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Prognostic Factors for Leukemic Induction Failure in Children With Acute Lymphoblastic Leukemia and Outcome After Salvage Therapy: The FRALLE 93 Study

Caroline Oudot, Marie-Françoise Auclerc, Vincent Levy, Raphaël Porcher, Christophe Piguet, Yves Perel, Virginie Gandemer, Marianne Debre, Christiane Vermylen, Brigitte Pautard, Claire Berger, Claudine Schmitt, Thierry Leblanc, Jean-Michel Cayuela, Gérard Socie, Gérard Michel, Guy Leverger, André Baruchel

From the Service d’Hématologie et Oncologie Pédiatrique, Hôpital Mère-Enfant, Limoges; Service de Pédiatrie à Orientation Hématologique; Centre d’Investigations Cliniques; L’Institut National de la Santé et de la Recherche Médicale U717; Département de Biostatistique et Informatique Médicales; Laboratoire d’Hématologie Moléculaire, Service de Greffe de Moelle; Hôpital St Louis, Assistance Publique–Hôpitaux de Paris (AP-HP); Service d’Hématologie Pédiatrique, Hôpital Necker Enfants Malades, AP-HP; Service d’Onco-Hématologie Pédiatrique, Hôpital Trousseau, AP-HP, Paris; Service d’Onco-Hématologie Pédiatrique, Hôpital Pellegrin, Bordeaux; Service d’Onco-Hématologie Pédiatrique, Hôpital Sud, Rennes; Service d’Onco-Hématologie Pédiatrique, Hôpital Nord, Amiens; Institut de Cancérologie de la Loire, Saint-Priest en Jarez; Service d’Hématologie Pédiatrique, Hôpital des Enfants, Vandoeuvre les Nancy; Service d’Hématologie Pédiatrique, Hôpital La Timone, Marseille, France; and Service d’Onco-Hématologie Pédiatrique, Hôpital St Luc, Bruxelles, Belgique

Corresponding author: André Baruchel, MD, Service de Pédiatrie à Orientation Hématologique, Hôpital Saint-Louis, Assistance Publique–Hôpitaux de Paris and Université Denis Diderot Paris 7, 1 avenue Claude Vellefaux, 75010 Paris, France; e-mail: andre.baruchel{at}sls.aphp.fr

Purpose: To identify prognostic factors and to evaluate the outcome of children with acute lymphoblastic leukemia (ALL) failure after induction therapy.

Patients and Methods: Between June 1993 and December 1999, 1,395 leukemic children were included in the French Acute Lymphoblastic Leukemia 93 study.

Results: Fifty-three patients (3.8%) had a leukemic induction failure (LIF) after three- or four-drug induction therapy. In univariate analysis, high WBC count (P = .001), mediastinal mass (P = .017), T-cell phenotype (T-ALL; P = .001), t(9;22) translocation (P = .001), and a slow early response (at day 8 and/or on day 21, P = .001) were predictive of LIF. The following three prognostic groups for LIF were identified by multivariate analysis: a low-risk group with B-cell progenitor (BCP) ALL without t(9;22) (odds ratio [OR] = 1), an intermediate-risk group with T-ALL and a mediastinal mass (OR = 7.4, P < .0001), and a high-risk group with BCP-ALL and t(9;22) or T-ALL without a mediastinal mass (OR = 28.4, P < .0001). Complete remission (CR) was subsequently obtained in 43 patients (81%). The 5-year overall survival (OS) rate of the 53 patients was 30% ± 6%. The 5-year OS rate among allogeneic graft recipients, autologous graft recipients, and after chemotherapy were 30.4% ± 9.6% (50% ± 26% after genoidentical transplantation), 50% ± 17.7%, and 41.7% ± 14.2%, respectively (P = .18). Fourteen patients (26%) were still in first CR after a median of 83 months (range, 53 to 117 months).

Conclusion: Three risk categories for LIF in children with ALL were identified. Approximately one third of patients with LIF can be successfully treated with salvage therapy overall. Subsequent CR after LIF is mandatory for cure.

Authors’ disclosures of potential conflicts of interest and author contributions are found at the end of this article.