Intermittent combined chemotherapy with doxorubicin in recurrent childhood acute lymphoblastic leukemia

Remission induction and continuation therapy in children with their first relapse of acute lymphoid leukemia. A Pediatric Oncology Group study

Between January 1979 and April 1983, 113 children undergoing their first relapse of acute lymphoid leukemia (ALL) at any site were registered in Pediatric Oncology Group study 7834; 98 were eligible and evaluable. In addition to radiotherapy administered to sites of local relapse, induction consisted of vincristine, doxorubicin, and prednisone (VAP) chemotherapy. Continuation therapy consisted of triple-drug intrathecal therapy and regimens of 6-thioguanine and cytarabine alternating with vincristine, prednisone, cyclophosphamide, and cytarabine. Randomization in continuation was between VAP pulses or no pulse, regardless of the site of relapse. This report provides long-term follow-up of these patients. Thirty-two of 39 children with bone marrow involvement achieved a complete response (CR). Only one of these is alive in an unmaintained remission, a child who did not have an initial CR. Thirty-four of 36 evaluable children with central nervous system involvement as the site of relapse achieved CR. Of these ten are alive; eight are in continuing CR. Nineteen of 20 boys with testicular relapse achieved CR. Of these, 14 are still alive and not receiving therapy, although only one half received treatment in compliance with the protocol described. These results illustrate the possibility of cure of patients who have relapsed with ALL when it is (1) confined to a meningeal or gonadal site and (2) treated vigorously with radiotherapy and a new regimen of systemic chemotherapy. The results reconfirm the need to prevent an initial relapse at any site.

Which treatment for childhood acute lymphoblastic leukaemia in second remission?

The best therapy for children with acute lymphoblastic leukaemia (ALL) who have an initial bone marrow relapse and subsequently achieve second remission is controversial. Some findings suggest that bone marrow transplantation (BMT) is better than chemotherapy whereas others do not. An analysis of 871 children treated by BMT or chemotherapy showed that outcome was correlated with risk factors at diagnosis and with length of first remission. BMT seemed superior in patients who relapsed within 18 months of first remission while on maintenance chemotherapy. BMT was not demonstrably superior in patients who relapsed more than 18 months after first remission. The choice of treatment in childhood ALL must be based on prognostic variables at diagnosis and on the circumstances of the relapse.

Modified Capizzi maintenance regimen in children with relapsed acute lymphoblastic leukaemia

Improved survival of children with acute lymphoblastic leukaemia who relapse during therapy has been reported using the Capizzi maintenance regimen. We have treated ten such patients, without histocompatible donors, with this regimen, which consisted of fortnightly doses of vincristine (1.5 mg/m2) and an escalating dose of intravenous methotrexate (90-470 mg/m2) followed 24 hours later by asparaginase (15,000 units). Remission of disease had been successfully achieved in all patients using conventional therapy prior to the start of maintenance treatment. Cerebrospinal fluid concentrations of methotrexate were estimated serially in several patients but remained relatively low despite dose escalation. It appears that additional intrathecal chemotherapy is therefore necessary. Treatment was generally well tolerated but there is concern about the incidence of neurotoxicity in patients who had previously received cranial irradiation and intensive intrathecal therapy. The median duration of bone marrow remission was only 35 weeks (range 18-50). Two patients who had not been receiving IT therapy had early isolated CNS relapses. In conclusion, it appears that contrary to early expectations this treatment approach is unlikly to offer a significantly better outlook for these patients, in whom the chance of early marrow relapse remains high.