Page 244 - Essential Haematology

230 / Chapter 17 Acute lymphoblastic leukaemia

Induction 100
e.g. vincristine, asparginase, 96±3
Probability of overall survival (%)
dexamethasone (or prednisolone) ± daunorubicin 80 84±2
Consolidation 81±2 74±2
e.g. daunorubicin, cytosine arabinoside, vincristine, 60
etoposide, thioguanine or mercaptopurine,
cyclophosphamide in one to four courses 40 48±2
Possible stem cell
transplantation 20
Cranial prophylaxis
e.g. high dose systemic methotrexate 21±4
or multiple intrathecal methotrexate 0
or cranial irradiation (1800–2400 rad) 0 10 20 30 40
+ intrathecal methotrexate
Years after diagnosis
Studies 1 to 4, 1962–1966
Maintenance therapy Studies 5 to 9, 1967–1979
e.g. mercaptopurine, methotrexate, vincristine, Study 10, 1979–1983
dexamethasone (or prednisolone) Studies 11 and 12, 1984–1991
Studies 13A, 13B and 14, 1991–1999
Study 15, 2000–2010
Late intensification (as consolidation)
(b)
Maintenance therapy as above (2–3 years)
(a)

Figure 17.6 Acute lymphoblastic leukaemia (ALL). (a) Flow chart illustrating typical treatment regimen.

(b) Kaplan – Meier analyses of overall survival in 2628 children with newly diagnosed ALL. (Updated from
Pui C.H. and Evans W.E. (2006) N Engl J Med 354 , 169 .)

Normal BM ALL diagnosis ALL remission

CD10 PE CD10 PE CD10 PE

CD34 PerCP CD38 FITC CD34 PerCP CD38 FITC CD34 PerCP

CD38 FITC
CD19 APC

Figure 17.7 Detection of minimal residual disease (MRD) by four - colour fl ow cytometry in: normal bone marrow

mononuclear cells (BM), BM from a patient with B lineage ALL at diagnosis and in remission 6 weeks after
diagnosis. The cells were detected with four different antibodies (anti - CD10, anti - CD19, anti - CD34, anti - CD38)
attached to fl uorescent labels abbreviated as PE, APC, PerCP and FITC, respectively. The tridimensional plot
+
shows the immunophenotype of CD19 lymphoid cells in the three samples. MRD of 0.03% of cells expressing
−
+
+
the leukaemia - associated phenotype (CD10 , CD34 , CD38 ) were detected at 6 weeks, confi rmed by polymer-
ase chain reaction (PCR) analysis. (From Campana D. and Coustan - Smith E. (1999) Commun Clin Cytometry
38 , 139 – 52, with permission.)