We thank Ramzan M and Yadav SP for their comments and observations as well as for adding to the body of literature on T lineage acute lymphoblastic leukemia (ALL) from India [1].

Authors report that the percentage of T lineage ALL at their institution is 14.2%, which is much lower than most previous reports form India. It would be very important to know the socioeconomic distribution of the families presenting with T lineage ALL at their predominantly non-public funded institution. It has been recently shown by investigators from Chennai that improvement in and hence; higher socioeconomic status is associated with a lower frequency of T lineage immunophenotype [2]. Differences, in socioeconomic strata, could partly or fully explain this disparity. Moreover, robust conclusions about the percentage of T lineage ALL are difficult due to small sample size in the authors study.

The definition of hyperleukocytosis is white cell count >100,000 per microliter and not >50000 per microliter. Hence the information presented is inaccurate. It would be helpful to know why children were treated with varying protocols and if there were any financial factors that influenced these decisions.

The overall survival (26.8%) at the authors institution is much less as compared to the outcome published by us [3].

The sample size is however far too small for head to head protocol comparison. From the given data it is also difficult to infer baseline characteristics. High-risk disease, nutritional comorbidities, sepsis, infrastructural and supportive care facilities and financial constraints influence treatment related mortality especially in the Indian setting. High treatment related mortality on the BFM arm further underscores the need of excellent supportive care and multidisciplinary management [3].

In conclusion, it is not only the choice of protocol that would influence the outcome of T cell ALL but also a complex web of a large number of other co-factors and confounders that would determine the ultimate outcome.

1. Ramzan M, Yadav SP. Does choice of treatment protocol have impact on outcome in T-cell lymphoblastic leukemia? Indian Pediatr. 2012;49:248.

2. Rajalekshmy KR, Abitha AR, Anuratha N, Sagar TG. Time trend in frequency of occurrence of major immunophenotypes in paediatric acute lymphoblastic leukemia cases as experienced by Cancer Institute, Chennai, south India during the period 1989-2009. Indian J Cancer. 2011;48:310-5.