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Koh KN, Im HJ, Kim H, Kang HJ, Park KD, Shin HY, Ahn HS, Lee JW, Yoo KH, Sung KW, Koo HH, Lim YT, Park JE, Park BK, Park HJ, Seo JJ. Outcome of Reinduction Chemotherapy with a Modified Dose of Idarubicin for Children with Marrow-Relapsed Acute Lymphoblastic Leukemia: Results of the Childhood Acute Lymphoblastic Leukemia (CALL)-0603 Study. J Korean Med Sci 2017; 32:642-649. [PMID: 28244291 PMCID: PMC5334163 DOI: 10.3346/jkms.2017.32.4.642] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 01/07/2017] [Indexed: 01/06/2023] Open
Abstract
This multicenter, prospective trial was conducted to develop an effective and safe reinduction regimen for marrow-relapsed pediatric acute lymphoblastic leukemia (ALL) by modifying the dose of idarubicin. Between 2006 and 2009, the trial accrued 44 patients, 1 to 21 years old with first marrow-relapsed ALL. The reinduction regimen comprised prednisolone, vincristine, L-asparaginase, and idarubicin (10 mg/m²/week). The idarubicin dose was adjusted according to the degree of myelosuppression. The second complete remission (CR2) rate was 72.7%, obtained by 54.2% of patients with early relapse < 24 months after initial diagnosis and 95.0% of those with late relapse (P = 0.002). Five patients entered remission with extended treatment, resulting in a final CR2 rate of 84.1%. The CR2 rate was not significantly different according to the idarubicin dose. The induction death rate was 2.3% (1/44). The 5-year event-free and overall survival rates were 22.2% ± 6.4% and 27.3% ± 6.7% for all patients, 4.2% ± 4.1% and 8.3% ± 5.6% for early relapsers, and 43.8% ± 11.4% and 50.0% ± 11.2% for late relapsers, respectively. Early relapse and slow response to reinduction chemotherapy were predictors of poor outcomes. In conclusion, a modified dose of idarubicin was effectively incorporated into the reinduction regimen for late marrow-relapsed ALL with a low toxic death rate. However, the CR2 rate for early relapsers was suboptimal, and the second remission was not durable in most patients.
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Affiliation(s)
- Kyung Nam Koh
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, Seoul, Korea
| | - Ho Joon Im
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, Seoul, Korea
| | - Hyery Kim
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, Seoul, Korea
| | - Hyoung Jin Kang
- Department of Pediatrics, Cancer Research Institute, Seoul National University College of Medicine, Seoul National University Children's Hospital, Seoul, Korea
| | - Kyung Duk Park
- Department of Pediatrics, Cancer Research Institute, Seoul National University College of Medicine, Seoul National University Children's Hospital, Seoul, Korea
| | - Hee Young Shin
- Department of Pediatrics, Cancer Research Institute, Seoul National University College of Medicine, Seoul National University Children's Hospital, Seoul, Korea
| | - Hyo Seop Ahn
- Department of Pediatrics, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Ji Won Lee
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Keon Hee Yoo
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ki Woong Sung
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hong Hoe Koo
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Tak Lim
- Department of Pediatrics, Pusan National University College of Medicine, Busan, Korea
| | - Jun Eun Park
- Department of Pediatrics, Ajou University College of Medicine, Suwon, Korea
| | - Byung Kiu Park
- Center for Pediatric Cancer, National Cancer Center, Goyang, Korea
| | - Hyeon Jin Park
- Center for Pediatric Cancer, National Cancer Center, Goyang, Korea
| | - Jong Jin Seo
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center Children's Hospital, Seoul, Korea.
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Guolo F, Minetto P, Clavio M, Miglino M, Di Grazia C, Ballerini F, Pastori G, Guardo D, Colombo N, Kunkl A, Fugazza G, Rebesco B, Sessarego M, Lemoli RM, Bacigalupo A, Gobbi M. High feasibility and antileukemic efficacy of fludarabine, cytarabine, and idarubicin (FLAI) induction followed by risk-oriented consolidation: A critical review of a 10-year, single-center experience in younger, non M3 AML patients. Am J Hematol 2016; 91:755-62. [PMID: 27084986 DOI: 10.1002/ajh.24391] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Revised: 03/16/2016] [Accepted: 04/13/2016] [Indexed: 11/09/2022]
Abstract
About 105 consecutive acute myeloid leukemia (AML) patients treated with the same induction-consolidation program between 2004 and 2013 were retrospectively analyzed. Median age was 47 years. The first induction course included fludarabine (Flu) and high-dose cytarabine (Ara-C) plus idarubicin (Ida), with or without gemtuzumab-ozogamicin (GO) 3 mg/m(2) (FLAI-5). Patients achieving complete remission (CR) received a second course without fludarabine but with higher dose of idarubicin. Patients not achieving CR received an intensified second course. Patients not scheduled for early allogeneic bone marrow transplantation (HSCT) where planned to receive at least two courses of consolidation therapy with Ara-C. Our double induction strategy significantly differs from described fludarabine-containing regimens, as patients achieving CR receive a second course without fludarabine, to avoid excess toxicity, and Ara-C consolidation is administrated at the reduced cumulative dose of 8 g/m(2) per cycle. Toxicity is a major concern in fludarabine containing induction, including the recent Medical Research Council AML15 fludarabine, cytarabine, idaraubicin and G-CSF (FLAG-Ida) arm, and, despite higher anti-leukemic efficacy, only a minority of patients is able to complete the full planned program. In this article, we show that our therapeutic program is generally well tolerated, as most patients were able to receive subsequent therapy at full dose and in a timely manner, with a 30-day mortality of 4.8%. The omission of fludarabine in the second course did not reduce efficacy, as a CR rate of 83% was achieved and 3-year disease-free survival and overall survival (OS) were 49.6% and 50.9%, respectively. Our experience shows that FLAI-5/Ara-C + Ida double induction followed by risk-oriented consolidation therapy can result in good overall outcome with acceptable toxicity. Am. J. Hematol. 91:755-762, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Fabio Guolo
- Hematology Clinic, Department of Internal Medicine (DiMI); University of Genoa, IRCCS AOU S. Martino-IST; Genoa Italy
| | - Paola Minetto
- Hematology Clinic, Department of Internal Medicine (DiMI); University of Genoa, IRCCS AOU S. Martino-IST; Genoa Italy
| | - Marino Clavio
- Hematology Clinic, Department of Internal Medicine (DiMI); University of Genoa, IRCCS AOU S. Martino-IST; Genoa Italy
| | - Maurizio Miglino
- Hematology Clinic, Department of Internal Medicine (DiMI); University of Genoa, IRCCS AOU S. Martino-IST; Genoa Italy
| | - Carmen Di Grazia
- Second Division of Hematology and Bone Marrow Transplantation; IRCCS AOU S. Martino-IST; Genoa Italy
| | - Filippo Ballerini
- Hematology Clinic, Department of Internal Medicine (DiMI); University of Genoa, IRCCS AOU S. Martino-IST; Genoa Italy
| | - Giordana Pastori
- Hematology Clinic, Department of Internal Medicine (DiMI); University of Genoa, IRCCS AOU S. Martino-IST; Genoa Italy
| | - Daniela Guardo
- Hematology Clinic, Department of Internal Medicine (DiMI); University of Genoa, IRCCS AOU S. Martino-IST; Genoa Italy
| | - Nicoletta Colombo
- Hematology Clinic, Department of Internal Medicine (DiMI); University of Genoa, IRCCS AOU S. Martino-IST; Genoa Italy
| | - Annalisa Kunkl
- Service of Flow-Cytometry, Department of Pathology; IRCCS AOU S. Martino-IST; Genoa Italy
| | - Giuseppina Fugazza
- Hematology Clinic, Department of Internal Medicine (DiMI); University of Genoa, IRCCS AOU S. Martino-IST; Genoa Italy
| | - Barbara Rebesco
- Pharmacology Division; IRCCS AOU S. Martino-IST; Genoa Italy
| | - Mario Sessarego
- Hematology Clinic, Department of Internal Medicine (DiMI); University of Genoa, IRCCS AOU S. Martino-IST; Genoa Italy
| | - Roberto Massimo Lemoli
- Hematology Clinic, Department of Internal Medicine (DiMI); University of Genoa, IRCCS AOU S. Martino-IST; Genoa Italy
| | - Andrea Bacigalupo
- Second Division of Hematology and Bone Marrow Transplantation; IRCCS AOU S. Martino-IST; Genoa Italy
| | - Marco Gobbi
- Hematology Clinic, Department of Internal Medicine (DiMI); University of Genoa, IRCCS AOU S. Martino-IST; Genoa Italy
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Yoon JH, Park JA, Kim EK, Kang HJ, Shin HY, Ahn HS. Improvement of induction remission rate by modifying the dose of idarubicin for relapsed childhood acute lymphoblastic leukemia. J Korean Med Sci 2009; 24:281-8. [PMID: 19399271 PMCID: PMC2672129 DOI: 10.3346/jkms.2009.24.2.281] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2007] [Accepted: 06/10/2008] [Indexed: 11/20/2022] Open
Abstract
Relapse is the major cause of treatment failure in acute lymphoblastic leukemia (ALL), yet there is no established treatment for relapsed ALL. To improve the induction remission rate, we modified the dose of idarubicin in the original Children's Cancer Group (CCG)-1884 protocol, and retrospectively compared the results. Twenty-eight patients diagnosed with relapsed ALL received induction chemotherapy according to the CCG-1884 protocol. Complete remission (CR) rate in all patients after induction chemotherapy was 57%. The idarubicin 10 mg/m(2)/week group showed CR rate of 74%, compared with the 22% CR rate of the idarubicin 12.5 mg/m(2)/week group (p=0.010). Remission failure due to treatment-related mortality (TRM) was 44% and 5.2% in the idarubicin 12.5 mg/m(2)/week and 10 mg/m(2)/week groups, respectively (p=0.011). Overall survival (OS) and 4-yr event-free survival (EFS) were 12.8% and 10.3%, respectively. OS and 4-yr EFS were higher in the idarubicin 10 mg/m(2)/week group (19.3% and 15.6%) than in the 12.5 mg/m(2)/week group (0% and 0%). In conclusion, a modified dose of idarubicin from 12.5 mg/m(2)/week to 10 mg/m(2)/week resulted in an improved CR rate in the treatment of relapsed ALL, which was due to lower TRM. However, despite improved CR rate with modified dose of idarubicin, survival rates were unsatisfactory.
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Affiliation(s)
- Jong Hyung Yoon
- Department of Pediatrics, Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Jeong Ah Park
- Department of Pediatrics, Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Eun Kyung Kim
- Department of Pediatrics, Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Hyoung Jin Kang
- Department of Pediatrics, Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Hee Young Shin
- Department of Pediatrics, Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Hyo Seop Ahn
- Department of Pediatrics, Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
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Leahey AM, Bunin NJ, Belasco JB, Meek R, Scher C, Lange BJ. Novel multiagent chemotherapy for bone marrow relapse of pediatric acute lymphoblastic leukemia. MEDICAL AND PEDIATRIC ONCOLOGY 2000; 34:313-8. [PMID: 10797352 DOI: 10.1002/(sici)1096-911x(200005)34:5<313::aid-mpo1>3.0.co;2-q] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Despite improvements in the treatment of pediatric acute lymphoblastic leukemia, approximately one in five patients will develop recurrent disease. The majority of these patients do not survive. This limited institution study sought to improve event-free survival (EFS) by intensification of chemotherapy. PROCEDURE Twenty-one patients with either an isolated marrow (n = 16) or a combined marrow and central nervous system relapse (n = 5) received treatment according to Children's Hospital of Philadelphia protocol CHP-540. Six patients had an initial remission of <36 months, and five patients had relapsed within 1 year of completion of phase III therapy. Induction and reinduction therapy consisted of idarubicin, vincristine, dexamethasone, asparaginase, and triple intrathecal chemotherapy. Consolidation and reconsolidation therapy employed high-dose cytarabine, etoposide, and asparaginase given in a sequential manner. Maintenance therapy included courses of high- or low-dose cytarabine followed by sequential etoposide and asparaginase pulse, moderate-dose methotrexate with delayed leukovorin rescue, and vincristine/dexamethasone pulses. Therapy continued for 2 years from the start of interim maintenance in the 16 patients who did not receive a bone marrow transplant (BMT). Two patients underwent an HLA-identical sibling BMT specified by protocol. Four received a nonprotocol-prescribed alternative donor BMT. RESULTS The complete remission induction rate was 95%. With a median follow-up from date of relapse of 49 months in survivors, the actuarial EFS based on intent to treat is 75%. There were three toxic deaths in patients in CR and two deaths from relapse. CONCLUSIONS This regimen is toxic but effective and deserves study in a larger setting.
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Affiliation(s)
- A M Leahey
- Department of Pediatrics, Division of Oncology, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia 19104, USA
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Harris RE, Sather HN, Feig SA. High-dose cytosine arabinoside and L-asparaginase in refractory acute lymphoblastic leukemia: the Children's Cancer Group experience. MEDICAL AND PEDIATRIC ONCOLOGY 1998; 30:233-9. [PMID: 9473758 DOI: 10.1002/(sici)1096-911x(199804)30:4<233::aid-mpo5>3.0.co;2-h] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PROBLEM Therapy of children with relapsed acute lymphoblastic leukemia (ALL) not achieving a second remission (CR2) after an initial reinduction attempt is problematic. METHODS 52 children with ALL in first relapse received high-dose cytosine arabinoside and L-asparaginase (HDAraC/L-Asp) after failed attempts to achieve CR2. AraC was given at a dose of 3 gm/m2 q12 h x 4 on days 0-1 and 7-8. L-asparaginase was given IM 6,000 IU/m2 3 hours after completion of each 2-day cycle of AraC. RESULTS Of the 42 surviving to day 28, 22 (42% of all patients) achieved CR2. Ten died before day 28 (19%); four from leukemia and six from infections or toxicity (12% regimen-related mortality), There were 17 bacterial infections (three fatal), 17 invasive fungal infections (12 fatal), one fatal adenoviral infection, and one-non-fatal Pneumocystis pneumonia. One patient was surviving when lost to follow-up at four months and one patient survives over 5 years after transplant. Sixteen of the 22 patients who entered CR2 subsequently relapsed, five died of non-leukemic causes, and one was lost to follow-up. The median duration of second remission was 3 months (range 0.7 to 19 months). CONCLUSIONS HDAraC/L-Asp rescue reinduction for relapsed childhood ALL achieves CR2 in approximately 40% of patients who fail reinduction, but remissions are short for most patients and maintenance of CR2 remains unsatisfactory.
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Affiliation(s)
- R E Harris
- Stem Cell Transplanting Program, Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Neuendank A, Hartmann R, Bührer C, Winterhalter B, Klumper E, Veerman AJ, Henze G. Acute toxicity and effectiveness of idarubicin in childhood acute lymphoblastic leukemia. Eur J Haematol 1997; 58:326-32. [PMID: 9222288 DOI: 10.1111/j.1600-0609.1997.tb01679.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Anthracyclines have become important components of multi-agent remission induction and continuation therapy of acute lymphoblastic leukemia (ALL). New anthracycline derivatives are being investigated in an attempt to shift the balance of side effects and antileukemic potency. To evaluate the toxicity and efficacy of idarubicin (IDA) in childhood ALL, a prospective multicenter phase-II study was performed. A total of 51 children with prognostically poor recurrences of ALL were enrolled, all of whom had been exposed to anthracyclines during front-line treatment. A single 48-h continuous infusion of IDA at 24 mg/m2 was started on the first day of salvage treatment without concomitant systemic cytostatic agents. The response was assessed by reduction of leukemic blasts in the bone marrow and other compartments 2 wk later. IDA monotherapy caused complete and partial remissions in 5 and 20 patients, respectively (49%). Delays of treatment with subsequent polychemotherapy courses were frequent and mainly caused by prolonged intervals of myelosuppression and high rates of systemic infection. Non-hematological toxicities including acute cardiac reactions were transient and moderate. Our findings suggest that IDA is an effective drug for remission induction in children with ALL, with acute hematological toxicity being dose-limiting.
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Affiliation(s)
- A Neuendank
- Department of Pediatric Oncology/Hematology, Virchow Medical Center, Humboldt University, Berlin, Germany
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Feig SA, Ames MM, Sather HN, Steinherz L, Reid JM, Trigg M, Pendergrass TW, Warkentin P, Gerber M, Leonard M, Bleyer WA, Harris RE. Comparison of idarubicin to daunomycin in a randomized multidrug treatment of childhood acute lymphoblastic leukemia at first bone marrow relapse: a report from the Children's Cancer Group. MEDICAL AND PEDIATRIC ONCOLOGY 1996; 27:505-14. [PMID: 8888809 DOI: 10.1002/(sici)1096-911x(199612)27:6<505::aid-mpo1>3.0.co;2-p] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The outcome of children with acute lymphoblastic leukemia (ALL) and bone marrow relapse has been unsatisfactory largely because of failure to prevent subsequent leukemia relapses. Ninety-six patients were enrolled and received vincristine, prednisone, L-asparaginase, and an anthracycline as reinduction therapy. Ninety-two patients were randomized to receive either daunomycin (DNR) or idarubicin (IDR). After achievement of second complete remission (CR2), maintenance chemotherapy included the same anthracycline, IDR or DNR, high-dose cytarabine, and escalating-dose methotrexate. Compared to DNR (45 mg/m2/week x 3), IDR (12.5 mg/m2/week x 3) was associated with prolonged myelosuppression and more frequent serious infections. Halfway through the study, the dose of IDR was reduced to 10 mg/m2. Overall, second remission was achieved in 71% of patients. Reinduction rate was similar for IDR and DNR. Reasons for induction failure differed; none of 15, 1 of 5, and 5 of 7 reinduction failures were due to infection for DNR, IDR (10 mg/m2), and IDR (12.5 mg/m2), respectively. Two-year event-free survival (EFS) was better among patients who received IDR (12.5 mg/m2) (27 +/- 18%) compared to DNR (10 +/- 8%, P = 0.05) and IDR (10 mg/m2) (6 +/- 12%, P = 0.02). However, after 3 years of follow-up, late events in the high-dose IDR group result in a similar EFS to the lower-dose IDR and DNR groups. In conclusion, IDR is an effective agent in childhood ALL. When used weekly at 12.5 mg/m2 during induction, the EFS outcome during the first 2 years of treatment appears better than lower-dose IDR or DNR (45 mg/m2), although this difference was not sustained at longer periods of follow-up. Increased hematopoietic toxicity seen at this dose might be reduced through the use of supportive measures, such as hematopoietins and intestinal decontamination.
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Klumper E, Pieters R, den Boer ML, Huismans DR, Loonen AH, Veerman AJ. In vitro anthracycline cross-resistance pattern in childhood acute lymphoblastic leukaemia. Br J Cancer 1995; 71:1188-93. [PMID: 7779709 PMCID: PMC2033825 DOI: 10.1038/bjc.1995.231] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Daunorubicin (DNR) is a major front-line drug in the treatment of childhood acute lymphoblastic leukaemia (ALL). Previously, we showed that in vitro resistance to DNR at diagnosis is related to a poor long-term clinical outcome in childhood ALL and that relapsed ALL samples are more resistant to DNR than untreated ALL samples. In cell line studies, idarubicin (IDR), aclarubicin (ACR) and mitoxantrone (MIT) showed a (partial) lack of cross-resistance to the conventional anthracyclines DNR and doxorubicin (DOX), but clinical studies in childhood ALL have been inconclusive about the suggested lack of cross-resistance. In the present study we determined the in vitro cross-resistance pattern between DNR, DOX, IDR, ACR and MIT in 48 untreated and 39 relapsed samples from children with ALL using the MTT assay. The relapsed ALL group was about twice as resistant to DNR, DOX, IDR, ACR and MTT as the untreated ALL group. Thus, resistance developed to all five drugs. We found a significant cross-resistance between DNR, DOX, IDR, ACR and MIT, although in some individual cases in vitro anthracycline cross-resistance was less pronounced. We conclude that IDR, ACR and MIT cannot circumvent in vitro resistance to DNR in childhood ALL. Clinical studies may still prove whether IDR, ACR or MIT has a more favourable toxicity profile than DNR.
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Affiliation(s)
- E Klumper
- Department of Paediatrics, Free University Hospital, Amsterdam, The Netherlands
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