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Indian Pediatr 2012;49: 248 |
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Does Choice of Treatment Protocol have Impact
on outcome in T-cell Lymphoblastic Leukemia?
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Mohammed Ramzan and Satya Prakash Yadav
Pediatric Hematology Oncology and Bone
Marrow Transplant Unit, Institute of Child Health,
Sir Ganga Ram Hospital, Delhi 110 060, India.
Email:
[email protected]
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We read the article by Arya, et al. on T-cell
acute lymphoblastic leukemia (ALL) outcome with interest [1]. Although
ALL outcome has improved in India but sepsis and loss to follow up
remain barriers to improving outcome [2]. Here we describe impact of
choice of protocol on patients with T-cell ALL at our center. Out of 288
children newly diagnosed as ALL between July 2005 to Jan 2011, 41
(14.2%) had T-cell ALL, which is similar to Western data 15-18% [3].
However, it is much lower than that reported by Arya, et al.
(30%) [1]. Median age of presentation was 7.5 years (9 month-18 years)
(M:F=6:1) and 34% aged >10 years. 39% patients had hyperleukocytosis
(>50000/mm 3), which is lower
than 58.3% reported by Arya, et al. [1]. Children were treated as
per BFM-95, UKALL-XI, MCP-841 and Interfant-99 protocols. Twelve (29.2%)
were lost to follow up (LFU) and 29 opted for treatment, of these
24(82.7%) achieved complete remission (CR1). Four died in induction and
one had refractory disease. Four died in remission. Nine (31%) relapsed
(Medullary-4, combined-3, testicular-1,isolated CNS-1). Eleven (38%)
patients are alive and in CR1.Eighteen patients were treated on BFM 95
protocol (14 medium risk and 4 high risk as per BFM-95 risk
stratification), of these 13 achieved CR1, 4 died in induction and 1 had
refractory disease. Out of 13, 8 are in CR1 (at median follow up of 2.5
years), one relapsed and 4 had remission deaths. Ten patients were
treated on UKALL-XI protocol, 9 achieved CR1 and 1 died in induction.
Out of 9 in CR1, 7 relapsed, 1 alive and 1 LFU. Two patients were
treated on MCP-841 protocol one is in CR1 and 1 LFU. One infant was
treated on Interfant-99 protocol who relapsed at 18 months from
diagnosis and died. Relapse rate was significantly lower for more
intensive BFM-95 as compared to UKALL-XI protocol (P-value
0.001). However treatment related mortality was very high (44%) for
BFM-95 as compared to 10% for UKALL-XI protocol. Our results are
inferior to original BFM-95 protocol (74.8% 6-year event free survival
(EFS) in T-cell ALL) [4] while UKALL XI protocol [5] showed 61% 8-year
EFS with no separate data for T-immunophenotype. We conclude that choice
of treatment protocol has huge impact on outcome in T-cell ALL.
References
1. Arya LS, Padmanjali KS, Sazawal S, Saxena R,
Bhargava M, Kulkarni KP, et al. Childhood T-lineage acute
lymphoblastic leukemia: management and outcome at a tertiary care center
in North India. Indian Pediatr. 2011;48:785-90.
2. Yadav SP, Dua V, Sachdeva A. Sepsis is a major
barrier to improving survival in childhood acute lymphoblastic leukemia
in the developing World. J Pediatr Hematol Oncol. 2011;33:636.
3. Vrooman LM, Silverman LB. Childhood acute
lymphoblastic leukemia: update on prognostic factors. Curr Opin Pediatr.
2009;21:1-8.
4. Möricke A, Reiter A, Zimmermann M, Gadner H,
Stanulla M, Dördelmann M, et al. Risk-adjusted therapy of acute
lymphoblastic leukemia can decrease treatment burden and improve
survival: treatment results of 2169 unselected pediatric and adolescent
patients enrolled in the trial ALL-BFM 95. Blood. 2008;111:4477-89.
5. Chessells JM, Harrison G, Richards SM, Gibson BE,
Bailey CC, Hill FG, et al. Failure of a new protocol to improve
treatment results in paediatric lymphoblastic leukaemia: lessons from
the UK Medical Research Council trials UKALL X and UKALL XI. Br J
Haematol. 2002;118:445-55.
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