple intrathecal chemotherapy (methotrexate, cytarabine, and hydrocortisone) with methotrexate as the sole intrathecal agent in nonirradiated patients.[20]
   1. There was no significant difference in either CNS or non-CNS toxicities.
   2. Although triple intrathecal chemotherapy was associated with a lower rate of isolated CNS relapse (3.4% ± 1.0% compared with 5.9% ± 1.2% for intrathecal methotrexate; P = .004), there was no difference in event-free survival (EFS).
      • The reduction in CNS relapse rate was especially notable in patients with CNS2 status at diagnosis (lymphoblasts seen in CSF cytospin, but with <5 WBC/high-power field [hpf] on CSF cell count); the isolated CNS relapse rate was 7.7% ± 5.3% for CNS2 patients who received triple intrathecal chemotherapy compared with 23.0% ± 9.5% for those who received intrathecal methotrexate alone (P = .04).
      • There were more bone marrow relapses in the group that received the triple intrathecal chemotherapy, leading to a worse overall survival (OS) (90.3% ± 1.5%) compared with the intrathecal methotrexate group (94.4% ± 1.1%; P = .01).
      • When the analysis was restricted to patients with precursor B-cell ALL and rapid early response (M1 marrow on day 14), there was no difference between triple and single intrathecal chemotherapy in terms of rates of CNS relapse rate, OS, or EFS.
      • The findings of this trial need to be interpreted within the context of other therapy administered to patients. Dexamethasone, which has been associated with lower CNS relapse rates and improved EFS in standard-risk patients in other trials,[7,21] was not used in CCG-1952 (prednisone was the only steroid administered to patients).[22] It is not clear whether the results of the CCG-1952 trial are generalizable to protocols that include the use of dexamethasone and/or other CNS-directed systemic therapies.
   3. In a follow-up study of neurocognitive functioning in the two groups, there were no clinically significant differences.[23][Level of evidence: 1iiC]

CNS Therapy for High-risk and Very High-risk Patients

Controversy exists as to whether high-risk and very high-risk patients should be treated with cranial radiation. Depending on the protocol, up to 20% of children with ALL receive cranial radiation as part of their CNS-directed therapy, even if they present without CNS involvement at diagnosis. Patients receiving cranial radiation on many treatment regimens include the following:[10]

• Patients with T-cell phenotype and high initial WBC count.
• Patients with high-risk precursor B-cell ALL (e.g., extremely high presenting leukocyte counts and/or adverse cytogenetic abnormalities and/or CNS3 disease).

Both the proportion of patients receiving radiation and the dose of radiation administered has decreased over the last 2 decades.

Evidence (cranial radiation):

1. In a trial conducted between 1990 and 1995, the Berlin-Frankfurt-Münster (BFM) group demonstrated that a reduced dose of prophylactic radiation (12 Gy instead of 18 Gy) provided effective CNS prophylaxis in high-risk patients.[24]
2. In the follow-up trial conducted by the BFM group between 1995 and 2000 (BFM-95), cranial radiation was administered to approximately 20% of patients (compared with 70% on the previous trial), including patients with T-cell phenotype, a slow early response (as measured by peripheral blood blast count after a 1-week steroid prophase), and/or adverse cytogenetic abnormalities.[17]
   • While the rate of isolated CNS relapses was higher in the nonirradiated higher-risk patients compared with historic (irradiated) cohorts, their overall EFS rate was not significantly different.
3. Several groups, including the St. Jude Children's Research Hospital (SJCRH), the Dutch Childhood Oncology Group (DCOG), and the European Organization for Research and Treatment of Cancer (EORTC), have published results of trials that omitted cranial radiation for all patients, including high-risk subsets.[11,12,25] Most of these trials have included at least four doses of high-dose methotrexate during postinduction consolidation and an increased frequency of intrathecal chemotherapy. The SJCRH and DCOG studies also included frequent vincristine/dexamethasone pulses and intensified dosing of pegaspargase,[11,12] while the EORTC trials included additional high-dose methotrexate and multiple doses of high-dose cytarabine during postinduction treatment phases for CNS3 (CSF with ≥5 WBC/µL and cytospin positive for blasts) patients.[25]
   • The 5-year cumulative incidence of isolated CNS relapse on those trials was between 2% and 4%, although some patient subsets had a significantly higher rate of CNS relapse. On the SJCRH study, clinical features associated with a significantly higher risk of isolated CNS relapse included T-cell phenotype, the t(1;19) translocation, or the presence of blasts in the CSF at diagnosis.[11]
   • The overall EFS for the SJCRH study was 85.6% and 81% for the DCOG study, both in line with outcomes achieved by contemporaneously conducted clinical trials on which some patients received prophylactic radiation, but was lower on the EORTC trial (8-year EFS, 69.6%).[25]
   • Of note, on the SJCRH study, 33 of 498 (6.6%) patients in first remission with high-risk features (including 26 with high minimal residual disease (MRD), six with Philadelphia chromosome-positive ALL, and one with near haploidy) received an allogeneic hematopoietic stem cell transplant , which included total-body irradiation.[11]
4. In a meta-analysis of aggregated data from more than 16,000 patients treated between 1996 and 2007 by ten cooperative groups, the use of cranial radiation therapy did not appear to impact 5-year OS or cumulative incidence of any event.[13]
   • In subgroup analyses of high-risk subsets, only those with CNS3 status at diagnosis appeared to benefit from cranial radiation, with a significantly lower rate of CNS relapses (isolated/any) in irradiated patients; however, even within this subgroup, OS was similar with or without the use of radiation therapy.
   • This study suggests that cranial radiation therapy may not be an essential component of treatment, even for high-risk patients; however, interpretation is limited by the considerable variation in treatment administered to patients by the different cooperative groups.

CNS Therapy for Patients With CNS Involvement (CNS3 Disease) at Diagnosis

Therapy for ALL patients with clinically evident CNS disease (≥5 WBC/hpf with blasts on cytospin; CNS3) at diagnosis typically includes intrathecal chemotherapy and cranial radiation (usual dose is 18 Gy).[17,19] Spinal radiation is no longer used.

Evidence (cranial radiation):

1. SJCRH, DCOG, and the EORTC have published results of trials that omitted cranial radiation for all patients, including high-risk subsets.[11,25] These trials have included at least four doses of high-dose methotrexate during postinduction consolidation and an increased frequency of intrathecal chemotherapy. The SJCRH study also included higher cumulative doses of anthracycline than on Children’s Oncology Group (COG) trials, and frequent vincristine/dexamethasone pulses and intensified dosing of pegaspargase,[11] while the EORTC trials included additional high-dose methotrexate and multiple doses of high-dose cytarabine, during postinduction treatment phases for CNS3 (CSF with ≥5 WBC/µL and cytospin positive for blasts) patients.[25]
   • On the SJCRH Total XV (TOTXV) study, patients with CNS3 status (N = 9) were treated without cranial radiation (observed 5-year EFS, 43% ± 23%%; OS, 71% ± 22%).[11] On this study, CNS leukemia at diagnosis (defined as CNS3 status or traumatic lumbar puncture with blasts) was an independent predictor of inferior EFS.
   • On the DCOG-9 trial, the 5-year EFS of CNS3 patients (n = 21) treated without cranial radiation was 67% ± 10%.[12]
   • On the EORTC trial, the 8-year EFS of CNS3 patients (n = 49) treated without cranial radiation was 68%. The cumulative incidence of isolated CNS relapse for those patients was 9.4%.[25][Level of evidence: 2A]
2. A meta-analysis of aggregated data from more than 16,000 patients treated between 1996 and 2007 by ten cooperative groups evaluated whether the use of cranial radiation therapy affected outcome in high-risk patient subsets.[13]
   • In subgroup analyses of high-risk subsets, only those with CNS3 status at diagnosis appeared to benefit from cranial radiation therapy, with a significantly lower rate of CNS relapses (isolated/any) in irradiated patients; however, even within this subgroup, OS was similar with or without the use of radiation therapy.

Larger prospective studies will be necessary to fully elucidate the safety of omitting cranial radiation in CNS3 patients.

Presymptomatic CNS Therapy Options Under Clinical Evaluation

Information about National Cancer Institute (NCI)–supported clinical trials can be found on the NCI website. For information about clinical trials sponsored by other organizations, refer to the ClinicalTrials.gov website.

The following are examples of national and/or institutional clinical trials that are currently being conducted:

1. NCI-2014-00712; AALL1231 (NCT02112916) (Combination Chemotherapy With or Without Bortezomib in Treating Younger Patients With Newly Diagnosed T-Cell ALL or Stage II–IV T-Cell Lymphoblastic Lymphoma): This trial is for patients with T-cell ALL and is testing, in a nonrandomized fashion, reduction in the proportion of T-cell ALL patients who receive prophylactic cranial radiation. In this study, only very high-risk patients (those with M3 marrow at day 29 or MRD >0.1% at end of consolidation, regardless of initial CNS status) and any other patient who is CNS3 at diagnosis receive cranial radiation therapy. CNS3 patients receive 18 Gy of cranial radiation, while the other patients allocated to cranial radiation receive 12 Gy. It is estimated that 10% to 15% of T-cell ALL patients will receive cranial radiation on AALL1231, compared with 85% to 90% of T-cell ALL patients on predecessor COG trials.
2. SJCRH Total XVI (TOTXVI; NCT00549848) (Total Therapy Study XVI for Newly Diagnosed Patients With ALL): Patients receive both intrathecal chemotherapy and high-dose methotrexate without radiation therapy. Certain patients with high-risk features, including those with a t(1;19) translocation, receive intensified intrathecal therapy.

Toxicity of CNS-Directed Therapy

Toxic effects of CNS-directed therapy for childhood ALL can be acute and subacute or late developing. (Refer to the Late Effects of the Central Nervous System section in the PDQ summary on Late Effects of Treatment for Childhood Cancer for more information.)

Acute and subacute toxicities

The most common acute side effect associated with intrathecal chemotherapy alone is seizures. Up to 5% of nonirradiated patients with ALL treated with frequent doses of intrathecal chemotherapy will have at least one seizure during therapy.[11] Higher rates of seizure were observed with consolidation regimens that included multiple doses of high-dose methotrexate in addition to intrathecal chemotherapy.[26] Intrathecal and high-dose intravenous methotrexate has also been associated with a stroke-like syndrome, which, in most cases, appears to be reversible.[27]

Patients with ALL who develop seizures during the course of treatment and who receive anticonvulsant therapy should not receive phenobarbital or phenytoin as anticonvulsant treatment, as these drugs may increase the clearance of some chemotherapeutic drugs and adversely affect treatment outcome.[28] Gabapentin or valproic acid are alternative anticonvulsants with less enzyme-inducing capabilities.[28]

Late-developing toxicities

Late effects associated with CNS-directed therapies include subsequent neoplasms, neuroendocrine disturbances, leukoencephalopathy, and neurocognitive impairments.

Subsequent neoplasms are observed primarily in survivors who received cranial radiation. Meningiomas are common and typically of low malignant potential, but high-grade lesions also occur. In a SJCRH retrospective study of more than 1,290 ALL patients who had never relapsed, the 30-year cumulative incidence of a subsequent neoplasm occurring in the CNS was 3%; excluding meningiomas, the 30-year cumulative incidence was 1.17%.[29] Nearly all of these CNS subsequent neoplasms occurred in previously irradiated patients.

Neurocognitive impairments, which can range in severity and functional consequences, have been documented in long-term ALL survivors treated both with and without radiation therapy. In general, patients treated without cranial radiation have less severe neurocognitive sequelae than irradiated patients, and the deficits that do develop represent relatively modest declines in a limited number of domains of neuropsychological functioning.[30-33] For patients who receive cranial radiation therapy, the frequency and severity of toxicities appear dose-related; patients treated with 18 Gy of cranial radiation therapy appear to be at lower risk of severe impairments compared with those treated with doses of 24 Gy or higher. Younger age at diagnosis and female sex have been reported in many studies to be associated with a higher risk of neurocognitive late effects.[34]

Several studies have also evaluated the impact of other components of treatment on the development of late neurocognitive impairments. A comparison of neurocognitive outcomes of patients treated with methotrexate versus triple intrathecal chemotherapy showed no clinically meaningful difference.[23][Level of evidence: 3iiiC] Controversy exists about whether patients who receive dexamethasone have a higher risk of neurocognitive disturbances.[35] In a SJCRH study of nonirradiated long-term survivors, treatment with dexamethasone was associated with increased risk of impairments in attention and executive function.[36] Conversely, long-term neurocognitive testing in 92 children with a history of standard-risk ALL who had received either dexamethasone or prednisone during treatment did not demonstrate any meaningful differences in cognitive functioning based on corticosteroid randomization.[37]

Evidence (neurocognitive late effects of cranial radiation):

1. A SJCRH study of 567 adult long-term survivors of childhood ALL underwent neurocognitive testing (mean time from diagnosis, 26 years).[36]
   • Patients treated with 24 Gy of cranial radiation showed the highest rates of impairment. Up to one-third of these patients demonstrated impairments (defined as test scores 2 or more standard deviations below age-adjusted national norms) in attention, memory, processing speed, and executive function.
   • Significantly fewer patients who had received 18 Gy of cranial radiation demonstrated severe impairments compared with those who had received 24 Gy. In general, there was no significant difference in rates of impairment between nonirradiated survivors and those who received 18 Gy of cranial radiation; however, the 18-Gy group was at increased risk of academic problems.
   • In addition to being dose-related, the neurocognitive impact of cranial radiation was also dependent on age at diagnosis, with higher frequency of impairments in patients diagnosed at a younger age.
2. A study compared memory impairment in patients receiving 18 Gy of cranial radiation (n = 127) versus 24 Gy of cranial radiation (n = 138).[38]
   • Long-term survivors who received 24 Gy, but not 18 Gy, of cranial radiation demonstrated significant impairments in immediate and delayed memory.
3. In a randomized trial comparing irradiated (at a dose of 18 Gy) and nonirradiated standard-risk ALL patients, the following was observed: [30][Level of evidence: 1iiC]
   • Cognitive function for both groups (assessed at a median of 6 years postdiagnosis) was in the average range, with only subtle differences noted between the groups in cognitive skills.
4. In a randomized trial, hyperfractionated radiation (at a dose of 18 Gy) did not decrease neurologic late effects when compared with conventionally fractionated radiation; cognitive function for both groups was not significantly impaired.[39]

Evidence (neurocognitive late effects in nonirradiated patients):

1. In the SJCRH long-term follow-up study of 567 adult long-term survivors, some nonirradiated patients also demonstrated neurocognitive impairments.[36]
   • The age-adjusted mean test scores for nonirradiated patients were very similar to that of expected national norms; however, approximately 15% of the nonirradiated survivors participating in this study demonstrated impairments in some domains, including attention, memory, processing speed, and executive function.
   • Despite the impairments noted on neurocognitive testing, overall, the educational attainment and employment status of the tested ALL survivors were similar to age- and sex-adjusted expected proportions using census data for the U.S. population.
2. In a second study from SJCRH, patients enrolled on Total Study XV (which omitted cranial radiation in all patients) underwent comprehensive neuropsychological assessments at induction, end of maintenance, and 2 years after completion of therapy.[40]
   • Neurocognitive function was largely age appropriate 2 years after completing therapy, without evidence of excess impairment on measures of intellectual functioning, academic abilities, learning, and memory. Problems with sustained attention were observed at an increased frequency in this population compared with normative expectations.
   • High-risk patients who received more intensive CNS-directed chemotherapy (including high-dose methotrexate and more doses of intrathecal chemotherapy) were at greater risk of difficulties in attention, processing speed, and academics.

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30. Waber DP, Turek J, Catania L, et al.: Neuropsychological outcomes from a randomized trial of triple intrathecal chemotherapy compared with 18 Gy cranial radiation as CNS treatment in acute lymphoblastic leukemia: findings from Dana-Farber Cancer Institute ALL Consortium Protocol 95-01. J Clin Oncol 25 (31): 4914-21, 2007. [PUBMED Abstract]
31. Jansen NC, Kingma A, Schuitema A, et al.: Neuropsychological outcome in chemotherapy-only-treated children with acute lymphoblastic leukemia. J Clin Oncol 26 (18): 3025-30, 2008. [PUBMED Abstract]
32. Espy KA, Moore IM, Kaufmann PM, et al.: Chemotherapeutic CNS prophylaxis and neuropsychologic change in children with acute lymphoblastic leukemia: a prospective study. J Pediatr Psychol 26 (1): 1-9, 2001 Jan-Feb. [PUBMED Abstract]
33. Copeland DR, Moore BD 3rd, Francis DJ, et al.: Neuropsychologic effects of chemotherapy on children with cancer: a longitudinal study. J Clin Oncol 14 (10): 2826-35, 1996. [PUBMED Abstract]
34. von der Weid N, Mosimann I, Hirt A, et al.: Intellectual outcome in children and adolescents with acute lymphoblastic leukaemia treated with chemotherapy alone: age- and sex-related differences. Eur J Cancer 39 (3): 359-65, 2003. [PUBMED Abstract]
35. Waber DP, Carpentieri SC, Klar N, et al.: Cognitive sequelae in children treated for acute lymphoblastic leukemia with dexamethasone or prednisone. J Pediatr Hematol Oncol 22 (3): 206-13, 2000 May-Jun. [PUBMED Abstract]
36. Krull KR, Brinkman TM, Li C, et al.: Neurocognitive outcomes decades after treatment for childhood acute lymphoblastic leukemia: a report from the St Jude lifetime cohort study. J Clin Oncol 31 (35): 4407-15, 2013. [PUBMED Abstract]
37. Kadan-Lottick NS, Brouwers P, Breiger D, et al.: A comparison of neurocognitive functioning in children previously randomized to dexamethasone or prednisone in the treatment of childhood acute lymphoblastic leukemia. Blood 114 (9): 1746-52, 2009. [PUBMED Abstract]
38. Armstrong GT, Reddick WE, Petersen RC, et al.: Evaluation of memory impairment in aging adult survivors of childhood acute lymphoblastic leukemia treated with cranial radiotherapy. J Natl Cancer Inst 105 (12): 899-907, 2013. [PUBMED Abstract]
39. Waber DP, Silverman LB, Catania L, et al.: Outcomes of a randomized trial of hyperfractionated cranial radiation therapy for treatment of high-risk acute lymphoblastic leukemia: therapeutic efficacy and neurotoxicity. J Clin Oncol 22 (13): 2701-7, 2004. [PUBMED Abstract]
40. Jacola LM, Krull KR, Pui CH, et al.: Longitudinal Assessment of Neurocognitive Outcomes in Survivors of Childhood Acute Lymphoblastic Leukemia Treated on a Contemporary Chemotherapy Protocol. J Clin Oncol 34 (11): 1239-47, 2016. [PUBMED Abstract]

Postinduction Treatment for Specific ALL Subgroups

In This Section

• T-Cell ALL
  • Treatment options for T-cell ALL
  • Treatment options under clinical evaluation for T-cell ALL
  • Current Clinical Trials
• Infants With ALL
  • Treatment options for infants with MLL (KMT2A) rearrangements
  • Treatment options for infants without MLL (KMT2A) rearrangements
  • Treatment options under clinical evaluation for infants with ALL
• Adolescents and Young Adults With ALL
  • Treatment options
  • Treatment options under clinical evaluation for adolescent and young adult patients with ALL
• Philadelphia Chromosome–positive (BCR-ABL1–positive) ALL
  • Treatment options
  • Treatment options under clinical evaluation for Ph+ ALL
  • Current Clinical Trials

T-Cell ALL

Historically, patients with T-cell acute lymphoblastic leukemia (ALL) have had a worse prognosis than children with precursor B-cell ALL. In a review of a large number of patients treated on Children's Oncology Group (COG) trials over a 15-year period, T-cell immunophenotype still proved to be a negative prognostic factor on multivariate analysis.[1] However, with current treatment regimens, outcomes for children with T-cell ALL are now approaching those achieved for children with precursor B-cell ALL. For example, the 10-year overall survival (OS) for children with T-cell ALL treated on the Dana-Farber Cancer Institute (DFCI) DFCI-95001 (NCT00004034) trial was 90.1%, compared with 88.7% for patients with B-cell disease.[2] Another example is the COG trial for T-cell ALL (AALL0434 [NCT00408005]) that resulted in a 5-year event-free survival (EFS) rate of 83.8% and an OS rate of 89.5%.[3]

Treatment options for T-cell ALL

1. Protocols of the former Pediatric Oncology Group (POG) treated children with T-cell ALL differently from children with B-lineage ALL. The POG-9404 protocol for patients with T-cell ALL was designed to evaluate the role of high-dose methotrexate. The multiagent chemotherapy regimen for this protocol was based on the DFCI-87001 regimen.[4]
   • Results of the POG-9404 study indicated that the addition of high-dose methotrexate to the DFCI-based chemotherapy regimen resulted in significantly improved EFS in patients with T-cell ALL (10-year EFS, 78% for those randomly assigned to high-dose methotrexate versus 68% for those randomly assigned to therapy without high-dose methotrexate, P = .05).
   • High-dose methotrexate was associated with a lower incidence of relapses involving the central nervous system (CNS).[5] This POG study was the first clinical trial to provide evidence that high-dose methotrexate can improve outcome for children with T-cell ALL. High-dose asparaginase, doxorubicin, and prophylactic cranial irradiation were also important components of this regimen.[2,5]
2. In the POG-9404 study, patients were randomly assigned to doxorubicin with or without dexrazoxane to determine the efficacy of dexrazoxane in preventing late cardiac mortality.[6][Level of evidence: 1iiDi]
   • There was no difference in EFS between patients with T-cell ALL who were treated with dexrazoxane and patients who were not treated with dexrazoxane (cumulative doxorubicin dose, 360 mg/m2).[6]
   • The frequency of grade 3 and grade 4 toxicities that occurred during therapy was similar between the randomized groups, and there was no difference in cumulative incidence of second malignant neoplasms. Three years after initial diagnosis, left ventricular shortening fraction and left ventricular wall thickness were both significantly worse in patients who received doxorubicin alone than in patients who received dexrazoxane, indicating that dexrazoxane was cardioprotective.[6]
   • With combined data from three COG trials that randomized dexrazoxane with doxorubicin therapy (P9404, P9425, and P9426) and had a median follow-up of 12.6 years, dexrazoxane did not appear to compromise long-term survival.[7][Level of evidence: 1iiA]
3. Protocols of the former Children’s Cancer Group (CCG) treated children with T-cell ALL on the same treatment regimens as children with precursor B-cell ALL, basing protocol and treatment assignment on the patients' clinical characteristics (e.g., age and white blood cell [WBC] count) and the disease response to initial therapy. Most children with T-cell ALL meet National Cancer Institute (NCI) high-risk criteria.
   • Results from CCG-1961 for high-risk ALL including T-cell ALL showed that an augmented Berlin-Frankfurt-Münster (BFM) regimen with a single delayed intensification course produced the best results for patients with morphologic rapid response to initial induction therapy (estimated 5-year EFS, 83%).[8,9] With this approach, patients with a presenting WBC count greater than 200,000 had similar outcomes to those with a WBC count of less than 200,000.[10][Level of evidence: 1iiDi]
   • Overall results from POG-9404 and CCG-1961 were similar, although POG-9404 used higher cumulative dose of anthracyclines and cranial radiation for every patient, while CCG-1961 used cranial radiation only for patients with slow morphologic response.[9,5]
   • Among children with NCI standard-risk T-cell ALL, the 7-year EFS for those treated on CCG-1952, COG-1991 and POG-9404 is comparable with the CCG regimens utilizing significantly less anthracycline in a less intensive chemotherapy backbone without the prophylactic cranial irradiation included in POG-9404.[11]
4. In the COG, children with T-cell ALL are not treated on the same protocols as children with precursor B-cell ALL.
   • Pilot studies from the COG have demonstrated the feasibility of incorporating nelarabine (a nucleoside analog with demonstrated activity in patients with relapsed and refractory T-cell lymphoblastic disease) [12-14] in the context of a BFM regimen for patients with newly diagnosed T-cell ALL. The pilot study showed a 5-year EFS rate of 73% for all patients receiving nelarabine and 69% for those patients with a slow early response.[15]
   • The COG AALL0434 (NCT00408005) trial treated patients with T-cell ALL on an augmented BFM regimen and randomly assigned patients to receive either high-dose methotrexate with leucovorin rescue or escalating methotrexate without leucovorin (Capizzi).[16] Nearly all patients received either prophylactic (12 Gy) or therapeutic (18 Gy) cranial irradiation; only 10% of patients considered to be low risk were not irradiated. Patients assigned to the Capizzi methotrexate arm received cranial radiation earlier than did patients assigned to the high-dose methotrexate arm (week 8 vs. week 26). Patients on the Capizzi methotrexate arm also received two additional doses of pegaspargase. Results indicate a better DFS for patients who were randomly assigned to the Capizzi arm (5-year DFS, 91.5%) than for patients randomly assigned to the high-dose methotrexate arm (5-year DFS, 85.3%; P = .005).[3] Correspondingly, the cumulative incidence of CNS relapse and isolated bone marrow relapse were reduced for patients receiving Capizzi methotrexate (0.4% and 2.2%, respectively) compared with patients receiving high-dose methotrexate (3.0% and 5.9%, respectively).
5. The use of prophylactic cranial radiation in the treatment of T-cell ALL is declining. Some groups, such as St. Jude Children's Research Hospital (SJCRH) and the Dutch Childhood Oncology Group (DCOG), do not use cranial radiation in first-line treatment of ALL, and other groups, such as DFCI, COG, and BFM, are now limiting radiation to patients with very high-risk features or CNS3 disease.

Treatment options under clinical evaluation for T-cell ALL

Information about NCI-supported clinical trials can be found on the NCI website. For information about clinical trials sponsored by other organizations, refer to the ClinicalTrials.gov website.

The following is an example of a national and/or institutional clinical trial that is currently being conducted:

1. NCI-2014-00712; AALL1231 (NCT02112916) (Combination Chemotherapy With or Without Bortezomib in Treating Younger Patients With Newly Diagnosed T-Cell ALL or Stage II–IV T-Cell Lymphoblastic Lymphoma): This phase III trial is utilizing a modified augmented BFM regimen for patients aged 1 to 30 years with T-cell ALL. Patients are classified into one of three risk groups (standard, intermediate, or very high) based on morphologic response at day 29, minimal residual disease (MRD) status at day 29 and end of consolidation, and CNS status at diagnosis. Age and presenting leukocyte count are not used to stratify patients. The objectives of the trial include the following:
   • To compare EFS in patients who are randomly assigned to receive or not to receive bortezomib on a modified augmented BFM backbone. For those randomly assigned to receive bortezomib, it is given during the induction phase (four doses) and again during the delayed intensification phase (four doses).
   • To determine the safety and feasibility of modifying standard COG therapy for T-cell ALL by using dexamethasone instead of prednisone during the induction and maintenance phases and additional doses of pegaspargase during the induction and delayed intensification phases.
   • To determine whether prophylactic cranial radiation can be omitted in 85% to 90% of T-cell ALL patients (non–very high risk, non-CNS3) without an increase in relapse risk, compared with historic controls.
   • To determine the proportion of patients with end consolidation MRD >0.1% who become MRD-negative after intensification therapy using three high-risk BFM blocks that include high-dose cytarabine, high-dose methotrexate, ifosfamide, and etoposide.

Current Clinical Trials

Use our advanced clinical trial search to find NCI-supported cancer clinical trials that are now enrolling patients. The search can be narrowed by location of the trial, type of treatment, name of the drug, and other criteria. General information about clinical trials is also available.

Infants With ALL

Infant ALL is uncommon, representing approximately 2% to 4% of cases of childhood ALL.[17] Because of their distinctive biological characteristics and their high risk of leukemia recurrence, infants with ALL are treated on protocols specifically designed for this patient population. Common therapeutic themes of the intensive chemotherapy regimens used to treat infants with ALL are the inclusion of postinduction intensification courses with high doses of cytarabine and methotrexate.[18-20]

Infants diagnosed within the first few months of life have a particularly poor outcome. In one study, patients diagnosed within 1 month of birth had a 2-year OS rate of 20%.[21][Level of evidence: 2A] In another study, the 5-year EFS for infants diagnosed at younger than 90 days was 16%.[20][Level of evidence: 2A]

For infants with MLL (KMT2A) gene rearrangement, the EFS rates continue to be in the 35% range.[18-20,22][Level of evidence: 2A] Factors predicting poor outcome for infants with MLL rearrangements include the following:[19,20]; [23][Level of evidence: 3iDii]

• A very young age (≤90 days).
• Extremely high presenting leukocyte count (≥200,000–300,000/μL).
• Poor early response, as reflected by a poor response to a prednisone prophase or high levels of MRD at the end of induction and consolidation phases of treatment.

Infants have significantly higher relapse rates than older children with ALL and are at higher risk of developing treatment-related toxicity, especially infection. With current treatment approaches for this population, treatment-related mortality has been reported to occur in about 10% of infants, a rate that is much higher than the rate in older children with ALL.[19,20] On the COG AALL0631 (NCT00557193) trial, an intensified induction regimen resulted in an induction death rate of 15.4% (4 of 26 patients); the trial was subsequently amended to include a less-intensive induction and enhanced supportive care guidelines, resulting in a significantly lower induction death rate (1.6%; 2 of 123 patients) and significantly higher complete remission (CR) rate (94% vs. 68% with the previous, more intensified induction regimen).[24]

Treatment options for infants with MLL (KMT2A) rearrangements

Infants with MLL (KMT2A) gene rearrangements are generally treated on intensified chemotherapy regimens using agents not typically incorporated into frontline therapy for older children with ALL. However, despite these intensified approaches, EFS rates remain poor for these patients.

Evidence (intensified chemotherapy regimens for infants with MLL [KMT2A] rearrangements):

1. The international Interfant clinical trials consortium utilized a cytarabine-intensive chemotherapy regimen, with increased exposure to both low- and high-dose cytarabine during the first few months of therapy, resulting in a 5-year EFS of 37% for infants with MLL (KMT2A) rearrangements.[19]
2. The COG tested intensification of therapy with a regimen including multiple doses of high-dose methotrexate, cyclophosphamide, and etoposide, resulting in a 5-year EFS of 34% for infants with MLL rearrangements.[18]
3. On the COG P9407 (NCT00002756) trial, infants were treated with a shortened (46-week) intensive chemotherapy regimen. The 5-year EFS for infants with MLLrearrangements was 36%.[20][Level of evidence: 2A]

The role of allogeneic hematopoietic stem cell transplant (HSCT) during first remission in infants with MLL (KMT2A) gene rearrangements remains controversial.

Evidence (allogeneic HSCT in first remission for infants with MLL [KMT2A] rearrangements):

1. On a Japanese clinical trial conducted between 1998 and 2002, all infants with MLL(KMT2A)-rearrangement were intended to proceed to allogeneic HSCT from the best available donor (related, unrelated, or umbilical cord) 3 to 5 months after diagnosis.[25]
   • The 3-year EFS for all enrolled infants was 44%. This result was due, in part, to the high frequency of early relapses, even with intensive chemotherapy; of the 41 infants with MLL rearrangement on that study who achieved CR, 11 infants (27%) relapsed before proceeding to transplant.
2. In a COG report that included 189 infants treated on CCG or POG infant ALL protocols between 1996 and 2000, there was no difference in EFS between patients who underwent HSCT in first CR and those who received chemotherapy alone.[26]
3. The Interfant clinical trials group, after adjusting for waiting time to transplantation, also did not observe any difference in DFS in high-risk infants (defined by prednisone response) with MLL (KMT2A) rearrangements treated on the Interfant-99 trial with either allogeneic HSCT in first CR or chemotherapy alone.[19]
   • In a subset analysis from the same trial, allogeneic HSCT in first remission was associated with a significantly better DFS for infants with MLL rearrangements who were younger than 6 months at diagnosis and had either a poor prednisone response at day 8 or leukocyte counts of at least 300,000/µL.[27] In this subset, HSCT in first remission was associated with a 64% reduction in the risk of failure resulting from relapse or death compared with chemotherapy alone.
4. For infants with ALL who undergo transplantation in first CR, outcomes appear to be similar with non–total-body irradiation (TBI) regimens and TBI-based regimens.[26,28]

Treatment options for infants without MLL (KMT2A) rearrangements

The optimal treatment for infants without MLL (KMT2A) rearrangements also remains unclear.

1. On the Interfant-99 trial, patients without MLL (KMT2A) rearrangement achieved a relatively favorable outcome with the cytarabine-intensive treatment regimen (4-year EFS was 74%).[19]
2. The COG P9407 (NCT00002756) trial of intensified chemotherapy reported a 70% 5-year EFS in infants without the MLL rearrangement.[20][Level of evidence: 2A]
3. A favorable outcome for this subset of patients was obtained in a Japanese study using therapy comparable to that used to treat older children with ALL;[22] however, that study was limited by small numbers (n = 22) and a highly unusual sex distribution (91% males).

Treatment options under clinical evaluation for infants with ALL

Information about NCI-supported clinical trials can be found on the NCI website. For information about clinical trials sponsored by other organizations, refer to the ClinicalTrials.gov website.

The following is an example of national and/or institutional clinical trial that is currently being conducted:

1. AALL15P1 (NCT02828358) (Azacitidine and Combination Chemotherapy in Treating Infants with ALL and KMT2A Gene Rearrangement): This COG protocol is a nonrandomized pilot study that is testing the feasibility of adding azacitidine (a DNA demethylating agent) to the Interfant chemotherapy backbone. Patients younger than 12 months with newly diagnosed B-cell ALL or acute leukemia of ambiguous lineage are eligible for enrollment. Patients begin treatment with a 4-week multiagent induction phase. Following induction, infants without KMT2A (MLL) rearrangements discontinue therapy at the end of the induction phase, while infants with KMT2Arearrangements continue on the study, receiving four 5-day courses of azacitidine therapy, as epigenetic priming, just before each major block of postinduction chemotherapy on the Interfant chemotherapy backbone. The primary objective of this trial is to determine whether azacitidine can be safely incorporated into the Interfant chemotherapy backbone.

Adolescents and Young Adults With ALL

Adolescents and young adults with ALL have been recognized as high risk for decades. Outcomes in almost all studies of treatment are inferior in this age group compared with children younger than 10 years.[29-31] The reasons for this difference include more frequent presentation of adverse prognostic factors at diagnosis, including the following:

• T-cell immunophenotype.
• Philadelphia chromosome–positivity (Ph+) and BCR-ABL1-like (Ph-like) disease.
• Lower incidence of favorable cytogenetic abnormalities.

In addition to more frequent adverse prognostic factors, patients in this age group have higher rates of treatment-related mortality [30-33] and nonadherence to therapy.[32,34]

Treatment options

Studies from the United States and France were among the first to identify the difference in outcome based on treatment regimens.[35] Other studies have confirmed that older adolescent and young adult patients fare better on pediatric rather than adult regimens.[35-42]; [43][Level of evidence: 2A] These study results are summarized in Table 5.

Given the relatively favorable outcome that can be obtained in these patients with chemotherapy regimens used for high-risk pediatric ALL, there is no role for the routine use of allogeneic HSCT for adolescents and young adults with ALL in first remission.[31]

Evidence (use of a pediatric treatment regimen for adolescents and young adults with ALL):

1. Investigators reported on 197 patients aged 16 to 21 years treated on the CCG study (a pediatric ALL regimen) who showed a 7-year EFS of 63% compared with 124 adolescents and young adults treated on the Cancer and Leukemia Group B (CALGB) study (an adult ALL regimen) with a 7-year EFS of 34%.[35]
2. A study from France of patients aged 15 to 20 years and diagnosed between 1993 and 1999 demonstrated superior outcome for patients treated on a pediatric trial (67%; 5-year EFS) compared with patients treated on an adult trial (41%; 5-year EFS).[40]
3. In the COG high-risk study (CCG-1961), the 5-year EFS rate for 262 patients aged 16 to 21 years was 71.5%.[31][Level of evidence: 1iiDi] For rapid responders randomly assigned to early intensive postinduction therapy on the augmented intensity arms of this study, the 5-year EFS rate was 82% (n = 88).
4. The DFCI ALL Consortium reported that a study of 51 adolescents aged 15 to 18 years in a pediatric trial had a 5-year EFS of 78%.[37]
5. In an SJCRH study, 44 adolescents aged 15 to 18 years had an EFS of approximately 85% ± 5%.[30]
6. In a Spanish study, 35 adolescents (aged 15–18 years) and 46 young adults (aged 19–30 years) with standard-risk ALL were treated with a pediatric-based regimen.[43][Level of evidence: 2A]
   • EFS rate was 61%.
   • The OS rate was 69%.
   • There were no differences in outcome between adolescents and young adults.
7. In a trial conducted in Japan, 139 adolescent and young adult patients (aged 15–24 years) with Philadelphia chromosome–negative ALL were treated with a high-risk pediatric regimen.[44]
   • The 5-year DFS rate was 67%, and the 5-year OS rate was 73%—significantly better than the outcome observed in similar-aged patients treated in the predecessor trial using a nonpediatric regimen (5-year DFS, 44% and OS, 45%).
   • There did not appear to be more severe adverse events in adolescent and young adult patients than in younger patients treated with the same high-risk regimen.
   • Twenty-one percent of the adolescent and young adult patients did not receive the full intended course of treatment; these patients had a significantly worse DFS.
8. The UKALL2003 (NCT00222612) trial studied treatment intensification according to MRD at the end of induction. Patients aged 16 to 24 years (N = 229) who were Philadelphia chromosome negative were enrolled in the study.[45][Level of evidence: 1iiDi]
   • Five-year EFS overall for this group was 72%.
   • Five-year EFS for low risk patients was 93%.
   • There were more serious adverse events in this age group than in younger patients.

Other studies have confirmed that older adolescent patients and young adults fare better on pediatric rather than adult regimens (refer to Table 5).[36,38,41,42]; [43][Level of evidence: 2A]

The reason that adolescents and young adults achieve superior outcomes with pediatric regimens is not known, although possible explanations include the following:[36]

• Treatment setting (i.e., site experience in treating ALL).
• Adherence to protocol therapy.
• The components of protocol therapy.

Table 5. Outcome According to Treatment Protocol for Adolescents and Young Adults with ALL

Site and Study Group	Adolescent and Young Adult Patients (No.)	Median age (y)	Survival (%)
ALL = acute lymphoblastic leukemia; EFS = event-free survival; OS = overall survival.
AIEOP = Associazione Italiana di Ematologia e Oncologia Pediatrica; CALGB = Cancer and Leukemia Group B; CCG = Children's Cancer Group; DCOG = Dutch Childhood Oncology Group; FRALLE = French Acute Lymphoblastic Leukaemia Study Group; GIMEMA = Gruppo Italiano Malattie EMatologiche dell'Adulto; HOVON = Dutch-Belgian Hemato-Oncology Cooperative Group; LALA = France-Belgium Group for Lymphoblastic Acute Leukemia in Adults; MRC = Medical Research Council (United Kingdom); NOPHO = Nordic Society for Pediatric Hematology and Oncology; UKALL = United Kingdom Acute Lymphoblastic Leukaemia.
United States [35]
CCG (Pediatric)	197	16	67, OS 7 y
CALGB (Adult)	124	19	46
France [40]
FRALLE 93 (Pediatric)	77	16	67 EFS
LALA 94	100	18	41
Italy [46]
AIEOP (Pediatric)	150	15	80, OS 2 y
GIMEMA (Adult)	95	16	71
Netherlands [47]
DCOG (Pediatric)	47	12	71 EFS
HOVON	44	20	38
Sweden [48]
NOPHO 92 (Pediatric)	36	16	74, OS 5 y
Adult ALL	99	18	39
United Kingdom[38]
MRC ALL (Pediatric)	61	15–17	71, OS 5 y
UKALL XII (Adult)	67	15–17	56
UKALL 2003 [45]	229	16–24	72 EFS

Osteonecrosis

Adolescents with ALL appear to be at higher risk than younger children for developing therapy-related complications, including osteonecrosis, deep venous thromboses, and pancreatitis.[37,49,50] Before the use of postinduction intensification for treatment of ALL, osteonecrosis was infrequent. The improvement in outcome for children and adolescents aged 10 years and older was accompanied by an increased incidence of osteonecrosis.

The weight-bearing joints are affected in 95% of patients who develop osteonecrosis and operative interventions are needed for management of symptoms and impaired mobility in more than 40% of cases. The majority of the cases are diagnosed within the first 2 years of therapy and often the symptoms are recognized during maintenance.

Evidence (osteonecrosis):

1. In the CCG-1961 high-risk ALL study, alternate-week dosing of dexamethasone was compared with standard continuous dexamethasone during delayed intensification to see if the osteonecrosis risk could be reduced.[49]
   • The median age at symptom onset was 16 years.
   • The cumulative incidence was higher in adolescents and young adults aged 16 to 21 years (20% at 5 years) than in those aged 10 to 15 years (9.9%) or in patients aged 1 to 9 years (1%).
   • Operative interventions are needed for management of symptoms and impaired mobility in more than 40% of cases.
   • The use of alternate-week dosing of dexamethasone as compared with standard continuous dexamethasone during delayed intensification in CCG-1961 reduced the risk of osteonecrosis. The greatest impact was seen in females aged 16 to 21 years, who showed the highest incidence of osteonecrosis with standard therapy containing continuous dexamethasone; osteonecrosis was reduced with alternate-week dexamethasone postinduction (57.6% to 5.6%).
2. In the COG AALL0232 (NCT00075725) high-risk ALL trial, patients were randomly assigned during induction to receive either 14 days of dexamethasone or 28 days of prednisone.[51]
   • The incidence of osteonecrosis in patients older than 10 years who received dexamethasone was 24.3%, compared with an incidence of 15.9% in those receiving prednisone (P = .001)
   • Efficacy and other toxicities were comparable in the two arms.

Treatment options under clinical evaluation for adolescent and young adult patients with ALL

Information about NCI-supported clinical trials can be found on the NCI website. For information about clinical trials sponsored by other organizations, refer to the ClinicalTrials.gov website.

The following are examples of national and/or institutional clinical trials that are currently being conducted:

1. NCI-2014-00712; AALL1231 (NCT02112916) (Combination Chemotherapy With or Without Bortezomib in Treating Younger Patients With Newly Diagnosed T-Cell ALL or Stage II–IV T-Cell Lymphoblastic Lymphoma): This phase III trial for patients aged 1 to 30 years with T-cell ALL is utilizing a modified augmented BFM regimen. Patients are classified into one of three risk groups (standard, intermediate, or very high) based on morphologic response at day 29, MRD status at day 29 and end of consolidation, and CNS status at diagnosis. Age and presenting leukocyte count are not used to stratify patients. The objectives of the trial include the following:
   • To compare EFS in patients who are randomly assigned to receive or not to receive bortezomib on a modified augmented BFM backbone.
   • To determine the safety and feasibility of modifying standard COG therapy for T-cell ALL by using dexamethasone instead of prednisone during the induction and maintenance phases and additional doses of pegaspargase during the induction and delayed intensification phases.
   • To determine whether prophylactic cranial radiation can be omitted in 85% to 90% of T-cell ALL patients (non-very high risk, non-CNS3) without an increase in relapse risk, compared with historic controls.
   • To determine the proportion of patients with end consolidation MRD >0.1% who become MRD-negative after intensification therapy using three high-risk BFM blocks that include high-dose cytarabine, high-dose methotrexate, ifosfamide, and etoposide.
2. A041501 (NCT03150693) (Inotuzumab Ozogamicin and Frontline Chemotherapy in Treating Young Adults With Newly Diagnosed B-cell ALL): This is a National Clinical Trials Network trial to further expand on the experience of using a pediatric-inspired chemotherapy backbone in young adults with ALL. Patients who are in remission after induction will be randomly assigned to receive the pediatric backbone either with or without two courses of inotuzumab ozogamicin (a toxin-conjugated anti-CD22 monoclonal antibody) before starting consolidation therapy.
3. COG-AALL1131 (NCT01406756) (Combination Chemotherapy in Treating Young Patients With Newly Diagnosed High-Risk ALL):
   This protocol is open to patients with B-cell ALL who are aged 30 years or younger. Patients on this trial are classified as high risk if they are NCI high risk (by age or WBC) but lack very high-risk features (see below). Patients are classified as very high risk if they meet any of the following criteria:
   1. Age 13 years and older.
   2. CNS3 at diagnosis.
   3. M3 marrow at day 29.
   4. Unfavorable genetics (e.g., iAMP21, low hypodiploidy, MLL [KMT2A] gene rearrangement).
   5. High marrow MRD (>0.01% by flow cytometry) at day 29 (with the exception of NCI standard-risk patients with favorable genetics).
   Non-Down syndrome patients:
   Patients on this trial receive a four-drug induction (vincristine, corticosteroid, daunorubicin, and IV pegaspargase) with intrathecal chemotherapy. Patients younger than 10 years receive 2 weeks of dexamethasone during induction, and those aged 10 years and older receive 4 weeks of prednisone.
   All patients are screened for BCR-ABL1–like ALL; patients who have a gene fusion involving a kinase that is sensitive to dasatinib (e.g., ABL1, ABL2, CSF1F, and PDGFRB) are assigned to treatment with dasatinib added to standard chemotherapy (modified augmented BFM backbone, including an interim maintenance phase with high-dose methotrexate and one delayed intensification phase). Dasatinib treatment is initiated after induction therapy is complete, and it continues through maintenance therapy.
   For high-risk patients, the study compared triple intrathecal chemotherapy (methotrexate, cytarabine, and hydrocortisone) with intrathecal methotrexate in a randomized fashion to determine whether triple intrathecal chemotherapy reduces CNS relapse rates and improves EFS. Interim monitoring revealed that a futility boundary was crossed, indicating that the study would be unable to demonstrate superiority of the triple intrathecal chemotherapy, and the randomization was closed in 2018. Therefore, high-risk patients without dasatinib-sensitive fusions are removed from the study protocol at the end of induction.
   For very high-risk patients, the study had evaluated whether intensification of the consolidation phase and second-half of delayed intensification phases improved DFS. However, that portion of the trial was closed when a futility boundary was crossed, indicating that the study would not be able to demonstrate the superiority of the experimental arm. Therefore, very high-risk patients without dasatinib-sensitive fusions are also removed from protocol treatment; patients with low end-induction MRD are removed at the end of that phase and patients with M3 marrow at day 29 are also removed. Patients with high end-induction MRD (day 29) receive treatment in the consolidation phase, after which MRD is re-assessed and the patient is removed from study treatment.
   Down Syndrome patients:
   Down Syndrome patients with NCI high-risk ALL are treated with reduced-intensity induction and postinduction therapy regimens to test, in a nonrandomized fashion, whether the modified therapy reduces the risk of treatment-related morbidity and mortality.

Philadelphia Chromosome–positive (BCR-ABL1–positive) ALL

Philadelphia chromosome–positive (Ph+) ALL is seen in about 3% of pediatric ALL cases, increases in adolescence, and is seen in 15% to 25% of adults. In the past, this subtype of ALL has been recognized as extremely difficult to treat with poor outcome. In 2000, an international pediatric leukemia group reported a 7-year EFS of 25%, with an OS of 36%.[52] In 2010, the same group reported a 7-year EFS of 31% and an overall survival of 44% in Ph+ ALL patients treated without tyrosine kinase inhibitors.[53] Treatment of this subgroup has evolved from emphasis on aggressive chemotherapy, to bone marrow transplantation, and currently to combination therapy using chemotherapy plus a tyrosine kinase inhibitor.

Treatment options

Pre-tyrosine kinase inhibitor era

Before the use of imatinib mesylate, HSCT from a matched sibling donor was the treatment of choice for patients with Ph+ ALL.[54] Data to support this include a retrospective multigroup analysis of children and young adults with Ph+ ALL, in which HSCT from a matched sibling donor was associated with a better outcome than standard (pre-imatinib mesylate) chemotherapy.[52] In this retrospective analysis, Ph+ ALL patients undergoing HSCT from an unrelated donor had a very poor outcome. However, in a follow-up study by the same group evaluating outcomes in the subsequent decade (pre-imatinib mesylate era), transplantation with matched-related or matched-unrelated donors were equivalent. DFS at the 5-year time point showed an advantage for transplantation in first remission compared with chemotherapy that was borderline significant (P = .049), and OS was also higher for transplantation compared with chemotherapy, although the advantage at 5 years was not significant.[53]

Factors significantly associated with favorable prognosis in the pre-tyrosine kinase inhibitor era included the following:

• Younger age at diagnosis.[53]
• Lower leukocyte count at diagnosis.[53]
• Early response measures.[53,55,56]
• Ph+ ALL with a rapid morphologic response or rapid peripheral blood response to induction therapy.[53,55]

Following MRD by reverse transcription polymerase chain reaction (PCR) for the BCR-ABL1fusion transcript may also be useful to help predict outcome for Ph+ patients.[57-59]

Tyrosine kinase inhibitor era

Imatinib mesylate is a selective inhibitor of the BCR-ABL protein kinase. Phase I and II studies of single-agent imatinib in children and adults with relapsed or refractory Ph+ ALL have demonstrated relatively high response rates, although these responses tended to be of short duration.[60,61]

Clinical trials in adults and children with Ph+ ALL have demonstrated the feasibility of administering imatinib mesylate in combination with multiagent chemotherapy.[62-64] Outcome of results for Ph+ ALL demonstrated a better outcome after HSCT if imatinib was given before or after transplant.[65-69] Clinical trials have also demonstrated that many pediatric Ph+ ALL patients can be successfully treated without transplant using a combination of intensive chemotherapy and a tyrosine kinase inhibitor.[69,70]

Dasatinib, a second-generation inhibitor of tyrosine kinases, has also been studied in the treatment of Ph+ ALL. Dasatinib has shown significant activity in the CNS, both in a mouse model and a series of patients with CNS-positive leukemia.[71] The results of a phase I trial of dasatinib in pediatric patients indicated that once-daily dosing was associated with an acceptable toxicity profile, with few nonhematologic grade 3 or 4 adverse events.[72]

Evidence (tyrosine kinase inhibitor):

1. A retrospective study of 30 pediatric patients with Ph+ ALL (19 patients treated between 1991–2004 without a tyrosine kinase inhibitor, and 11 patients treated between 2004–2012 with either imatinib or dasatinib) indicated that tyrosine kinase inhibitors, when started mid-induction, are associated with lower end-induction MRD.[73]
2. The COG-AALL0031 study evaluated whether imatinib mesylate could be incorporated into an intensive chemotherapy regimen for children with Ph+ ALL. Patients received imatinib mesylate in conjunction with chemotherapy during postinduction therapy. Some children proceeded to allogeneic HSCT after two cycles of consolidation chemotherapy with imatinib mesylate, while other patients received imatinib mesylate in combination with chemotherapy throughout all treatment phases.[64,69]
   • The 5-year DFS for the 25 patients who received intensive chemotherapy with continuous dosing of imatinib mesylate was 70% ± 12%. These patients fared better than historic controls treated with chemotherapy alone (without imatinib mesylate), and at least as well as the other patients on the trial who underwent allogeneic transplantation. Five-year DFS was 66% for patients undergoing sibling-donor transplant (n = 21) and 59% for those undergoing unrelated donor transplant (n = 13).
   • Patients with additional cytogenetic abnormalities had worse outcomes (P = .05).
3. The COG-AALL0622 (NCT00720109) study tested the use of dasatinib (instead of imatinib) combined with a chemotherapy backbone similar to that used in COG-AALL0031.[74][Level of evidence: 2A] On this trial, dasatinib was started on day 15 of induction, resulting in higher rates of CR and a higher proportion of patients with low end-induction MRD compared with AALL0031, on which imatinib was not started until after the induction phase was completed.
   • Outcomes in the two trials were similar: 5-year OS was 81% and 86% and 5-year DFS was 68% and 60% for AALL0031 and AALL0622, respectively.
   • Excessive toxicity with dasatinib was not observed.
   • In a subset analysis that included patients who had diagnostic banked samples available, IKZF1 deletion was identified in 57% of patients and was associated with inferior EFS and OS.
4. The EsPhALL trial tested whether imatinib (administered discontinuously) given in the context of intensive chemotherapy improves outcome for pediatric Ph+ ALL patients, most of whom (80%) received an allogeneic HSCT in first CR. Patients were classified as either good risk or poor risk based on early response measures and remission status at the end of induction. Good-risk patients (n = 90) were randomly assigned to receive imatinib or not; poor-risk patients (n = 70) were directly assigned to imatinib. Interpretation of this study is limited due to the high noncompliance rate with randomized assignment in good-risk patients and early closure before reaching goal accrual due to publication of the results of the COG AALL0031 trial on which imatinib had been given continuously with chemotherapy.[70]
   • The overall DFS of patients treated on this trial appeared to be better than historic controls, and when analyzed as-treated (and not by intent-to-treat), good-risk patients who received imatinib had a superior DFS.
   • The EsPhALL trial has since been amended to test continuous dosing of imatinib; results are pending.

Treatment options under clinical evaluation for Ph+ ALL

Information about NCI-supported clinical trials can be found on the NCI website. For information about clinical trials sponsored by other organizations, refer to the ClinicalTrials.gov website.

The following is an example of a national and/or institutional clinical trial that is currently being conducted:

1. AALL1631 (NCT03007147) (Imatinib Mesylate and Combination Chemotherapy in Treating Patients with Newly Diagnosed Ph+ ALL): AALL1631 is an international collaborative protocol conducted by the COG and the European EsPhALL group. Ph+ ALL patients enter the trial at day 15 of induction IA and begin daily imatinib at that time. After the induction IB phase (weeks 10–12), MRD is assessed by immunoglobulin H/T-cell receptor (IgH-TCR) PCR, and patients are classified as standard risk (MRD <5 × 10-4) or high risk (MRD >5 × 10-4 ). Standard-risk patients are randomly assigned to receive one of the following two cytotoxic chemotherapy backbones:
   • The EsPhALL backbone used in previous EsPhALL protocols and COG AALL1122; or
   • A less-intensive regimen similar to those typically administered to non-Ph+ high-risk B-cell ALL patients on COG trials.
   Standard-risk patients on both arms will continue to receive imatinib until the completion of all planned chemotherapy (2 years of treatment). The objective of the standard-risk randomization is to determine whether the less-intensive chemotherapy backbone is associated with a similar DFS but lower rates of treatment-related toxicity compared with the standard therapy (EsPhALL chemotherapy backbone).
   High-risk patients (approximately 15%–20% of patients) will proceed to HSCT after completion of three consolidation blocks of chemotherapy. Imatinib will be restarted after HSCT and administered from day +56 until day +365 to test the feasibility of post-HSCT administration of this agent and describe the outcome of patients treated in this manner.

Current Clinical Trials

Use our advanced clinical trial search to find NCI-supported cancer clinical trials that are now enrolling patients. The search can be narrowed by location of the trial, type of treatment, name of the drug, and other criteria. General information about clinical trials is also available.

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Treatment of Relapsed Childhood ALL

In This Section

• Prognostic Factors After First Relapse of Childhood ALL
  • Site of relapse
  • Time from diagnosis to relapse
  • Patient characteristics
  • Risk group classification at initial diagnosis
  • Response to reinduction therapy
  • Cytogenetics/genomic alterations
  • Immunophenotype
• Standard Treatment Options for First Bone Marrow Relapse of Childhood ALL
  • Reinduction chemotherapy
  • Postreinduction therapy for patients achieving a second complete remission
• Treatment Options for Second and Subsequent Bone Marrow Relapse
• Hematopoietic Stem Cell Transplantation for First and Subsequent Bone Marrow Relapse
  • Components of the transplantation process
  • Intrathecal medication after HSCT to prevent relapse
  • Relapse after allogeneic HSCT for relapsed ALL
• Immunotherapeutic Approaches for Refractory ALL
  • Monoclonal antibody therapy
  • CAR T-cell therapy
• Treatment of Isolated Extramedullary Relapse
  • Isolated CNS relapse
  • Isolated testicular relapse
• Treatment Options Under Clinical Evaluation for Relapsed Childhood ALL
  • Trials for ALL in first relapse
  • Trials for ALL in second or subsequent relapse or refractory ALL
  • Current Clinical Trials

Prognostic Factors After First Relapse of Childhood ALL

The prognosis for a child with acute lymphoblastic leukemia (ALL) whose disease recurs depends on multiple factors.[1-14]; [15][Level of evidence: 3iiDi]

The two most important prognostic risk factors after first relapse of childhood ALL are the following:

• Site of relapse.
• Time from diagnosis to relapse.

Other prognostic factors include the following:

• Patient characteristics (e.g., age and peripheral blast count at time of relapse).
• Risk group classification at initial diagnosis.
• Response to reinduction therapy.
• Cytogenetics/genomic alterations.
• Immunophenotype.

Site of relapse

Patients who have isolated extramedullary relapse fare better than those who have relapse involving the marrow. In some studies, patients with combined marrow/extramedullary relapse had a better prognosis than did those with a marrow relapse; however, other studies have not confirmed this finding.[5,13,16]

Time from diagnosis to relapse

For patients with relapsed precursor B-cell ALL, early relapses fare worse than later relapses, and marrow relapses fare worse than isolated extramedullary relapses. For example, survival rates range from less than 20% for patients with marrow relapses occurring within 18 months from diagnosis to 40% to 50% for those whose relapses occur more than 36 months from diagnosis.[5,13]

For patients with isolated central nervous system (CNS) relapses, the overall survival (OS) rates for early relapse (<18 months from diagnosis) are 40% to 50% and 75% to 80% for those with late relapses (>18 months from diagnosis).[13,17] No evidence exists that early detection of relapse by frequent surveillance (complete blood counts or bone marrow tests) in off-therapy patients improves outcome.[18]

Patient characteristics

Age 10 years and older at diagnosis and at relapse have been reported as independent predictors of poor outcome.[13,16] A Children’s Oncology Group (COG) study further showed that although patients aged 10 to 15 years at initial diagnosis do worse than patients aged 1 to 9 years (35% vs. 48%, 3-year postrelapse survival), those older than age 15 years did much worse (3-year OS, 15%; P = .001).[19]

The Berlin-Frankfurt-Münster (BFM) group has also reported that high peripheral blast counts (>10,000/μL) at the time of relapse were associated with inferior outcomes in patients with late marrow relapses.[10]

Children with Down syndrome with relapse of ALL have generally had inferior outcomes resulting from increased induction deaths, treatment-related mortality, and relapse.

• The BFM group showed that since 2000, improvements in supportive care have led to decreases in treatment-related mortality in children with Down syndrome, but the risk of relapse remains high.[20]
• An analysis of data from the Center for International Blood and Marrow Transplant Research (CIBMTR) on 27 Down syndrome patients with ALL who underwent hematopoietic stem cell transplantation (HSCT) between 2000 and 2009 substantiated this finding. They noted that with current transplant practices, hematopoietic recovery, graft-versus-host disease (GVHD), and transplant-related mortality were within the expected range compared with non–Down syndrome ALL patients. However, relapse was higher than expected (>50%) and was the primary cause of treatment failure, leading to poor survival (24% disease-free survival [DFS] at 3 years).[21][Level of evidence: 3iiiA]

Risk group classification at initial diagnosis

The COG reported that risk group classification at the time of initial diagnosis was prognostically significant after relapse; patients who met National Cancer Institute (NCI) standard-risk criteria at initial diagnosis fared better after relapse than did NCI high-risk patients.[13]

Response to reinduction therapy

Patients with marrow relapses who have persistent morphologic disease at the end of the first month of reinduction therapy have an extremely poor prognosis, even if they subsequently achieve a second complete remission (CR).[22][Level of evidence: 2Di]; [23][Level of evidence: 3iiiA] Several studies have demonstrated that minimal residual disease (MRD) levels after the achievement of second CR are of prognostic significance in relapsed ALL.[22,24-26]; [27][Level of evidence: 3iiiDi] High levels of MRD at the end of reinduction and at later time points have been correlated with an extremely high risk of subsequent relapse.

Cytogenetics/genomic alterations

Changes in mutation profiles from diagnosis to relapse have been identified by gene sequencing.[28,29] While oncogenic gene fusions (e.g., TCF3-PBX1, ETV6-RUNX1) are almost always observed between the time of initial diagnosis and relapse, single nucleotide variants and copy number variants may be present at diagnosis, but not at relapse, and vice versa.[28] For example, while RAS family mutations are common at both diagnosis and relapse, the specific RAS family mutations may change from diagnosis to relapse as specific leukemic subclones rise and fall during the course of treatment.[28] By contrast, relapse-specific mutations in NT5C2 (a gene involved in nucleotide metabolism) have been noted in as many as 45% of ALL cases with early relapse.[28,30,31]

TP53 alterations (mutations and/or copy number alterations) are observed in approximately 11% of patients with ALL at first relapse and have been associated with an increased likelihood of persistent leukemia after initial reinduction (38.5% TP53 alteration vs. 12.5% TP53 wild-type) and poor event-free survival (EFS) (9% TP53 alteration vs. 49% TP53 wild-type).[32] Approximately one-half of the TP53 alterations were present at initial diagnosis and half were newly observed at time of relapse.[32] A second genomic alteration found to predict for poor prognosis in patients with precursor B-cell ALL in first bone marrow relapse is IKZF1 deletion.[33] The frequency of IKZF1 deletion in precursor B-cell ALL patients at first relapse patients was 33% in patients in the Acute Lymphoblastic Leukemia Relapse (ALL-REZ) BFM 2002 (NCT00114348 ) study, which was approximately twice as high as the frequency described in children at initial diagnosis of ALL.[33]

RAS pathway mutations (KRAS, NRAS, FLT3, and PTPN11) are common at relapse in precursor B-cell ALL patients, and they were found in approximately 40% of patients at first relapse in one study of 206 children.[28,34] As observed at diagnosis, the frequency of RAS pathway mutations at relapse differs by cytogenetic subtype (e.g., high frequency in hyperdiploid cases and low frequency in ETV6-RUNX1 cases). The presence of RAS pathway mutations at relapse was associated with early relapse. However, presence of RAS pathway mutations at relapse was not an independent predictor of outcome.

Patients with ETV6-RUNX1-positive ALL appear to have a relatively favorable prognosis at first relapse, consistent with the high percentage of such patients who relapse more than 36 months after diagnosis.[33,35]

• In the ALL-REZ BFM 2002 (NCT00114348) study, an EFS of 84% ± 7% was observed for patients with ETV6-RUNX1 ALL with bone marrow relapse.[33] In this study, 94% of patients with ETV6-RUNX1 had a duration of first remission that extended at least 6 months beyond completion of their primary treatment, and on multivariate analysis, time to relapse (and not the presence of ETV6-RUNX1) was an independent predictor of outcome.
• Similarly, the 5-year OS for ETV6-RUNX1 patients enrolled on the French Acute Lymphoblastic Leukaemia Study Group (FRALLE) 93 trial who relapsed at any site more than 36 months after diagnosis was 81%, and the presence of ETV6-RUNX1 was associated with a favorable survival outcome compared with other late relapsing patients.[35] However, the 3-year OS of ETV6-RUNX1 patients who experienced an early relapse (<36 months) was only 31%.

Immunophenotype

Immunophenotype is an important prognostic factor at relapse. Patients with T-cell ALL who experience a marrow relapse (isolated or combined) at any time during treatment or posttreatment are less likely to achieve a second remission and long-term EFS than are patients with B-cell ALL.[5,22]

Standard Treatment Options for First Bone Marrow Relapse of Childhood ALL

Standard treatment options for first bone marrow relapse include the following:

1. Reinduction chemotherapy.
2. Postreinduction therapy for patients achieving a second CR.

Reinduction chemotherapy

Initial treatment of relapse consists of reinduction therapy to achieve a second CR. Using either a four-drug reinduction regimen (similar to that administered to newly diagnosed high-risk patients) or an alternative regimen including high-dose methotrexate and high-dose cytarabine, approximately 85% of patients with a marrow relapse achieve a second CR at the end of the first month of treatment.[5]; [36][Level of evidence: 2A]; [22][Level of evidence: 2Di] Patients with early marrow relapses have a lower rate of achieving a morphologic second CR (approximately 70%) than do those with late marrow relapses (approximately 95%).[22,36]

Evidence (reinduction chemotherapy):

1. A COG study used three blocks of intensive reinduction therapy with an initial four-drug combination including doxorubicin followed by two intensive consolidation blocks before either HSCT or chemotherapy continuation.[22]
   • Second remission was achieved after block 1 in 68% of patients with early relapse (<36 months from initial diagnosis) and in 96% of those with later relapse.
   • Blocks 2 and 3 reduced MRD in 40 of 56 patients who were MRD-positive after block 1.
2. A United Kingdom–based randomized trial of ALL patients in first relapse compared reinduction with a four-drug combination using idarubicin versus mitoxantrone.[37][Level of evidence: 1iiA]
   • There was no difference in second CR rates or end-reinduction MRD levels between the two study arms.
   • A significant improvement in OS in the mitoxantrone arm (69% vs. 45%, P = .007) due to decreased relapse after transplantation was reported.
   The potential benefit of mitoxantrone in relapsed ALL regimens requires further investigation.
3. Investigators from the ALL-REZ BFM group used a six-drug reinduction approach, including high-dose methotrexate. A randomized comparison of 1 g/m2 of methotrexate versus 5 g/m2 of methotrexate with reinduction showed no advantage at the higher dose.[38]
4. The combination of clofarabine, cyclophosphamide, and etoposide was reported to induce remission in 42% to 56% of patients with refractory or multiply relapsed disease.[39,40]; [41][Level of evidence: 2A]
5. The combination of bortezomib plus vincristine, dexamethasone, pegaspargase, and doxorubicin has been reported to induce complete response (with or without platelet recovery) in 70% to 80% of multiply relapsed patients with precursor B-cell ALL.[42][Level of evidence: 3iiiA]; [43][Level of evidence: 3iiiDiv]
6. In a study of induction therapy comprising intensive asparaginase (weekly pegaspargase or 12 doses of E.coli asparaginase) with prednisone, vincristine, and doxorubicin for patients with first relapse, the second CR rate was 86% for those receiving pegaspargase and 81% for those receiving E.coli asparaginase.[44][Level of evidence: 2Di]

Patients with relapsed T-cell ALL have much lower rates of achieving second CR with standard reinduction regimens than do patients with precursor B-cell phenotype.[22] Treatment of children with first relapse of T-cell ALL in the bone marrow with single-agent therapy using the T-cell selective agent, nelarabine, has resulted in response rates of approximately 50%.[45] The combination of nelarabine, cyclophosphamide, and etoposide has produced remissions in patients with relapsed/refractory T-cell ALL.[46]

Reinduction failure is a poor prognostic factor, but subsequent attempts to obtain remission can be successful and lead to survival after HSCT. Approaches have traditionally included the use of drug combinations distinct from the first attempt at treatment; these regimens often contain newer agents under investigation in clinical trials. Although survival is progressively less likely after each attempt, two to four additional attempts are often pursued, with diminishing levels of success measured after each attempt.[47]

Postreinduction therapy for patients achieving a second complete remission

Early-relapsing precursor B-cell ALL

For precursor B-cell patients with an early marrow relapse, allogeneic transplant from a human leukocyte antigen (HLA)-identical sibling or matched unrelated donor that is performed in second remission has been reported in most studies to result in higher leukemia-free survival than a chemotherapy approach.[7,27,48-56] However, even with transplantation, the survival rate for patients with early marrow relapse is less than 50%. (Refer to the Hematopoietic Stem Cell Transplantation for First and Subsequent Bone Marrow Relapse section of this summary for more information.)

Late-relapsing precursor B-cell ALL

For patients with a late marrow relapse of precursor B-cell ALL, a primary chemotherapy approach after achievement of second CR has resulted in survival rates of approximately 50%, and it is not clear whether allogeneic transplantation is associated with superior cure rate.[5,9,37,57-59]; [60][Level of evidence: 3iiA] End-reinduction MRD levels may help to identify patients with a high risk of subsequent relapse if treated with chemotherapy alone (no HSCT) in second CR. Results from one study suggest that patients with a late marrow relapse who have high end-reinduction MRD may have a better outcome if they receive an allogeneic HSCT in second CR.[61]

Evidence (MRD-based risk stratification for late-relapse of precursor B-cell ALL):

1. In a St. Jude Children's Research Hospital study, which included 23 patients with late relapses treated with chemotherapy in second CR, the 2-year cumulative incidence of relapse was 49% for the 12 patients who were MRD-positive at the end of reinduction and 0% for the 11 patients who were MRD-negative.[24]
2. In BFM studies, patients are considered to be intermediate risk if they have a late isolated marrow relapse or an early or late combined marrow/extramedullary relapse. In the ALL-REZ BFM P95/96 study from this group, end-reinduction MRD (assessed by a polymerase chain reaction–based assay) significantly predicted outcomes of children with intermediate-risk relapsed B-cell ALL treated with chemotherapy alone in second CR (no HSCT).[26]
   • Patients with low MRD (<10-3) had a 10-year EFS of 73%, while those with high MRD (>10-3) had a 10-year EFS of 10%. On multivariate analysis, end-reinduction MRD was the strongest independent prognostic factor.
3. In a subsequent BFM study (ALL-REZ BFM 2002 [NCT00114348]), patients with intermediate-risk relapse were allocated to allogeneic HSCT if they had high MRD at the end of the first month of treatment. Those who had low end-reinduction MRD were treated with chemotherapy only (no HSCT).[61]
   • The EFS of patients with high end-reinduction MRD treated with allogeneic HSCT in second CR was 64%, which was significantly better than what had been observed on the previous P95/96 trial, during which such patients received chemotherapy without HSCT. The improvement in EFS was primarily because of a significantly lower risk of relapse in the cohort receiving HSCT in second CR (cumulative incidence of relapse, 27% on the 2002 trial compared with 59% on the P95/96 trial).
   • Patients with late marrow-involved relapses and low end-reinduction MRD, treated with chemotherapy only, had a 5-year EFS of 76%, confirming the results seen in the previous P95/96 trial. However, the chemotherapy-only strategy resulted in a significantly worse outcome for patients with early-combined relapses (marrow plus extramedullary site) and low end-reinduction MRD; the 5-year EFS for these patients was only 37%. Thus, patients with early-combined relapses are no longer considered intermediate risk on BFM trials, and their treatment is not risk-stratified on the basis of end-reinduction MRD.

T-cell ALL

For patients with T-cell ALL who achieved remission after bone marrow relapse, outcomes with postreinduction chemotherapy alone have generally been poor,[5] and these patients are usually treated with allogeneic HSCT in second CR, regardless of time to relapse. At 3 years, OS after allogeneic transplant for T-cell ALL in second remission was reported to be 48% and DFS was 46%.[62][Level of evidence: 3iiiA]

Treatment Options for Second and Subsequent Bone Marrow Relapse

Although there are no studies directly comparing chemotherapy with HSCT for patients in third or subsequent CR, because cure with chemotherapy alone is rare, transplant is generally considered a reasonable approach for those achieving remission. Long-term survival for all patients after a second relapse is particularly poor, in the range of less than 10% to 20%.[54] One of the main reasons for this is failure to obtain a third remission. Numerous attempts at novel combination approaches have resulted in only about 40% of children in second relapse achieving remission.[63] However, two studies that added bortezomib to standard reinduction agents in multiply relapsed refractory patients have resulted in 70% to 80% complete remission rates.[42][Level of evidence: 3iiiA]; [43][Level of evidence: 3iiiDiv] If these patients achieve CR, HSCT has been shown to cure 20% to 35%, with failures occurring due to high rates of relapse and transplant-related mortality.[64-68][Level of evidence: 3iiA]

Hematopoietic Stem Cell Transplantation for First and Subsequent Bone Marrow Relapse

Components of the transplantation process

An expert panel review of indications for HSCT was published in 2012.[69] Components of the transplant process that have been shown to be important in improving or predicting outcome of HSCT for children with ALL include the following:

1. Total-body irradiation (TBI)-containing transplant preparative regimens.
2. MRD detection just before transplant.
3. MRD detection posttransplant.
4. Donor type and HLA match.
5. Role of GVHD/graft-versus-leukemia (GVL) in ALL and immune modulation after transplant to prevent relapse.

TBI-containing transplant preparative regimens

For patients proceeding to allogeneic HSCT, TBI appears to be an important component of the conditioning regimen. Two retrospective studies and a randomized trial suggest that transplant conditioning regimens that include TBI produce higher cure rates than do chemotherapy-only preparative regimens.[48,70,71] Fractionated TBI (total dose, 12–14 Gy) is often combined with cyclophosphamide, etoposide, thiotepa, or a combination of these agents. Study findings with these combinations have generally resulted in similar rates of survival,[72-74] although one study suggested that if cyclophosphamide is used without other chemotherapy drugs, a dose of TBI in the higher range may be necessary.[75] Many standard regimens include cyclophosphamide with TBI dosing between 13.2 and 14 Gy. On the other hand, when cyclophosphamide and etoposide were used with TBI, doses above 12 Gy resulted in worse survival resulting from excessive toxicity.[73]

Although some studies of non-TBI approaches have shown reasonable outcomes [76,77] and have prompted a large BFM study comparing TBI versus non-TBI regimens, TBI for all but the youngest children (age <3 or <4 years) remains the most commonly used therapy in most centers in North America.[62,67]

MRD detection just before transplant

Remission status at the time of transplantation has long been known to be an important predictor of outcome, with patients not in CR at HSCT having very poor survival rates.[78] Several studies have also demonstrated that the level of MRD at the time of transplant is a key risk factor in children with ALL in CR undergoing allogeneic HSCT.[25,79-85][Level of evidence: 3iiA]; [86][Level of evidence: 3iiB] Survival rates of patients who are MRD-positive pretransplant have been reported between 20% and 47%, compared with 60% to 88% in patients who are MRD-negative.

When patients have received two to three cycles of chemotherapy in an attempt to achieve an MRD-negative remission, the benefit of further intensive therapy for achieving MRD negativity must be weighed against the potential for significant toxicity. In addition, there is not clear evidence showing that MRD positivity in a patient who has received multiple cycles of therapy is a biological disease marker for poor outcome that cannot be modified, or whether further intervention bringing such patients into an MRD negative remission will overcome this risk factor and improve survival.

• In one report, 13 patients with ALL and high MRD at the time of planned transplant received an additional cycle of chemotherapy in an attempt to lower MRD before proceeding to HSCT. Ten of the 13 patients (77%) remained in CR post-HSCT, with no relapses observed in the eight patients who achieved low MRD after the additional chemotherapy cycle. In comparison, only 6 of 21 high-MRD patients (29%) who proceeded directly to HSCT without receiving additional pre-HSCT chemotherapy remained in CR.[79]

MRD detection posttransplant

The presence of detectable MRD post-HSCT has been associated with an increased risk of subsequent relapse.[85,87-90] The accuracy of MRD for predicting relapse increases as time from HSCT elapses and relapse risk is also higher for patients who have higher levels of MRD detected at any given time. One study showed higher sensitivity for predicting relapse using next-generation sequencing assays than with flow cytometry, especially early after HSCT.[89]

Donor type and HLA match

Survival rates after matched unrelated donor and umbilical cord blood transplantation have improved significantly over the past decade and offer an outcome similar to that obtained with matched sibling donor transplants.[52,91-94]; [95,96][Level of evidence: 2A]; [97][Level of evidence: 3iiiA]; [98][Level of evidence: 3iiiDii] Rates of clinically extensive GVHD and treatment-related mortality remain higher after unrelated donor transplantation compared with matched sibling donor transplants.[53,64,91] However, there is some evidence that matched unrelated donor transplantation may yield a lower relapse rate, and National Marrow Donor Program and CIBMTR analyses have demonstrated that rates of GVHD, treatment-related mortality, and OS have improved over time.[99-101]; [102,103][Level of evidence: 3iiA]

Another CIBMTR study suggests that outcome after one or two antigen mismatched cord blood transplants may be equivalent to that for a matched family donor or a matched unrelated donor.[104] In certain cases in which no suitable donor is found or an immediate transplant is considered crucial, a haploidentical transplant utilizing large doses of stem cells may be considered.[105]

Role of GVHD/GVL in ALL and immune modulation after transplant to prevent relapse

Most studies of pediatric and young adult patients that address this issue suggest an effect of both acute and chronic GVHD in decreasing relapse.[91,106-108]

• In a COG trial of transplantation for children with ALL, grades I to III acute GVHD were associated with lower relapse risk (hazard ratio [HR], 0.4; P = .04) and better EFS (multivariate analysis, HR, 0.5; P = .02). Any effect of grade IV acute GVHD in decreasing relapse risk was obscured by a marked increase in transplant-related mortality (HR, 6.4; P = .003), while grades I to III acute GVHD had no statistically detectable effect on transplant-related mortality (HR, 0.6; P = .42).[108]
• In a multivariate model, both pretransplant MRD and acute GVHD were independent predictors of relapse, with the lowest risk of relapse observed in patients with both low pretransplant MRD and grades I to III acute GVHD.[88] For patients who did not develop acute GVHD by day 55 post-HSCT, nearly all relapses occurred between days 100 and 400 post-HSCT.

Harnessing this GVL effect, a number of approaches to prevent relapse after transplantation have been studied, including withdrawal of immune suppression or donor lymphocyte infusion and targeted immunotherapies, such as monoclonal antibodies and natural killer cell therapy.[109,110] Trials in Europe and the United States have shown that patients defined as having a high risk of relapse based upon increasing recipient chimerism (i.e., increased percentage of recipient DNA markers) can successfully undergo withdrawal of immune suppression without excessive toxicity.[111,112]

• One study showed that in 46 patients with increasing recipient chimerism, the 31 patients who underwent immune suppression withdrawal, donor lymphocyte infusion, or both therapies had a 3-year EFS of 37% versus 0% in the nonintervention group (P < .001).[113]
• Other studies have shown better-than-expected rates of survival of pre-HSCT, MRD-positive patients when tapering has occurred for MRD detected after HSCT.[114]

Intrathecal medication after HSCT to prevent relapse

The use of post-HSCT intrathecal chemotherapy chemoprophylaxis is controversial.[115-118]

Relapse after allogeneic HSCT for relapsed ALL

For patients with B-cell ALL who relapse after allogeneic HSCT and can be successfully weaned from immune suppression and have no GVHD, tisagenlecleucel and other 4-1BB chimeric antigen receptor (CAR) T-cell approaches have resulted in EFS rates exceeding 50% at 12 months.[119] For patients with T-cell ALL who relapse or for patients with B-cell ALL who are unable to undergo CAR T-cell therapy, a second ablative allogeneic HSCT may be feasible. However, many patients will be unable to undergo a second HSCT procedure because of failure to achieve remission, early toxic death, or severe organ toxicity related to salvage chemotherapy.[120] Among the highly selected group of patients able to undergo a second ablative allogeneic HSCT, approximately 10% to 30% will achieve long-term EFS.[120-124]; [68,125][Level of evidence: 3iiA] Prognosis is more favorable in patients with longer duration of remission after the first HSCT and in patients with CR at the time of the second HSCT.[122,123,126] In addition, one study showed an improvement in survival after second HSCT if acute GVHD occurred, especially if it had not occurred after the first transplant.[127]

Reduced-intensity approaches can also cure a percentage of patients when used as a second allogeneic transplant approach, but only if patients achieve a CR confirmed by flow cytometry.[128][Level of evidence: 2A] Donor leukocyte infusion has limited benefit for patients with ALL who relapse after allogeneic HSCT.[129]; [130][Level of evidence: 3iiiA]

Whether a second allogeneic transplant is necessary to treat isolated CNS and testicular relapse after HSCT is unknown. A small series has shown survival in selected patients using chemotherapy alone or chemotherapy followed by a second transplant.[131][Level of evidence: 3iA]

Immunotherapeutic Approaches for Refractory ALL

Immunotherapeutic approaches to the treatment of refractory ALL include monoclonal antibody therapy and chimeric antigen receptor (CAR) T-cell therapy.

Monoclonal antibody therapy

The following two immunotherapeutic agents have been studied for the treatment of refractory B-cell ALL:

• Blinatumomab. Blinatumomab is a bispecific monoclonal antibody with one site for CD3 (T cells) and the other site for CD19 (present on most B-ALL cells). Thus, blinatumomab promotes the binding of the patient’s own cytotoxic T cells to B lymphoblasts, resulting in tumor being killed. In a phase I/II trial of children younger than 18 years with relapsed/refractory B-cell ALL, 27 of 70 patients (39%) treated at the recommended phase II dose achieved a CR with single-agent blinatumomab; 52% of those achieving CR were MRD negative.[132]
• Inotuzumab. Inotuzumab is an anti-CD22 monoclonal antibody that is conjugated to calicheamicin. In trials of adult patients with relapsed/refractory B-cell ALL, CR was achieved in approximately 80% of patients.[133,134] Inotuzumab has not been extensively studied in pediatric patients with B-cell ALL and is not yet labeled for use in children.

CAR T-cell therapy

Chimeric antigen receptor (CAR) T-cell therapy is a therapeutic strategy for pediatric B-cell ALL patients with refractory disease or those in second or subsequent relapse. This treatment involves engineering T cells with a CAR that redirects T-cell specificity and function.[135] One widely utilized target of CAR-modified T cells is the CD19 antigen expressed on almost all normal B cells and most B-cell malignancies.

Treatment with CAR T cells has been associated with cytokine release syndrome, which can be life-threatening.[136,137] Cytokine release syndrome presents as fever, headache, myalgias, hypotension, capillary leak, hypoxia, and renal dysfunction. Neurotoxicity, including aphasia, altered mental status, and seizures, has also been observed with CAR T-cell therapy and the symptoms usually resolve spontaneously. CNS symptoms have not responded to interleukin-6 receptor (IL-6R)–targeting agents or other approaches. Other CAR T-cell therapy side effects include coagulopathy, hemophagocytic lymphohistiocytosis–like laboratory changes, and cardiac dysfunction. Between 20% and 40% of patients require treatment in the intensive care unit, mostly pressor support, with 10% to 20% of patients requiring intubation and/or dialysis.[135,136,138] Severe cytokine release syndrome has been effectively treated with tocilizumab, an anti–IL-6R antibody.[136] Long-term persistence of CAR T cells can lead to B-cell aplasia, necessitating immunoglobulin replacement.[136]

Several clinical trials of CAR T cells targeting CD19 in relapsed/refractory ALL have been conducted, with encouraging results.

Evidence (CAR T cell therapy):

1. In pilot clinical trials conducted at the Children’s Hospital of Philadelphia (CHOP) and the Hospital of the University of Pennsylvania, 30 children and adults (25 of whom were aged 22 years or younger) with multiply relapsed or refractory CD19-positive ALL were given T cells transduced with CD19-directed CAR lentiviral vector.[136][Level of evidence: 3iiiDi]
   • CR was obtained in 90% of patients, including 15 of 18 patients (83%) who had previously received allogeneic HSCT.
   • The 6-month EFS rate was 67%, with most patients showing persistence of the CAR T cells and B-cell aplasia through 6 months.
   • All 30 patients experienced some degree of cytokine release syndrome. Eight patients (27%) had severe symptoms requiring vasopressors and/or respiratory support. Cytokine release syndrome was effectively treated with tocilizumab.
2. A second report from the Pediatric Oncology Branch at the NCI described the use of a different CD-19 targeted CAR T-cell product that was prepared using a retroviral vector.[139]
   • This CD19-CAR T-cell product induced complete responses in 70% of patients (14 of 20) (aged 1–30 years) with relapsed/refractory B-cell ALL.
   • Persistence of CAR T cells in this study was 1 to 2 months, with recovery of normal B-cell lymphopoiesis in patients who achieved CR.
3. A third report of a phase I trial of 45 children and young adults with relapsed/refractory CD19-positive B-cell ALL who received 4-1BB–based lentiviral vector expanded CAR T cells showed the following:[138]
   • An overall remission rate of 89% for all patients enrolled using an intent-to-treat analysis.
   • Improved long-term persistence of CAR T cells and B-cell aplasia in patients who: (1) received lymphodepleting strategies that contain fludarabine and cyclophosphamide, and (2) started the treatment with a higher percentage of cells expressing CD19, either on blasts or normal B cells.
4. A global phase II trial of the anti-CD19 4-1BB vector developed at the CHOP and the University of Pennsylvania led to U.S. Food and Drug Administration approval of tisagenlecleucel for children with multiply relapsed or refractory B-cell ALL.[119]
   • Of 92 patients enrolled, 75 were infused with successfully manufactured CAR T cells. Eighty-one percent of infused patients had two measures noting CR within the first 3 months of infusion and 100% of the remissions were MRD negative.
   • EFS of infused patients was 73% at 6 months and 50% at 12 months. OS of infused patients was 90% at 6 months and 70% at 12 months.

Treatment of Isolated Extramedullary Relapse

With improved success in treating children with ALL, the incidence of isolated extramedullary relapse has decreased. The incidence of isolated CNS relapse is less than 5%, and testicular relapse is less than 1% to 2%.[140-142] As with bone marrow and mixed relapses, time from initial diagnosis to relapse is a key prognostic factor in isolated extramedullary relapses.[143] In addition, age older than 6 years at relapse was noted in one study as an adverse prognostic factor for patients with an isolated extramedullary relapse, while a second study suggested age 10 years as a better cutoff.[16,144] Of note, in the majority of children with isolated extramedullary relapses, submicroscopic marrow disease can be demonstrated using sensitive molecular techniques,[145] and successful treatment strategies must effectively control both local and systemic disease. Patients with an isolated CNS relapse who show greater than 0.01% MRD in a morphologically normal marrow have a worse prognosis (5-year EFS, 30%) than do patients with either no MRD or MRD less than 0.01% (5-year EFS, 60%).[145]

Isolated CNS relapse

Standard treatment options for childhood ALL that has recurred in the CNS include the following:

1. Systemic and intrathecal chemotherapy.
2. Cranial or craniospinal radiation.
3. HSCT.

While the prognosis for children with isolated CNS relapse had been quite poor in the past, aggressive systemic and intrathecal therapy followed by cranial or craniospinal radiation has improved the outlook, particularly for patients who did not receive cranial radiation during their first remission.[17,143,146,147]

Evidence (chemotherapy and radiation therapy):

1. In a Pediatric Oncology Group (POG) study using this strategy, children who had not previously received radiation therapy and whose initial remission was 18 months or longer had a 4-year EFS rate of approximately 80%, compared with EFS rates of approximately 45% for children with CNS relapse within 18 months of diagnosis.[143]
2. In a follow-up POG study, children who had not previously received radiation therapy and who had initial remission of 18 months or more were treated with intensive systemic and intrathecal chemotherapy for 1 year followed by 18 Gy of cranial radiation only.[17] The 4-year EFS was 78%. Children with an initial remission of less than 18 months also received the same chemotherapy but had craniospinal radiation (24 Gy cranial/15 Gy spinal) as in the first POG study and achieved a 4-year EFS of 52%.

A number of case series describing HSCT in the treatment of isolated CNS relapse have been published.[148,149] Although some reports have suggested a possible role for HSCT for patients with isolated CNS disease with very early relapse and T-cell disease, there is less evidence for the need for HSCT in early relapse and no evidence in late relapse. The use of transplantation to treat isolated CNS relapse occurring less than 18 months from diagnosis, especially T-cell CNS relapse, requires further study.

Evidence (HSCT):

1. Another study compared the outcome of patients treated with either HLA-matched sibling transplants or chemoradiation therapy as in the POG studies above.[150][Level of evidence: 3iiiDii] This retrospective, registry-based study included transplantation of both early (<18 months from diagnosis) and late relapses.
   • The 8-year probabilities of leukemia-free survival adjusted for age (58%) and duration of first remission (66%) were similar.
   • Because of the relatively good outcome of patients with isolated CNS relapse more than 18 months from diagnosis treated with chemoradiation therapy alone (>75%), transplantation is generally not recommended by the COG for this group.
2. The MRC ALLR3 trial tested intensive induction with mitoxantrone versus idarubicin in relapsed ALL patients, defining a superior outcome when mitoxantrone was used. A subanalysis of 80 patients entering the trial with isolated CNS relapse included 13 patients with very early relapse (defined as <18 months from first diagnosis), 55 patients with early relapse (defined as >18 months from initial diagnosis but within 6 months of being off therapy), and 12 patients with late relapse.[16][Level of evidence: 2A]
   • Those with late relapse did very well with chemotherapy/cranial radiation therapy, with 11 of 12 patients surviving.
   • Allogeneic HSCT was recommended for very early and early relapse. Sixty-six patients were alive and relapse free after the planned three induction courses. Fifty-four patients with early and very early isolated CNS relapse were eligible for protocol-recommended HSCT, and 39 (72%) patients received HSCT. Twenty-one percent of these patients relapsed, compared with a relapse rate of 71% in the group not receiving HSCT.
   • Of those eligible for transplant, treatment with mitoxantrone rather than idarubicin during reinduction was associated with a survival advantage (3-year progression-free survival, 61% vs. 21%; P = .027). As in the larger trial, the major advantage from the mitoxantrone arm occurred in those receiving HSCT.[16] Low patient numbers in the very early group prohibited detailed analysis of this cohort, and rates of failure within the early group treated with chemotherapy/cranial radiation therapy are inferior to other published experiences, calling into question this chemotherapy approach to early isolated CNS relapse patients.

Isolated testicular relapse

The results of treatment of isolated testicular relapse depend on the timing of the relapse. The 3-year EFS of boys with overt testicular relapse during therapy is approximately 40%; it is approximately 85% for boys with late testicular relapse.[151]

Standard treatment options in North America for childhood ALL that has recurred in the testes include the following:

1. Chemotherapy.
2. Radiation therapy.

Standard approaches for treating isolated testicular relapse in North America include local radiation therapy along with intensive chemotherapy. In some European clinical trial groups, orchiectomy of the involved testicle is performed instead of radiation. Biopsy of the other testicle is performed at the time of relapse to determine if additional local control (surgical removal or radiation) is to be performed. A study that looked at testicular biopsy at the end of frontline therapy failed to demonstrate a survival benefit for patients with early detection of occult disease.[152]

There are limited clinical data concerning outcome without the use of radiation therapy or orchiectomy. Treatment protocols that have tested this approach have incorporated intensified dosing of chemotherapy agents (e.g., high-dose methotrexate) that may be able to achieve antileukemic levels in the testes.

Evidence (treatment of testicular relapse):

1. The COG AALL02P2 (NCT00096135) trial tested whether radiation therapy could be eliminated for patients with late isolated testicular relapse (occurring more than 18 months from diagnosis).[153] On this trial, testicular size was reassessed after the initial month of reinduction chemotherapy, which included high-dose methotrexate. If the testicle remained enlarged, biopsy was performed, and if positive, patients were to be treated with local radiation therapy. Those with testes that normalized in size or who had negative biopsies were to be treated without radiation therapy. Postinduction chemotherapy for all patients (whether or not they were irradiated) included multiple courses of high-dose methotrexate.[154]
   • Of 40 patients enrolled, 26 had persistent testicular enlargement after reinduction. Testicular biopsy was positive in 12 of these 26 patients, 11 of whom received testicular radiation therapy; all other patients on the trial were treated without radiation.
   • Participants who received testicular radiation therapy achieved a 5-year EFS of 73% versus 61% for those who did not receive radiation (P = 0.6); the 5-year OS was 73% for those who received testicular radiation versus 71% (P = .9) for those who did not receive testicular radiation.
   • Thus, for patients with isolated testicular relapse achieving a favorable response after initial induction (documented by size reduction and/or biopsy), omission of testicular radiation therapy appeared to be a feasible option.
2. Dutch investigators treated five boys with a late testicular relapse with high-dose methotrexate during induction (12 g/m2) and at regular intervals during the remainder of therapy (6 g/m2) without testicular radiation. All five boys were long-term survivors.[153]
3. In a small series of boys who had an isolated testicular relapse after a HSCT for a prior systemic relapse of ALL, five of seven boys had extended EFS without a second HSCT.[131][Level of evidence: 3iA]

Treatment Options Under Clinical Evaluation for Relapsed Childhood ALL

Trials for ALL in first relapse

Information about NCI-supported clinical trials can be found on the NCI website. For information about clinical trials sponsored by other organizations, refer to the ClinicalTrials.gov website.

The following are examples of national and/or institutional clinical trials that are currently being conducted:

1. COG-AALL1331; NCI-2014-00631 (NCT02101853) (Risk-Stratified Randomized Phase III Testing of Blinatumomab in First Relapse of Childhood B-Lymphoblastic Leukemia [B-ALL]): This trial is evaluating whether incorporation of blinatumomab improves DFS in patients with B-cell ALL in first relapse. Blinatumomab is a bi-specific antibody that binds to the CD19 antigen, expressed on nearly all B-cell ALL cells and the CD3 antigen expressed on T cells; in this way, blinatumomab juxtaposes B-lymphoblasts with a patient’s own T cells, promoting leukemia cell lysis. Patients are risk-stratified based on site of relapse (marrow-involved vs. isolated extramedullary relapse), time to relapse, and MRD status after the first month of treatment. The chemotherapy backbone for the trial is based on the United Kingdom ALLR3 regimen.[37] After the first month of treatment, high-risk and intermediate-risk patients are randomly assigned to receive either two blocks of consolidation chemotherapy or two cycles of blinatumomab. These patients will then proceed to HSCT. Low-risk patients are treated without transplant; they are randomly assigned to either a control arm based on the ALLR3 protocol or an investigational arm based on the same chemotherapy backbone and also including three cycles of blinatumomab.
2. TACL 2012-002 (NCT02879643) (Vincristine Sulfate Liposome Injection in Combination with UK ALL R3 Induction Chemotherapy for Children, Adolescents, and Young Adults with Relapsed ALL): This trial is assessing the safety and feasibility of vincristine sulfate liposome injection as replacement for standard vincristine in the UK ALL R3 induction regimen in ALL patients (B-cell ALL or T-cell ALL) with first, second, or third relapse. Patients with either M2 (5%–24% blasts) or M3 (>25% blasts) marrow involvement are eligible.

Trials for ALL in second or subsequent relapse or refractory ALL

Multiple clinical trials investigating new agents and new combinations of agents are available for children with second or subsequent relapsed or refractory ALL and should be considered. These trials are testing targeted treatments specific for ALL, including monoclonal antibody–based therapies and drugs that inhibit signal transduction pathways required for leukemia cell growth and survival.

Current Clinical Trials

Use our advanced clinical trial search to find NCI-supported cancer clinical trials that are now enrolling patients. The search can be narrowed by location of the trial, type of treatment, name of the drug, and other criteria. General information about clinical trials is also available.

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86. Sanchez-Garcia J, Serrano J, Serrano-Lopez J, et al.: Quantification of minimal residual disease levels by flow cytometry at time of transplant predicts outcome after myeloablative allogeneic transplantation in ALL. Bone Marrow Transplant 48 (3): 396-402, 2013. [PUBMED Abstract]
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88. Pulsipher MA, Langholz B, Wall DA, et al.: Risk factors and timing of relapse after allogeneic transplantation in pediatric ALL: for whom and when should interventions be tested? Bone Marrow Transplant 50 (9): 1173-9, 2015. [PUBMED Abstract]
89. Pulsipher MA, Carlson C, Langholz B, et al.: IgH-V(D)J NGS-MRD measurement pre- and early post-allotransplant defines very low- and very high-risk ALL patients. Blood 125 (22): 3501-8, 2015. [PUBMED Abstract]
90. Liu J, Wang Y, Xu LP, et al.: Monitoring mixed lineage leukemia expression may help identify patients with mixed lineage leukemia--rearranged acute leukemia who are at high risk of relapse after allogeneic hematopoietic stem cell transplantation. Biol Blood Marrow Transplant 20 (7): 929-36, 2014. [PUBMED Abstract]
91. Locatelli F, Zecca M, Messina C, et al.: Improvement over time in outcome for children with acute lymphoblastic leukemia in second remission given hematopoietic stem cell transplantation from unrelated donors. Leukemia 16 (11): 2228-37, 2002. [PUBMED Abstract]
92. Saarinen-Pihkala UM, Gustafsson G, Ringdén O, et al.: No disadvantage in outcome of using matched unrelated donors as compared with matched sibling donors for bone marrow transplantation in children with acute lymphoblastic leukemia in second remission. J Clin Oncol 19 (14): 3406-14, 2001. [PUBMED Abstract]
93. Muñoz A, Diaz-Heredia C, Diaz MA, et al.: Allogeneic hemopoietic stem cell transplantation for childhood acute lymphoblastic leukemia in second complete remission-similar outcomes after matched related and unrelated donor transplant: a study of the Spanish Working Party for Blood and Marrow Transplantation in Children (Getmon). Pediatr Hematol Oncol 25 (4): 245-59, 2008. [PUBMED Abstract]
94. Jacobsohn DA, Hewlett B, Ranalli M, et al.: Outcomes of unrelated cord blood transplants and allogeneic-related hematopoietic stem cell transplants in children with high-risk acute lymphocytic leukemia. Bone Marrow Transplant 34 (10): 901-7, 2004. [PUBMED Abstract]
95. Kurtzberg J, Prasad VK, Carter SL, et al.: Results of the Cord Blood Transplantation Study (COBLT): clinical outcomes of unrelated donor umbilical cord blood transplantation in pediatric patients with hematologic malignancies. Blood 112 (10): 4318-27, 2008. [PUBMED Abstract]
96. Peters C, Schrappe M, von Stackelberg A, et al.: Stem-cell transplantation in children with acute lymphoblastic leukemia: A prospective international multicenter trial comparing sibling donors with matched unrelated donors-The ALL-SCT-BFM-2003 trial. J Clin Oncol 33 (11): 1265-74, 2015. [PUBMED Abstract]
97. Smith AR, Baker KS, Defor TE, et al.: Hematopoietic cell transplantation for children with acute lymphoblastic leukemia in second complete remission: similar outcomes in recipients of unrelated marrow and umbilical cord blood versus marrow from HLA matched sibling donors. Biol Blood Marrow Transplant 15 (9): 1086-93, 2009. [PUBMED Abstract]
98. Zhang MJ, Davies SM, Camitta BM, et al.: Comparison of outcomes after HLA-matched sibling and unrelated donor transplantation for children with high-risk acute lymphoblastic leukemia. Biol Blood Marrow Transplant 18 (8): 1204-10, 2012. [PUBMED Abstract]
99. Gassas A, Sung L, Saunders EF, et al.: Graft-versus-leukemia effect in hematopoietic stem cell transplantation for pediatric acute lymphoblastic leukemia: significantly lower relapse rate in unrelated transplantations. Bone Marrow Transplant 40 (10): 951-5, 2007. [PUBMED Abstract]
100. Harvey J, Green A, Cornish J, et al.: Improved survival in matched unrelated donor transplant for childhood ALL since the introduction of high-resolution matching at HLA class I and II. Bone Marrow Transplant 47 (10): 1294-300, 2012. [PUBMED Abstract]
101. Majhail NS, Chitphakdithai P, Logan B, et al.: Significant improvement in survival after unrelated donor hematopoietic cell transplantation in the recent era. Biol Blood Marrow Transplant 21 (1): 142-50, 2015. [PUBMED Abstract]
102. MacMillan ML, Davies SM, Nelson GO, et al.: Twenty years of unrelated donor bone marrow transplantation for pediatric acute leukemia facilitated by the National Marrow Donor Program. Biol Blood Marrow Transplant 14 (9 Suppl): 16-22, 2008. [PUBMED Abstract]
103. Davies SM, Wang D, Wang T, et al.: Recent decrease in acute graft-versus-host disease in children with leukemia receiving unrelated donor bone marrow transplants. Biol Blood Marrow Transplant 15 (3): 360-6, 2009. [PUBMED Abstract]
104. Eapen M, Rubinstein P, Zhang MJ, et al.: Outcomes of transplantation of unrelated donor umbilical cord blood and bone marrow in children with acute leukaemia: a comparison study. Lancet 369 (9577): 1947-54, 2007. [PUBMED Abstract]
105. Klingebiel T, Handgretinger R, Lang P, et al.: Haploidentical transplantation for acute lymphoblastic leukemia in childhood. Blood Rev 18 (3): 181-92, 2004. [PUBMED Abstract]
106. Gustafsson Jernberg A, Remberger M, Ringdén O, et al.: Graft-versus-leukaemia effect in children: chronic GVHD has a significant impact on relapse and survival. Bone Marrow Transplant 31 (3): 175-81, 2003. [PUBMED Abstract]
107. Dini G, Zecca M, Balduzzi A, et al.: No difference in outcome between children and adolescents transplanted for acute lymphoblastic leukemia in second remission. Blood 118 (25): 6683-90, 2011. [PUBMED Abstract]
108. Pulsipher MA, Langholz B, Wall DA, et al.: The addition of sirolimus to tacrolimus/methotrexate GVHD prophylaxis in children with ALL: a phase 3 Children's Oncology Group/Pediatric Blood and Marrow Transplant Consortium trial. Blood 123 (13): 2017-25, 2014. [PUBMED Abstract]
109. Pulsipher MA, Bader P, Klingebiel T, et al.: Allogeneic transplantation for pediatric acute lymphoblastic leukemia: the emerging role of peritransplantation minimal residual disease/chimerism monitoring and novel chemotherapeutic, molecular, and immune approaches aimed at preventing relapse. Biol Blood Marrow Transplant 15 (1 Suppl): 62-71, 2008. [PUBMED Abstract]
110. Lankester AC, Bierings MB, van Wering ER, et al.: Preemptive alloimmune intervention in high-risk pediatric acute lymphoblastic leukemia patients guided by minimal residual disease level before stem cell transplantation. Leukemia 24 (8): 1462-9, 2010. [PUBMED Abstract]
111. Horn B, Soni S, Khan S, et al.: Feasibility study of preemptive withdrawal of immunosuppression based on chimerism testing in children undergoing myeloablative allogeneic transplantation for hematologic malignancies. Bone Marrow Transplant 43 (6): 469-76, 2009. [PUBMED Abstract]
112. Pochon C, Oger E, Michel G, et al.: Follow-up of post-transplant minimal residual disease and chimerism in childhood lymphoblastic leukaemia: 90 d to react. Br J Haematol 169 (2): 249-61, 2015. [PUBMED Abstract]
113. Bader P, Kreyenberg H, Hoelle W, et al.: Increasing mixed chimerism is an important prognostic factor for unfavorable outcome in children with acute lymphoblastic leukemia after allogeneic stem-cell transplantation: possible role for pre-emptive immunotherapy? J Clin Oncol 22 (9): 1696-705, 2004. [PUBMED Abstract]
114. Gandemer V, Pochon C, Oger E, et al.: Clinical value of pre-transplant minimal residual disease in childhood lymphoblastic leukaemia: the results of the French minimal residual disease-guided protocol. Br J Haematol 165 (3): 392-401, 2014. [PUBMED Abstract]
115. Rubin J, Vettenranta K, Vettenranta J, et al.: Use of intrathecal chemoprophylaxis in children after SCT and the risk of central nervous system relapse. Bone Marrow Transplant 46 (3): 372-8, 2011. [PUBMED Abstract]
116. Thompson CB, Sanders JE, Flournoy N, et al.: The risks of central nervous system relapse and leukoencephalopathy in patients receiving marrow transplants for acute leukemia. Blood 67 (1): 195-9, 1986. [PUBMED Abstract]
117. Oshima K, Kanda Y, Yamashita T, et al.: Central nervous system relapse of leukemia after allogeneic hematopoietic stem cell transplantation. Biol Blood Marrow Transplant 14 (10): 1100-7, 2008. [PUBMED Abstract]
118. Ruutu T, Corradini P, Gratwohl A, et al.: Use of intrathecal prophylaxis in allogeneic haematopoietic stem cell transplantation for malignant blood diseases: a survey of the European Group for Blood and Marrow Transplantation (EBMT). Bone Marrow Transplant 35 (2): 121-4, 2005. [PUBMED Abstract]
119. Maude SL, Laetsch TW, Buechner J, et al.: Tisagenlecleucel in Children and Young Adults with B-Cell Lymphoblastic Leukemia. N Engl J Med 378 (5): 439-448, 2018. [PUBMED Abstract]
120. Mehta J, Powles R, Treleaven J, et al.: Outcome of acute leukemia relapsing after bone marrow transplantation: utility of second transplants and adoptive immunotherapy. Bone Marrow Transplant 19 (7): 709-19, 1997. [PUBMED Abstract]
121. Kuhlen M, Willasch AM, Dalle JH, et al.: Outcome of relapse after allogeneic HSCT in children with ALL enrolled in the ALL-SCT 2003/2007 trial. Br J Haematol 180 (1): 82-89, 2018. [PUBMED Abstract]
122. Eapen M, Giralt SA, Horowitz MM, et al.: Second transplant for acute and chronic leukemia relapsing after first HLA-identical sibling transplant. Bone Marrow Transplant 34 (8): 721-7, 2004. [PUBMED Abstract]
123. Bosi A, Laszlo D, Labopin M, et al.: Second allogeneic bone marrow transplantation in acute leukemia: results of a survey by the European Cooperative Group for Blood and Marrow Transplantation. J Clin Oncol 19 (16): 3675-84, 2001. [PUBMED Abstract]
124. Willasch AM, Salzmann-Manrique E, Krenn T, et al.: Treatment of relapse after allogeneic stem cell transplantation in children and adolescents with ALL: the Frankfurt experience. Bone Marrow Transplant 52 (2): 201-208, 2017. [PUBMED Abstract]
125. Nishikawa T, Inagaki J, Nagatoshi Y, et al.: The second therapeutic trial for children with hematological malignancies who relapsed after their first allogeneic SCT: long-term outcomes. Pediatr Transplant 16 (7): 722-8, 2012. [PUBMED Abstract]
126. Bajwa R, Schechter T, Soni S, et al.: Outcome of children who experience disease relapse following allogeneic hematopoietic SCT for hematologic malignancies. Bone Marrow Transplant 48 (5): 661-5, 2013. [PUBMED Abstract]
127. Schechter T, Avila L, Frangoul H, et al.: Effect of acute graft-versus-host disease on the outcome of second allogeneic hematopoietic stem cell transplant in children. Leuk Lymphoma 54 (1): 105-9, 2013. [PUBMED Abstract]
128. Pulsipher MA, Boucher KM, Wall D, et al.: Reduced-intensity allogeneic transplantation in pediatric patients ineligible for myeloablative therapy: results of the Pediatric Blood and Marrow Transplant Consortium Study ONC0313. Blood 114 (7): 1429-36, 2009. [PUBMED Abstract]
129. Collins RH Jr, Goldstein S, Giralt S, et al.: Donor leukocyte infusions in acute lymphocytic leukemia. Bone Marrow Transplant 26 (5): 511-6, 2000. [PUBMED Abstract]
130. Levine JE, Barrett AJ, Zhang MJ, et al.: Donor leukocyte infusions to treat hematologic malignancy relapse following allo-SCT in a pediatric population. Bone Marrow Transplant 42 (3): 201-5, 2008. [PUBMED Abstract]
131. Bhadri VA, McGregor MR, Venn NC, et al.: Isolated testicular relapse after allo-SCT in boys with ALL: outcome without second transplant. Bone Marrow Transplant 45 (2): 397-9, 2010. [PUBMED Abstract]
132. von Stackelberg A, Locatelli F, Zugmaier G, et al.: Phase I/Phase II Study of Blinatumomab in Pediatric Patients With Relapsed/Refractory Acute Lymphoblastic Leukemia. J Clin Oncol 34 (36): 4381-4389, 2016. [PUBMED Abstract]
133. Kantarjian H, Thomas D, Jorgensen J, et al.: Results of inotuzumab ozogamicin, a CD22 monoclonal antibody, in refractory and relapsed acute lymphocytic leukemia. Cancer 119 (15): 2728-36, 2013. [PUBMED Abstract]
134. Kantarjian HM, DeAngelo DJ, Stelljes M, et al.: Inotuzumab Ozogamicin versus Standard Therapy for Acute Lymphoblastic Leukemia. N Engl J Med 375 (8): 740-53, 2016. [PUBMED Abstract]
135. Grupp SA, Kalos M, Barrett D, et al.: Chimeric antigen receptor-modified T cells for acute lymphoid leukemia. N Engl J Med 368 (16): 1509-18, 2013. [PUBMED Abstract]
136. Maude SL, Frey N, Shaw PA, et al.: Chimeric antigen receptor T cells for sustained remissions in leukemia. N Engl J Med 371 (16): 1507-17, 2014. [PUBMED Abstract]
137. Fitzgerald JC, Weiss SL, Maude SL, et al.: Cytokine Release Syndrome After Chimeric Antigen Receptor T Cell Therapy for Acute Lymphoblastic Leukemia. Crit Care Med 45 (2): e124-e131, 2017. [PUBMED Abstract]
138. Gardner RA, Finney O, Annesley C, et al.: Intent-to-treat leukemia remission by CD19 CAR T cells of defined formulation and dose in children and young adults. Blood 129 (25): 3322-3331, 2017. [PUBMED Abstract]
139. Lee DW, Kochenderfer JN, Stetler-Stevenson M, et al.: T cells expressing CD19 chimeric antigen receptors for acute lymphoblastic leukaemia in children and young adults: a phase 1 dose-escalation trial. Lancet 385 (9967): 517-28, 2015. [PUBMED Abstract]
140. Möricke A, Zimmermann M, Reiter A, et al.: Long-term results of five consecutive trials in childhood acute lymphoblastic leukemia performed by the ALL-BFM study group from 1981 to 2000. Leukemia 24 (2): 265-84, 2010. [PUBMED Abstract]
141. Silverman LB, Stevenson KE, O'Brien JE, et al.: Long-term results of Dana-Farber Cancer Institute ALL Consortium protocols for children with newly diagnosed acute lymphoblastic leukemia (1985-2000). Leukemia 24 (2): 320-34, 2010. [PUBMED Abstract]
142. Pui CH, Pei D, Sandlund JT, et al.: Long-term results of St Jude Total Therapy Studies 11, 12, 13A, 13B, and 14 for childhood acute lymphoblastic leukemia. Leukemia 24 (2): 371-82, 2010. [PUBMED Abstract]
143. Ritchey AK, Pollock BH, Lauer SJ, et al.: Improved survival of children with isolated CNS relapse of acute lymphoblastic leukemia: a pediatric oncology group study . J Clin Oncol 17 (12): 3745-52, 1999. [PUBMED Abstract]
144. Domenech C, Mercier M, Plouvier E, et al.: First isolated extramedullary relapse in children with B-cell precursor acute lymphoblastic leukaemia: results of the Cooprall-97 study. Eur J Cancer 44 (16): 2461-9, 2008. [PUBMED Abstract]
145. Hagedorn N, Acquaviva C, Fronkova E, et al.: Submicroscopic bone marrow involvement in isolated extramedullary relapses in childhood acute lymphoblastic leukemia: a more precise definition of "isolated" and its possible clinical implications, a collaborative study of the Resistant Disease Committee of the International BFM study group. Blood 110 (12): 4022-9, 2007. [PUBMED Abstract]
146. Ribeiro RC, Rivera GK, Hudson M, et al.: An intensive re-treatment protocol for children with an isolated CNS relapse of acute lymphoblastic leukemia. J Clin Oncol 13 (2): 333-8, 1995. [PUBMED Abstract]
147. Kumar P, Kun LE, Hustu HO, et al.: Survival outcome following isolated central nervous system relapse treated with additional chemotherapy and craniospinal irradiation in childhood acute lymphoblastic leukemia. Int J Radiat Oncol Biol Phys 31 (3): 477-83, 1995. [PUBMED Abstract]
148. Yoshihara T, Morimoto A, Kuroda H, et al.: Allogeneic stem cell transplantation in children with acute lymphoblastic leukemia after isolated central nervous system relapse: our experiences and review of the literature. Bone Marrow Transplant 37 (1): 25-31, 2006. [PUBMED Abstract]
149. Harker-Murray PD, Thomas AJ, Wagner JE, et al.: Allogeneic hematopoietic cell transplantation in children with relapsed acute lymphoblastic leukemia isolated to the central nervous system. Biol Blood Marrow Transplant 14 (6): 685-92, 2008. [PUBMED Abstract]
150. Eapen M, Zhang MJ, Devidas M, et al.: Outcomes after HLA-matched sibling transplantation or chemotherapy in children with acute lymphoblastic leukemia in a second remission after an isolated central nervous system relapse: a collaborative study of the Children's Oncology Group and the Center for International Blood and Marrow Transplant Research. Leukemia 22 (2): 281-6, 2008. [PUBMED Abstract]
151. Wofford MM, Smith SD, Shuster JJ, et al.: Treatment of occult or late overt testicular relapse in children with acute lymphoblastic leukemia: a Pediatric Oncology Group study. J Clin Oncol 10 (4): 624-30, 1992. [PUBMED Abstract]
152. Trigg ME, Steinherz PG, Chappell R, et al.: Early testicular biopsy in males with acute lymphoblastic leukemia: lack of impact on subsequent event-free survival. J Pediatr Hematol Oncol 22 (1): 27-33, 2000 Jan-Feb. [PUBMED Abstract]
153. van den Berg H, Langeveld NE, Veenhof CH, et al.: Treatment of isolated testicular recurrence of acute lymphoblastic leukemia without radiotherapy. Report from the Dutch Late Effects Study Group. Cancer 79 (11): 2257-62, 1997. [PUBMED Abstract]
154. Barredo JC, Hastings C, Lu X, et al.: 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. Pediatr Blood Cancer 65 (5): e26928, 2018. [PUBMED Abstract]

Changes to This Summary (01/31/2019)

The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.

World Health Organization (WHO) Classification System for Childhood Acute Lymphoblastic Leukemia (ALL)

Added this new section.

Postinduction Treatment for Childhood ALL

Revised text about the patient eligibility requirements and treatment regimens for the open COG-AALL1131 (NCT01406756) trial.

Postinduction Treatment for Specific ALL Subgroups

Revised text about the patient eligibility requirements and treatment regimens for the open COG-AALL1131 (NCT01406756) trial.

Treatment of Relapsed Childhood ALL

Added text to state that for patients with B-cell ALL who relapse after allogeneic hematopoietic stem cell transplantation (HSCT) and can be successfully weaned from immune suppression and have no graft-versus-host disease, tisagenlecleucel and other 4-1BB chimeric antigen receptor (CAR) T-cell approaches have resulted in event-free survival rates exceeding 50% at 12 months. Also revised text to state that for patients with T-cell ALL who relapse or for patients with B-cell ALL who are unable to undergo CAR T-cell therapy, a second ablative allogeneic HSCT may be feasible. Also added Kuhlen et al. as reference 121.

This summary is written and maintained by the PDQ Pediatric Treatment Editorial Board, which is editorially independent of NCI. The summary reflects an independent review of the literature and does not represent a policy statement of NCI or NIH. More information about summary policies and the role of the PDQ Editorial Boards in maintaining the PDQ summaries can be found on the About This PDQ Summary and PDQ® - NCI's Comprehensive Cancer Database pages.

About This PDQ Summary

Purpose of This Summary

This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about the treatment of childhood acute lymphoblastic leukemia. It is intended as a resource to inform and assist clinicians who care for cancer patients. It does not provide formal guidelines or recommendations for making health care decisions.

Reviewers and Updates

This summary is reviewed regularly and updated as necessary by the PDQ Pediatric Treatment Editorial Board, which is editorially independent of the National Cancer Institute (NCI). The summary reflects an independent review of the literature and does not represent a policy statement of NCI or the National Institutes of Health (NIH).

Board members review recently published articles each month to determine whether an article should:

• be discussed at a meeting,
• be cited with text, or
• replace or update an existing article that is already cited.

Changes to the summaries are made through a consensus process in which Board members evaluate the strength of the evidence in the published articles and determine how the article should be included in the summary.

The lead reviewers for Childhood Acute Lymphoblastic Leukemia Treatment are:

• Alan Scott Gamis, MD, MPH (Children's Mercy Hospital)
• Karen J. Marcus, MD (Dana-Farber Cancer Institute/Boston Children's Hospital)
• Michael A. Pulsipher, MD (Children's Hospital Los Angeles)
• Arthur Kim Ritchey, MD (Children's Hospital of Pittsburgh of UPMC)
• Lewis B. Silverman, MD (Dana-Farber Cancer Institute/Boston Children's Hospital)
• Malcolm A. Smith, MD, PhD (National Cancer Institute)

Any comments or questions about the summary content should be submitted to Cancer.gov through the NCI website's Email Us. Do not contact the individual Board Members with questions or comments about the summaries. Board members will not respond to individual inquiries.

Levels of Evidence

Some of the reference citations in this summary are accompanied by a level-of-evidence designation. These designations are intended to help readers assess the strength of the evidence supporting the use of specific interventions or approaches. The PDQ Pediatric Treatment Editorial Board uses a formal evidence ranking system in developing its level-of-evidence designations.

Permission to Use This Summary

PDQ is a registered trademark. Although the content of PDQ documents can be used freely as text, it cannot be identified as an NCI PDQ cancer information summary unless it is presented in its entirety and is regularly updated. However, an author would be permitted to write a sentence such as “NCI’s PDQ cancer information summary about breast cancer prevention states the risks succinctly: [include excerpt from the summary].”

The preferred citation for this PDQ summary is:

PDQ® Pediatric Treatment Editorial Board. PDQ Childhood Acute Lymphoblastic Leukemia Treatment. Bethesda, MD: National Cancer Institute. Updated <MM/DD/YYYY>. Available at: https://www.cancer.gov/types/leukemia/hp/child-all-treatment-pdq. Accessed <MM/DD/YYYY>. [PMID: 26389206]

Images in this summary are used with permission of the author(s), artist, and/or publisher for use within the PDQ summaries only. Permission to use images outside the context of PDQ information must be obtained from the owner(s) and cannot be granted by the National Cancer Institute. Information about using the illustrations in this summary, along with many other cancer-related images, is available in Visuals Online, a collection of over 2,000 scientific images.

Disclaimer

Based on the strength of the available evidence, treatment options may be described as either “standard” or “under clinical evaluation.” These classifications should not be used as a basis for insurance reimbursement determinations. More information on insurance coverage is available on Cancer.gov on the Managing Cancer Care page.

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More information about contacting us or receiving help with the Cancer.gov website can be found on our Contact Us for Help page. Questions can also be submitted to Cancer.gov through the website’s Email Us.

• Updated: January 31, 2019