Postinduction Treatment for Specific ALL Subgroups
The role of prophylactic cranial radiation in the treatment of T-cell ALL is controversial. 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, while other groups, such as DFCI, COG, and BFM, use radiation for the majority of patients with T-cell ALL.
Treatment options under clinical evaluation
The following is an example of a national and/or institutional clinical trial that is currently being conducted. Information about ongoing clinical trials is available from the NCI Web site.
- COG-AALL0434: COG-AALL0434 is a phase III trial for patients aged 1 to 30 years with T-cell ALL utilizing a modified augmented BFM regimen. Patients are classified into one of three risk groups (low, intermediate, or high) based on NCI age/leukocyte criteria, CNS status at diagnosis, morphologic marrow response on days 15 and 29, and minimal residual disease (MRD) level at day 29. The objectives of the trial are (1) to determine the safety and efficacy of adding nelarabine to the modified augmented BFM regimen in high- and intermediate-risk patients, (2) to determine the relative safety and efficacy of high-dose (5 g/m2) versus Capizzi escalating lower dose methotrexate without rescue during interim maintenance, and (3) to test the efficacy of treating NCI standard-risk T-cell ALL patients who are rapid responders (about 15% of patients) without cranial radiation.
Current Clinical Trials
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with T-cell childhood acute lymphoblastic leukemia. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
Infants With ALL
Infant ALL is uncommon, representing approximately 2% to 4% of cases of childhood ALL. Because of their distinctive biological characteristics and their high risk for 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.[11,12,13] Despite intensification of therapy, long-term EFS rates remain below 50%, and for those infants with MLL gene rearrangement, the EFS rates continue to be in the 17% to 40% range.[11,12,14,15,16][Level of evidence: 2A] Factors predicting poor outcome for infants with MLL translocations include a very young age (<6 months), extremely high presenting leukocyte count (?200,000-300,000/?L), and high levels of MRD at the end of induction and consolidation phases of treatment.; [Level of evidence: 3iDii] Infants with congenital leukemia (diagnosed within 1 month of birth) have a particularly poor outcome (17% overall survival).[Level of evidence: 2A]