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Pattern of Relapse in Childhood ALL: Challenges and Lessons From a Uniform Treatment Protocol

Arya, Laxman Singh MD*; Kotikanyadanam, S.P. DCH*; Bhargava, Manorama MD; Saxena, Renu MD; Sazawal, Sudha PhD; Bakhshi, Sameer MD; Khattar, Anshu MSc; Kulkarni, Ketan P. MD§; Adde, Melissa MD; Vats, Trib S. MD; Magrath, Ian MD

Journal of Pediatric Hematology/Oncology: July 2010 - Volume 32 - Issue 5 - p 370-375
doi: 10.1097/MPH.0b013e3181d7ae0d
Original Articles

This retrospective analysis of 254 children less than 15 years of age treated with MCP-841 protocol from June 1992 to June 2002 was undertaken to identify the pattern of relapse and determine management lacunae. Two hundred twenty-three (87.8%) children achieved a complete remission of whom 40 (17.9%) relapsed. The mean age of relapsed patients was 6.5 years. The male/female ratio was 9:1. There were 23 (57.5%) isolated bone marrow (BM), 7 (17.5%) isolated central nervous system (CNS), 2 (5%) isolated testicular, 5 (12.5%) BM+testes and 1 each of BM+CNS, CNS+testes, and isolated bone relapses. Twenty-seven children (67.5%) relapsed on-therapy whereas 13 (32.5%) relapsed posttherapy. All 9 CNS relapses occurred on-therapy whereas 5/8 (62.5%) of testicular relapses occurred posttherapy. Lymphadenopathy was the only significant predictor for relapse. High-risk features such as age less than 1 year and greater than 10 years (P=0.047) and white cell count greater than 50.0×109/L (P=0.044) were significantly more frequent in patients with early on-therapy relapse than in patients with off-therapy relapse. The overall survival in the entire study cohort was 67±3.5%. Modest survival outcome, relapse while on chemotherapy and the higher incidence of CNS and testicular relapse indicate the need for reappraisal of our treatment protocol. There is a need of identifying risk factors and high-risk groups in our set of patients and risk-stratified intensification of chemotherapy in them.

*Division of Pediatric Oncology, Department of Pediatrics

Department of Hematology

Department of Medical Oncology, Dr B R Ambedkar Institute-Rotary Cancer Hospital, All India Institute of Medical Sciences

§Division of Pediatric Oncology, Apollo Center for Advanced Pediatrics, Indraprastha Apollo Hospital, New Delhi, India

International Network for Cancer Treatment and Research, Brussels, Belgium

MD Anderson Cancer Center, Houston, TX

Reprints: Laxman Singh Arya, MD, Senior Consultant, Pediatric Oncology and Hematology, Apollo Center for Advanced Pediatrics, Indraprastha Apollo Hospital, Sarita Vihar, New Delhi 110076, India (e-mail:

Received for publication November 28, 2009; accepted February 3, 2010

© 2010 Lippincott Williams & Wilkins, Inc.