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Treatment for Newly Diagnosed Childhood ALL

    Standard Treatment Options for Newly Diagnosed ALL

    Standard treatment options for newly diagnosed childhood acute lymphoblastic leukemia (ALL) include the following:

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    1. Chemotherapy.

    Remission induction therapy

    Induction chemotherapy consists of the following drugs, with or without an anthracycline:

    The Children's Oncology Group (COG) protocols do not administer anthracycline during induction to patients with National Cancer Institute standard-risk precursor B-cell ALL. This three-drug induction regimen results in a complete remission rate of greater than 95% for standard-risk patients.[1]

    Patients treated by other study groups receive a four-drug induction regimen regardless of presenting features:

    • Berlin-Frankfurt-Münster Group in Europe.[2]
    • St. Jude Children's Research Hospital.[3]
    • Dana-Farber Cancer Institute ALL Consortium.[4]

    The most common four-drug induction regimen is vincristine, corticosteroid (either dexamethasone or prednisone), L-asparaginase, and either doxorubicin or daunorubicin. Some studies have suggested that this more intensive induction regimen may result in improved event-free survival (EFS) in patients presenting with high-risk features.[5,6] The COG reserves the use of a four-drug induction for patients with high-risk B-precursor ALL and T-cell ALL.

    For patients who are at standard risk or low risk of treatment failure, four-drug or more induction therapy does not appear necessary for favorable outcome provided that adequate postremission intensification therapy is administered.[5,7,8]

    Corticosteroid therapy

    Many current regimens utilize dexamethasone instead of prednisone during remission induction and later phases of therapy.

    Evidence (dexamethasone):

    1. The Children's Cancer Group conducted a randomized trial comparing dexamethasone and prednisone in standard-risk ALL patients.
      • The trial reported that dexamethasone was associated with a superior EFS.[9]
    2. Another randomized trial was conducted by the United Kingdom Medical Research Council.[10]
      • The trial demonstrated that dexamethasone was associated with a more favorable outcome than prednisolone in all patient subgroups.
      • Patients who received dexamethasone had a significantly lower incidence of both central nervous system (CNS) and non-CNS relapses than patients who received prednisolone.[10]
    3. Other randomized trials did not confirm an EFS advantage with dexamethasone.[11,12]

    The ratio of dexamethasone to prednisone dose used may influence outcome. Studies in which the dexamethasone to prednisone ratio is 1:5 to 1:7 have shown a better result for dexamethasone, while studies using a 1:10 ratio have shown similar outcomes.[13]

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