Originally published as JCO Early Release 10.1200/JCO.2004.10.050 on September 7 2004

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Outcome of Treatment in Adults With Acute Lymphoblastic Leukemia: Analysis of the LALA-94 Trial

From the Hôpital Edouard Herriot, Lyon; Hôpital du Haut Levêque, Pessac; Hôpital Purpan, Toulouse; Hôpital Saint-Louis; Hôpital Pitié-Salpétrière; Hôpital Necker, Paris; Institut Paoli Calmettes, Marseille; Centre Hospitalier Lapeyronie, Montpellier; Centre Hospitalier, Lille; Centre Henri Becquerel, Rouen; Hôtel-Dieu, Clermont-Ferrand; Centre Hospitalier, Caen; L’Institut National de la Santé et de la Recherche Médicale U268, Villejuif, France; Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland; Hôpital de Jolimont, Haine St Paul, Belgium; and Westmead Hospital, Westmead, Australia

Address reprint requests to Xavier Thomas, MD, PhD, Service d’Hématologie, Hôpital Edouard Herriot, 69437, Lyon Cedex 03, France; e-mail: xavier.thomas{at}chu-lyon.fr

	ABSTRACT

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION Appendix Authors’ Disclosures of... REFERENCES

 
PURPOSE: We analyzed the benefits of a risk-adapted postremission strategy in adult lymphoblastic leukemia (ALL), and re-evaluated stem-cell transplantation (SCT) for high-risk ALL.

PATIENTS AND METHODS: A total of 922 adult patients entered onto the trial according to risk groups: standard-risk ALL (group 1), high-risk ALL (group 2), Philadelphia chromosome-positive ALL (group 3), and CNS-positive ALL (group 4). All received a standard four-drug/4-week induction course. Patients from group 1 who achieved a complete remission (CR) after one course of induction therapy were randomly assigned between intensive and less intensive postremission chemotherapy, whereas those who achieved CR after salvage therapy were then included in group 2. Patients in groups 2, 3, and 4 with an HLA-identical sibling were assigned to allogeneic SCT. In groups 3 and 4, autologous SCT was offered to all other patients, whereas in group 2 they were randomly assigned between chemotherapy and autologous SCT.

RESULTS: Overall, 771 patients achieved CR (84%). Median disease-free survival (DFS) was 17.5 months, with 3-year DFS at 37%. In group 1, the 3-year DFS rate was 41%, with no difference between arms of postremission randomization. In groups 2 and 4, the 3-year DFS rates were 38% and 44%, respectively. In group 2, autologous SCT and chemotherapy resulted in comparable median DFS. Patients with an HLA-matched sibling (groups 2 and 4) had improved DFS. Three-year DFS was 24% in group 3.

CONCLUSION: Allogeneic SCT improved DFS in high-risk ALL in the first CR. Autologous SCT did not confer a significant benefit over chemotherapy for high-risk ALL.

	INTRODUCTION

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION Appendix Authors’ Disclosures of... REFERENCES

 
During the last two decades, clinical trials have demonstrated an improved response rate in adult acute lymphoblastic leukemia (ALL) using intensive chemotherapy. However, the duration of remission has been disappointingly short.¹ Similar to treatment in children, risk-adapted strategies are being applied to adults with ALL to improve survival. Both single institutions and multicenter studies have shown that aggressive induction plus more potent intensification programs with chemotherapy alone or chemotherapy plus stem-cell transplantation (SCT) may improve treatment results.^2-7

In a previous prospective multicenter trial (Leucémie Aiguës Lymphoblastique de l’Adulte [LALA]-87 trial), the French LALA Group tested three different strategies for postinduction therapy with the first aim to evaluate randomly, after consolidation chemotherapy, the benefits of autologous SCT compared with standard maintenance chemotherapy, and second, to evaluate the role of allogeneic SCT in first remission.³ Analyzed on an intention-to-treat basis, results showed an advantage of allogeneic SCT over chemotherapy.⁸ The difference between allogeneic SCT and the control arm was highly significant in high-risk ALL, with 10-year survival rates of 44% and 11%, respectively.⁹ Conversely, it seemed that allogeneic SCT was not superior to chemotherapy or autologous SCT in standard-risk ALL. When comparing autologous SCT with chemotherapy, there was only a trend for better results in the autologous SCT arm.

On the basis of these results, we designed a new multicenter regimen (LALA-94 trial) with the aims to assess the intensification of induction therapy to improve complete remission (CR) rates; to introduce a risk-adapted postremission strategy by stratifying patients according to initial features and to initial response to therapy; and to re-evaluate transplantation for high-risk ALL.

	PATIENTS AND METHODS

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION Appendix Authors’ Disclosures of... REFERENCES

 
Study Eligibility
Eligibility criteria included age 15 to 55 years, untreated ALL (excluding mature B-cell ALL), without prior malignancy or psychiatric disease. All participants were registered at the time of entry onto the study through a randomization between idarubicin (IDA) and daunorubicin (DNR) for induction therapy. Subsequent randomizations occurred after the patients had achieved remission and were ready to start postremission therapy. The study was approved by the Ethics Committee (Lyon, France). All patients gave signed informed consent.

Diagnostic Procedure
Morphologic and cytochemical studies. The morphologic diagnosis was based on May-Grünwald-Giemsa and cytochemical staining of bone marrow smears, and was classified according to the French-American-British classification.¹⁰

Immunologic studies. Immunophenotyping was performed by indirect immunofluorescence using flow cytometry, focusing on the blast cell population, and employed a panel of monoclonal antibodies to B-cell (CD10, CD19, CD20, CD22, CD79a, sIg, cIg), T-cell (CD1, CD2, CD3, CD4, CD5, CD7, CD8), myeloid (CD13, CD14, CD15, CD33, CD65, CD117, myeloperoxidase), and precursor cell (terminal deoxynucleotidyl transferase, CD34, HLA-DR) –associated antigens. Leukemic cells that expressed none of these markers were considered as undifferentiated. Myeloid-antigen–positive ALL was defined as coexpression of lymphoid markers and at least two myeloid-lineage–associated antigens. An arbitrary threshold of 20% of labeled blast cells was set as the positive cutoff for each marker.

Cytogenetics and molecular biology. Cytogenetic examination was performed on bone marrow and/or blood samples. Chromosomal abnormalities were classified according to structural and numerical changes. The presence of t(4;11), t(9;22), or t(1;19) chromosomal translocations was assessed by conventional cytogenetics, and their respective gene rearrangements (MLL-AF4, BCR-ABL, or E2A-PBX1) were assessed by reverse transcriptase polymerase chain reaction.

Risk Groups
Group 1 (standard-risk ALL) comprised all T-cell lineage ALL patients achieving CR after one course of chemotherapy and B-cell lineage ALL patients defined by the absence of CNS-positive ALL; the absence of Philadelphia (Ph) chromosome, t(4;11), t(1;19), or other abnormalities involving 11q23 rearrangements; a WBC count less than 30 x 10⁹/L; an immunophenotype characterized by CD10⁺/CD19⁺, or CD20⁺/CD19⁺ and the absence of myeloid markers; and achievement of CR after one course of chemotherapy. Group 2 (high-risk ALL) was defined as nonstandard-risk ALL without Ph-positive status or CNS involvement. Patients in whom any phenotypic and/or karyotypic analyses could not be performed because of marrow fibrosis were systematically included in group 2. Group 3 comprised Ph-positive and/or BCR-ABL–positive ALL. Group 4 included all patients with evidence of CNS leukemia at diagnosis based on cranial nerve palsies, leukemic blasts in the CSF, and/or mononuclear cell counts 5 x 10⁶/L and leukemic blasts in stained centrifuged spinal fluid.

Treatment
Treatment schedule is indicated on Figure 1. The induction course was administered over a 4-week period and consisted of prednisone, vincristine, cyclophosphamide (CPM), and DNR or IDA according to initial random assignment. Colony-stimulating factor could be administered according to each center’s policy. Marrow response status was determined by bone marrow aspirates at about day 28 of induction chemotherapy.

View larger version (24K): [in this window] [in a new window]   Fig 1. Schema of LALA-94 trial. IDA, idarubicin; DNR, daunorubicin; ALL, acute lymphoblastic leukemia; CR, complete remission; MTZ, mitoxantrone; IDaraC, intermediate-dose cytarabine; Ph+, presence of Philadelphia chromosome; CPM, cyclophosphamide; araC, cytarabine; MP, mercaptopurine; Allo, allogeneic; SCT, stem-cell transplantation; Auto, autologous; MTX, methotrexate.

On the basis of an intention-to-treat principle, all patients with Ph-positive ALL or with CNS-positive ALL were distributed in one of the two following SCT groups: matched related allogeneic bone marrow SCT if they had a sibling donor, or autologous peripheral-blood SCT if they did not meet criteria for the first group. Transplantation was planned to be performed at day 90 after initial random assignment. Donors were matched at the A, B, C, and DR regions of the HLA loci (molecular typing at the HLA class II loci). Alternative donors were admitted for Ph-positive ALL with related or unrelated donors who were mismatched at one or more of these loci. In group 2, patients without a sibling donor were randomly assigned between the chemotherapy program and autologous SCT. Patients eligible for SCT received one or two additional cycles of chemotherapy consisting of methotrexate (MTX) and L-asparaginase. Granulocyte colony-stimulating factor–mobilized autologous peripheral-blood stem cells were collected during the myeloid recovery following the consolidation course. The conditioning regimen, for both autologous and allogeneic SCT, consisted of CPM 60 mg/kg on days 1 and 2, and total-body irradiation, either 10 Gy as a single dose or 12 Gy in six fractions.¹¹ Etoposide 50 mg/kg on day 1 was added to the conditioning regimen for patients with Ph-positive ALL. For allogeneic SCT, graft-versus-host disease prophylaxis mostly consisted of cyclosporine plus MTX or cyclosporine alone, but did not include T-cell depletion. In groups 2 and 4, a maintenance therapy combining mercaptopurine and MTX was planned for 2 years after autologous SCT. During the early study period, few patients (n = 6) with Ph-positive ALL have undergone transplantation with purged autologous bone marrow stem cells. In these patients, bone marrow purging was performed by complement-dependent lysis using anti-CD19 and anti-CD20 monoclonal antibodies. A few patients (three patients in group 2, 10 patients in group 3, and one patient in group 4) received matched unrelated allogeneic SCT. In the statistical analysis, the four patients from groups 2 and 4 were analyzed in intention-to-treat according to their arm of randomization, whereas the 10 patients with Ph-positive ALL were analyzed in the allogeneic SCT arm.

CNS Prophylaxis and Therapy
CNS prophylaxis consisted of eight intrathecal injections (four during the first induction course and four during continuation therapy) combining araC 40 mg, MTX 15 mg, and methylprednisolone 40 mg. In addition, patients treated only with chemotherapy received a dose of 18 Gy cranial x-ray therapy (five 1.8-Gy sessions per week for 2 weeks).

In patients with CNS disease at diagnosis (group 4), therapy consisted of 18 triple intrathecal injections associated with a pretransplant 15-Gy cranial irradiation.

Criteria for Response and Relapse
Morphologic response was evaluated after induction therapy and eventually after the salvage therapy course. Response was classified as CR or failure, including resistant disease and early death. Patients were considered to be in CR when the neutrophil count was more than 1.5 x 10⁹/L, the platelet count was more than 150 x 10⁹/L, the bone marrow examination was normal, and all extramedullary disease had resolved.

In addition, patients had to be classified as early responders or nonresponders on a bone marrow aspiration and peripheral-blood examination performed at day 8 of induction course. Early response was defined as the absence of peripheral-blood blasts associated with fewer than 5% marrow blasts or a hypoplastic bone marrow.

Relapse was defined as the reappearance of leukemic cells in the bone marrow and/or clinical evidence of disease. Toxicity of induction therapy was evaluated according to WHO criteria.¹²

Statistical Analyses
Random assignment of patients was stratified by center for the first randomization, but also by initial induction arm for later randomizations. Reasons for discontinuing participation in the study were noncompliance of the patient, no CR after salvage regimen, excessive extramedullary drug toxicity, death, relapse, major protocol violation, or lost to follow-up. The planned accrual was 1,000 patients. An interim analysis was performed after 400 patients were enrolled. The primary study objective was disease-free survival (DFS) rates according to the different postremission therapeutic options. Secondary objectives included assessment of response rates to induction chemotherapy and overall survival (OS) rates according to the different postremission strategies.

Associations between pretreatment characteristics and response to induction and the assessment of comparability of characteristics for the two initial randomized groups were evaluated by the Pearson ² test. All tests were two sided with statistical significance set at .05. All analyses were performed on an intention-to-treat basis. Intent-to-treat groups were applied after initial CR achievement, rather than at baseline. Intent-to-treat in group 1 was based only on patients without high-risk features at diagnosis and who also achieved a CR after primary induction therapy, whereas in group 2 it was based on those with high-risk features at diagnosis who achieved a CR and those without high-risk features at diagnosis and who failed to respond after primary induction therapy, but achieved a CR after salvage therapy. Patients with CR who were randomly assigned but never received the allocated treatment were not excluded from the comparative analyses.

OS was defined as the time from study entry to death or last patient contact. DFS was defined from date of CR to date of relapse or death, or last contact with patient in continuous CR. DFS and OS distributions were estimated by the method of Kaplan and Meier. The analyses in CR patients included only those who were randomly assigned: in group 1 (early consolidation v no early consolidation), in groups 2 and 4 (donor v no donor), in group 2 (autologous SCT v chemotherapy), and in groups 3 and 4 (autologous SCT v allogeneic SCT). All treatment and subgroup comparisons were performed by the log-rank test. Simultaneous effects of multiple covariates were estimated with the maximum-likelihood logistic regression model for response and with the Cox model for DFS and OS, and tested by the likelihood-ratio test, which was also used in univariate analyses for continuous variables. Estimated hazard ratios are reported as relative risks with 95% CIs. Cumulative incidence of relapse and transplant-related mortality (TRM) were calculated as previously described.¹³ All computations were made using BMDP software (BMDP Statistical Software, Los Angeles, CA).

	RESULTS

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Patient Entry
Between June 1994 and January 2002, 1,000 patients entered onto the LALA-94 trial. Eleven patients were withdrawn (error in entry [three ALL patients were older than 55 years, one patient had lymphoblastic lymphoma, one patient had natural killer-cell lymphoma, four patients had late diagnosis of L3 subtype], patient refusal [one patient], and physician decision [one patient treated according to a pediatric schedule]). Seven additional patients were ineligible because of misdiagnosis (acute myeloid leukemia) and were not treated on this protocol. Data from 60 patients were not received or incomplete at the time of analysis. Thus we report on 922 eligible patients. The cutoff date was January 1, 2004. The median follow-up of this cohort was 5.2 years.

Pretreatment Characteristics
Pretreatment characteristics are summarized in Table 2. Median age was 33 years. Male-to-female ratio was 1.8. Immunophenotype was available for 902 patients: 72% of patients had B lineage, 26% had T lineage, and the remaining 2% had undifferentiated ALL. Five percent of patients displayed myeloid markers. Cytogenetic and/or molecular biology evaluation was performed in 863 patients. The Philadelphia chromosome and/or the BCR-ABL rearrangement were found in 198 patients (23%), t(4;11)/MLL-AF4 was found in 36 patients, and t(1;19)/E2A-PBX1 was found in 26 patients.

Results of Induction
Results of induction therapy are summarized in Table 3. Six hundred sixty (72%) of all eligible patients achieved CR after one course of chemotherapy, 35 (4%) died during the induction phase before their remission status could be ascertained, and 227 failed to respond. CR proportions were 71% in the IDA arm and 72% in the DNR arm. Treatment failure was observed in 24% of patients in the IDA arm and in 26% in the DNR arm. However, significantly higher TRM was observed with IDA (5% v 2%; P = .01). There was no difference in terms of survival between the two arms, but an advantage was observed for the IDA arm in terms of DFS in patients receiving only chemotherapy (patients in group 1 and patients randomly assigned to the chemotherapy arm in group 2; median DFS, 31.1 months with IDA v 18.2 months with DNR; P = .05; Fig 2).

View larger version (19K): [in this window] [in a new window]   Fig 2. Disease-free survival (DFS) according to first randomization for patients receiving only chemotherapy (307 patients in group 1 and 59 patients randomly assigned in the chemotherapy arm in group 2). CR, complete remission.

CR was achieved in 212 (89%) of 237 patients with T-lineage ALL (185 patients after one course and 27 patients after two courses), and in 390 (86%) of 454 patients with (non–Ph-positive) B-lineage ALL (349 patients after one course and 41 patients after two courses).

Overall, 771 patients achieved CR (84%), whereas resistant patients represented 11%. In logistic regression analysis, risk groups defined at diagnosis (P < .001) and response on day 8 (P < .001) were prognostic factors for achieving a CR after induction and/or salvage therapy.

Toxicity of Induction Therapy
Most patients (911 patients) were assessable for toxicity during the first course of induction chemotherapy. Neutrophils recovered to more than 0.5 x 10⁹/L at a median of 21 days (range, 0 to 49 days) after initiation of therapy (23 days with IDA and 19 days with DNR). Platelets recovered to more than 50 x 10⁹/L at a median of 18 days (range, 0 to 66 days; 22 days with IDA and 12 days with DNR). The most frequent extrahematologic severe (WHO grade 3) adverse effects were infection (19%), mucositis (15%), hepatotoxicity (15%), hemorrhage (12%), gastrointestinal side effects (7%), and neurotoxicity (7%). Severe cardiac toxicity was observed in 3% of patients. Severe extrahematologic toxicity was not significantly different between the two arms of first randomization, except for mucositis (22% with IDA v 8% with DNR; P < .0001) and infections (27% with IDA v 11% with DNR; P < .0001).

Severe adverse effects after salvage therapy (192 patients evaluated) were infection (31%), mucositis (15%), hemorrhage (9%), hepatotoxicity (5%), neurotoxicity (4%), cardiac toxicity (1%), and gastrointestinal adverse effects (1%).

The mortality rate after one or two courses of induction chemotherapy was 5%.

DFS and OS
Median OS was 23 months (Fig 3). Median DFS was 17.5 months, with 3-year DFS at 37% and 5-year DFS at 30%. The estimated 3-year DFS rate was 35% and 43% for T- and (non–Ph-positive) B-lineage ALL, respectively (Fig 4).

View larger version (14K): [in this window] [in a new window]   Fig 3. Overall survival (OS) of the entire cohort (922 patients). DFS, disease-free survival.

View larger version (22K): [in this window] [in a new window]   Fig 4. Disease-free survival (DFS) according to immunophenotype (390 patients with non–Philadelphia[Ph] -positive B-linage acute lymphoblastic leukemia [ALL] and 212 patients with T-lineage ALL) as compared with Ph-positive ALL (140 patients). CR, complete remission.

View larger version (18K): [in this window] [in a new window]   Fig 5. Disease-free survival (DFS) according to second randomization for patients in group 1 (154 patients in the not intensive arm and 153 patients in the intensive arm). MTZ, mitoxantrone; IDaraC, intermediate-dose cytarabine; NS, not significant.

View larger version (18K): [in this window] [in a new window]   Fig 6. Disease-free survival (DFS) according to second randomization for patients in group 2 (70 patients in the autologous stem-cell transplantation [SCT] arm and 59 patients in the chemotherapy arm). CR, complete remission.

View larger version (18K): [in this window] [in a new window]   Fig 7. Disease-free survival (DFS) according to genetic randomization. For this analysis, patients from group 2 (211 patients) and those from group 4 (48 patients) were pooled. The group with a sibling donor comprised 100 patients, whereas that with no sibling donor included 159 patients. CR, complete remission.

CNS-positive ALL (group 4). Median OS was 20.9 months with a 5-year OS rate of 36%. Eighteen patients with a sibling donor were allocated to the allogeneic SCT arm, whereas 30 without any donor followed the autologous SCT arm. Median DFS values were 11.4 and 21.7 months with 3-year DFS rates at 40% and 47%, respectively (P = .65). Median OS values were 16 and 22.7 months with 3-year OS rates at 40% and 46%, respectively (P = .64). All patients allocated to the allogeneic SCT arm followed treatment for their arm, whereas two patients randomly assigned in the autologous SCT arm did not (one early relapse and one matched unrelated donor allogeneic SCT).

Prognostic factors for DFS. In univariate analysis, WBC count less than 30 x 10⁹/L (P < .0001), age younger than 35 years (P = .0001), and early response on day 8 (P = .02) favorably affected DFS in the entire population. These covariates remained of prognostic value in a multivariate model also including phenotype and arm of first randomization. The same analysis was performed in the different risk groups as defined at time of diagnosis (Table 6) .

	DISCUSSION

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Better results in terms of CR may be obtained by using more intensive induction chemotherapy and better supportive care to reduce early deaths.¹⁶ In the LALA-87 trial, overall CR was achieved in 76% of patients (69% after one course of induction chemotherapy) and toxic deaths occurred in 9% of patients.³ Results were significantly improved in the LALA-94 trial in which we did not find any period effect (data not shown). Better results in the LALA-94 trial could be explained by reduced toxicity with fewer infections related to lower doses of corticosteroids¹⁷ and the use of CSF in some centers, and by the introduction of the combination of MTZ with IDaraC, instead of a combination of amsacrine with lower doses of araC as salvage therapy. We confirm here previous reports about the efficacy of intensive- or high-dose araC combined with anthracyclines or other related drugs in salvage therapy.^16,18-21 This type of therapy seems particularly important for the most aggressive ALL. Early intensified treatment may reduce the likelihood of the development of drug resistance, achieve sufficient drug levels in sanctuary sites, and thus increase the proportion of long-term, disease-free survivors.

There is evidence that anthracyclines increase CR when added to other classic components of ALL therapy.²² In our trial, a comparison of DNR and IDA did not show any significant difference, except for an advantage for IDA in terms of DFS in patients receiving only chemotherapy (predominantly patients in the standard-risk group and therefore patients with T-lineage ALL, of whom approximately 75% followed group 1 after CR achievement). A potential weakness is the uncertainty of anthracycline dose equivalence; that is, whether IDA 9 mg/m² on days 1, 2, 3, and 8 is equivalent to DNR 30 mg/m² on days 1, 2, 3, 15, and 16. A potential benefit is further obscured by different postremission strategies. In the chemotherapy-only arm, subgroup analysis suggested a benefit for standard-risk patients. The higher infection rate with IDA may indicate non–dose equivalence of the anthracyclines. Our results tend to confirm that CR is obtained earlier with the use of high-dose anthracyclines and that the optimal timing for anthracycline administration is probably the early phase of the disease.^23,24

The optimal consolidation therapy for adults with ALL in first CR remains unclear. The data for allogeneic SCT are sparse, and few comparative trials exist. Results from retrospective studies suggest a benefit for allogeneic SCT compared with standard chemotherapy. The lack of randomized studies limits our ability to infer a benefit of allogeneic SCT. Trials evaluating allogeneic SCT have uniformly shown higher treatment-related mortality and decreased disease relapse. In some studies, these effects offset one another and neutralize any benefit from allogeneic SCT, resulting in centers favoring a conservative approach and recommending transplantation only for patients younger than 30 years old with high-risk ALL.^25,26 In the LALA-87 trial, we did not find any statistical difference between allogeneic SCT and chemotherapy in the overall analysis. However, when the analysis was retrospectively restricted to high-risk patients,²⁷ survival rates were significantly higher in patients receiving allogeneic SCT.^8,9 This was confirmed prospectively by our present study, although Ph-positive ALL patients were considered apart. To date, no traditionally randomized controlled study has been performed to test the efficacy of allogeneic SCT in ALL. In the absence of true randomization, we must rely on genetic randomization.

Whether or not a sibling is HLA matched depends on the random assortment of genes at fertilization. The intention-to-treat analysis eliminates the time-to-treatment bias. However, there might be confounding factors due to the limitations of genetic randomization. The probability of having an HLA-identical sibling donor depends of the size of the sibship. Consequently, it is not equal for all patients. The physician and/or the patient may influence whether a donor is identified and/or accepted. Trial enrollment or withdrawal may also be influenced by a protocol with genetic randomization. Unfortunately, reports that include a donor analysis do not actually totally comply with the intention-to-treat principle. The allogeneic SCT group generally includes appropriately all patients with a donor, whereas the other two groups only include patients randomly assigned between autologous SCT and chemotherapy, thereby introducing potential biases. It is possible that the inclusion of all no-donor patients would strengthen the evidence in favor of allogeneic SCT. However, the apparent advantage for SCT in some subgroups was diminished by the poor results of chemotherapy, resulting in a disappointingly low DFS overall despite to the risk-adapted strategy employed. Allogeneic SCT appeared definitively of benefit to Ph-positive ALL¹⁴ and t(4;11) ALL.²⁸ This suggests the feasibility of using matched unrelated donor SCT in future clinical trials for those patients without a sibling donor.

Many single-institution studies have evaluated autologous SCT in adults ALL. The best results report a DFS rate of 65%, but follow-up was only 16 months.²⁹ However, the use of autologous SCT in first CR remains controversial and is still an investigational treatment. A major objective of our study was to test the advantage of autologous SCT compared with standard chemotherapy. Autologous SCT did not show superiority over chemotherapy in high-risk ALL patients. However, in the chemotherapy arm, a continuous pattern of relapse beyond the third year was observed. A different pattern of relapse was observed in the autologous SCT arm, with fewer late relapses. These results confirm those reported by our previous trial in the global analysis³ and in a subset analysis including only patients with poor prognostic factors.⁹ However, there were some flaws in both LALA-87 and LALA-94 studies: the number of patients in each arm was small, and some patients allocated to the transplantation group actually did not undergo transplantation. Maintenance chemotherapy for 2 years was theoretically scheduled after transplantation, given that this was postulated to be the reason for less relapses and improved DFS reported in a previous study,³⁰ but was often not given or stopped early because of cytopenia or infections. To evaluate the effect of consolidation by autologous SCT in a larger population of adult ALL patients, we recently performed a study reporting all patients included in one of the last three successive trials from our group.³¹ The results confirmed the absence of superiority of autologous SCT over chemotherapy alone, and the use of autologous SCT in first CR was not advocated because chemotherapy employed may not be optimal with regard to a standard therapy.

Few studies have evaluated comparatively more intensive versus standard therapy over short periods of maintenance. Previous studies, comparing consolidation courses versus regular maintenance, did not find any difference in terms of DFS.^32,33 In our trial, the second randomization for standard-risk patients, comparing an early intensive consolidation with no early intensification, showed no difference between the two arms of randomization. Previous studies also demonstrated the absence of benefit of early intensification, but reported that the early block of intensive treatment reduced the risk of relapse.^2,27

Results in standard-risk ALL (and therefore T-lineage ALL) were disappointing in comparison with the LALA-87 trial,³ suggesting a need for more intensive therapy. Indeed, T-cell phenotype is generally a favorable prognostic factor.^15,27,34,35 Improvements in outcome for T-lineage ALL have been attributed to the introduction of araC, CPM, and/or teniposide in consolidation regimens. In the LALA-87 trial, results in standard-risk ALL were similar for allogeneic SCT and for chemotherapy or autologous SCT. We concluded that allogeneic SCT should only be recommended for high-risk patients in first CR, and we therefore abandoned transplantation for this group of ALL patients in the LALA-94 trial.^8,9 A recent retrospective study showed particularly encouraging results of T-cell lineage ALL after allografting in first CR, with 74% DFS at 3 years.³⁶ The poor outcomes, even among T-cell lineage ALL in LALA-94 with chemotherapy alone, suggest studies examining allografts compared with more intensive chemotherapy regimens, even for favorable subsets, are warranted.

Surprisingly, patients with CNS involvement showed a favorable outcome, with a median DFS of 19.2 months and more than 44% survivors at more than 3 years. Although the presence of blasts in the CSF has been associated with factors of poor outcome,³⁷ and confers a high risk of CNS relapse if not treated intensively,³⁸ large previous series failed to show a significant impact of CNS involvement when treated intensively.^3,27 This appears to be confirmed by our study and brings some justification for intensifying the treatment of this leukemia subtype.

On the basis of the results from the LALA-94 study, we are currently testing a pilot trial in which indications for allogeneic SCT are increased in both non–Ph-positive B-lineage ALL and T-lineage ALL depending on initial prognostic factors and initial response to a prephase of corticosteroids and to initial chemotherapy evaluated on day 8; induction chemotherapy is intensified after day 15 for nonresponding patients; continuation therapy is intensified in nonallografted patients with application of pediatric-like treatment with blocks of intensive chemotherapy and late consolidation; autologous transplantation is withdrawn; and the therapeutic strategy is adapted to the evaluation of minimal residual disease.

	Appendix

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION Appendix Authors’ Disclosures of... REFERENCES

 
The following hospitals participated in the LALA-94 trial: Groupe d’Etude et de Traitement de la Leucémie Aiguë Lymphoblastique de l’Adulte (GET-LALA Group) - Hôpital Edouard Herriot, Lyon; Hôpital Saint-Louis, Paris; Hôpital du Haut Levêque, Pessac; Hôpital Purpan, Toulouse; Hôpital Henri Mondor, Créteil; Hôpital Pitié-Salpétrière, Paris; Institut Paoli Calmettes, Marseille; Hôpital Cochin, Paris; Hôpital de Hautepierre, Strasbourg; Hôpital de l’Archet, Nice; Hôpital Necker, Paris; Hôpital Jean Bernard, Poitiers; Hôpital Michallon, Grenoble; Institut Gustave Roussy, Villejuif; Hôpital du Bocage, Dijon; Hôpital Saint-Antoine, Paris; Centre Hospitalier, Caen; Hôpital Pontchaillou, Rennes; Centre Hospitalier de la Côte Basque, Bayonne; Centre Hospitalier Lyon-Sud, Pierre Bénite; HIA Percy, Clamart; Centre Hospitalier, Chambéry; Hôpital Dupuytren, Limoges; Centre Hospitalier, Avignon; Hôpital Louis Pasteur, Colmar; Centre Henri Becquerel, Rouen; Centre Hospitalier, Lille; Hôtel Dieu, Clermont-Ferrand; Hôpital André Mignot, Versailles; Hôpital Beaujon, Clichy; Centre Hospitalier, Annecy; Centre Hospitalier Lapeyronie, Montpellier; Centre Hospitalier, Aix en Provence; Hôpital Jean Monod, Le Havre; Hôpital Lariboisière, Paris; Hôpital Victor Dupouy, Argenteuil; Centre Hospitalier Dr Schaffner, Lens; Centre Antoine Lacassagne, Nice; Centre Hospitalier, Meaux; Centre Hospitalier, Perpignan; Clinique St Vincent, Lille; Centre Hospitalier, Nîmes; Centre Hospitalier, Roubaix, France. Cliniques St Luc, Bruxelles; Centre Hospitalier Notre Dame et Reine Fabiola, Charleroi; Cliniques de Mont Godinne, Yvoir; ASBL, Loverval; Hôpital Saint Joseph, Gilly; Hôpital de Jolimont, Haine St Paul; Hôpital St Joseph, Mons; Hôpital de la Citadelle, Liège; Laboratoire de Cytogénétique, Leuven, Belgium. Swiss Group for Clinical Cancer Research (SAKK) –Centre Hospitalier Universitaire Vaudois, Lausanne; Kantonsspital, St Gallen; Universitätsspital, Zürich; Hôpital Cantonal Universitaire, Genève; Kantonsspital, Basel; Inselspital, Bern; Kantonsspital, Winterthur; Kantonsspital, Luzern, Switzerland. Australasian Leukemia and Lymphoma Group (ALLG)–Westmead Hospital, Westmead; Adelaide Hospital, Adelaide; Mater Misericordae Hospital, Newcastle; Alfred Hospital, Melbourne; Royal Adelaide Hospital, Adelaide; Peter Mac Callum Cancer Centre Institute, Melbourne; Monash Medical Centre, Melbourne; Liverpool Hospital, Sydney; St George Hospital, Sydney, Australia.

	Authors’ Disclosures of Potential Conflicts of Interest

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION Appendix Authors’ Disclosures of... REFERENCES

 
The authors indicated no potential conflicts of interest.

	NOTES

 
Supported in part by PHRC No. 94-95-97.02, Ministère de l’Emploi et de la Solidarité, France.

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

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TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION Appendix Authors’ Disclosures of... REFERENCES

 
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Submitted October 8, 2003; accepted August 3, 2004.

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