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Background Prophylactic cranial irradiation has been a standard treatment in children with acute lymphoblastic leukemia (ALL) who are at high risk for central nervous system (CNS) relapse.
Methods We conducted a clinical trial to test whether prophylactic cranial irradiation could be omitted from treatment in all children with newly diagnosed ALL. A total of 498 patients who could be evaluated were enrolled. Treatment intensity was based on presenting features and the level of minimal residual disease after remission-induction treatment. The duration of continuous complete remission in the 71 patients who previously would have received prophylactic cranial irradiation was compared with that of 56 historical controls who received it.
Results The 5-year event-free and overall survival probabilities for all 498 patients were 85.6% (95% confidence interval [CI], 79.9 to 91.3) and 93.5% (95% CI, 89.8 to 97.2), respectively. The 5-year cumulative risk of isolated CNS relapse was 2.7% (95% CI, 1.1 to 4.3), and that of any CNS relapse (including isolated relapse and combined relapse) was 3.9% (95% CI, 1.9 to 5.9). The 71 patients had significantly longer continuous complete remission than the 56 historical controls (P=0.04). All 11 patients with isolated CNS relapse remained in second remission for 0.4 to 5.5 years. CNS leukemia (CNS-3 status) or a traumatic lumbar puncture with blast cells at diagnosis and a high level of minimal residual disease (
Conclusions With effective risk-adjusted chemotherapy, prophylactic cranial irradiation can be safely omitted from the treatment of childhood ALL. (ClinicalTrials.gov number, NCT00137111
[ClinicalTrials.gov]
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1%) after 6 weeks of remission induction were significantly associated with poorer event-free survival. Risk factors for CNS relapse included the genetic abnormality t(1;19)(TCF3-PBX1), any CNS involvement at diagnosis, and T-cell immunophenotype. Common adverse effects included allergic reactions to asparaginase, osteonecrosis, thrombosis, and disseminated fungal infection.
Source Information
From the Departments of Oncology (C.-H.P., D.C., J.T.S., S.C.K., R.C.R., J.E.R., E.C.-S., S.J., S.C.H., V.S., M.L.M., W.L., R.H.), Pathology (C.-H.P., D.C., S.C.R., M.O., J.R.D.), Biostatistics (D.P., C.C., J.M.B.), Radiological Sciences (S.C.K., L.E.K.), and Pharmaceutical Sciences (W.E.E., M.V.R.), St. Jude Children's Research Hospital; and the Colleges of Medicine (C.-H.P., D.C., J.T.S., S.C.K., R.C.R., J.E.R., S.C.R., M.O., L.E.K., S.J., S.C.H., M.L.M., W.L., J.R.D., W.E.E., M.V.R.) and Pharmacy (W.E.E., M.V.R.), University of Tennessee Health Science Center — both in Memphis; and Cook Children's Medical Center, Fort Worth, TX (W.P.B., A.B.).
Address reprint requests to Dr. Pui at St. Jude Children's Research Hospital, 262 Danny Thomas Pl., Memphis, TN 38105, or at ching-hon.pui{at}stjude.org.
Related Letters:
Treating Childhood Leukemia without Cranial Irradiation
Sallan S. E., Schrappe M., Silverman L. B., Naina H. V., Harris S., Patnaik M. M., Pui C.-H., Krull K., Relling M.
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N Engl J Med 2009;
361:1310-1312, Sep 24, 2009.
Correspondence
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