Journal of Clinical Oncology, Vol 14, 389-398, Copyright © 1996 by American Society of Clinical Oncology
Cytoreduction and prognosis in acute lymphoblastic leukemia--the importance of early marrow response: report from the Childrens Cancer Group
PG Steinherz, PS Gaynon, JC Breneman, JM Cherlow, NJ Grossman, JH Kersey, HS Johnstone, HN Sather, ME Trigg, R Chappell, D Hammond and WA Bleyer
Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
PURPOSE: To quantify the residual marrow lymphoblast fraction that best
defines patients at high risk for relapse, and the optimal time for
assessment during remission induction. PATIENTS AND METHODS: The residual
lymphoblast percentage was evaluated on day 7 (n = 220) and day 14 (n =
205) during a four- or five-drug induction in patients with poor prognostic
factors. The rate of cytoreduction was related to event- free survival
(EFS) and other factors. RESULTS: On the New York (NY) regimen, 68%, 14%,
and 18%, and on the Berlin-Frankfurt-Munster (BFM) regimen, 56%, 15%, and
29% of patients had M1 (< 5% blasts), M2 (5- 25%), or M3 (> 25%)
responses on day 7 (P = .075). On day 14, the corresponding values were
87%, 6%, 7% on NY and 84%, 8%, 8% on BFM. For patients who achieved
remission by day 28 and a day-7 marrow rating of M1, M2, or M3, the 6-year
EFS rate was 78%, 61%, and 49% (P < .001). The day-14 ratings predicted
for a 72%, 32%, or 40% EFS (P < .001). Patients with 5% to 10% blasts
day 7 had three times as many events as those with less than 5% and had no
better EFS than those with 11% to 25% blasts. Patients with a WBC count
more than 200,000/microL at diagnosis and an M1 day 7 marrow had an EFS
rate of 69%, while for those with M2 or M3, the EFS rate was 41%. Day-7
marrow had greater prognostic significance than the day-14 evaluation. For
slow responders on day 7, the day-14 marrow provided additional
information. EFS for patients who achieved M1 by day 14 was 65%. EFS
decreased to 20% for those still M2 or M3 on day 14. Day-7 and -14
evaluations had significance for patients of all ages and WBC levels.
CONCLUSION: Marrow aspiration on day 7 of therapy provided more useful
information than that on day 14. However, day-14 marrow provided additional
information for patients with a poor day-7 response. The rate of
cytoreduction is a powerful, independent prognostic factor that can
identify patients with a slow early response who are at risk for a short
remission duration.
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