Improved CNS Control of Childhood Acute Lymphoblastic Leukemia Without Cranial Irradiation: St Jude Total Therapy Study 16

Abstract

Purpose: Despite contemporary treatment, up to 10% of children with acute lymphoblastic leukemia still experience relapse. We evaluated whether a higher dosage of PEG-asparaginase and early intensification of triple intrathecal therapy would improve systemic and CNS control.

Patients and methods: Between 2007 and 2017, 598 consecutive patients age 0 to 18 years received risk-directed chemotherapy without prophylactic cranial irradiation in the St Jude Total Therapy Study 16. Patients were randomly assigned to receive PEG-asparaginase 3,500 U/m² versus the conventional 2,500 U/m². Patients presenting features that were associated with increased risk of CNS relapse received two extra doses of intrathecal therapy during the first 2 weeks of remission induction.

Results: The 5-year event-free survival and overall survival rates for the 598 patients were 88.2% (95% CI, 84.9% to 91.5%) and 94.1% (95% CI, 91.7% to 96.5%), respectively. Cumulative risk of any-isolated or combined-CNS relapse was 1.5% (95% CI, 0.5% to 2.5%). Higher doses of PEG-asparaginase did not affect treatment outcome. T-cell phenotype was the only independent risk factor for any CNS relapse (hazard ratio, 5.15; 95% CI, 1.3 to 20.6; P = . 021). Among 359 patients with features that were associated with increased risk for CNS relapse, the 5-year rate of any CNS relapse was significantly lower than that among 248 patients with the same features treated in the previous Total Therapy Study 15 (1.8% [95% CI, 0.4% to 3.3%] v 5.7% [95% CI, 2.8% to 8.6%]; P = .008). There were no significant differences in the cumulative risk of seizure or infection during induction between patients who did or did not receive the two extra doses of intrathecal treatment.

Conclusion: Higher doses of PEG-asparaginase failed to improve outcome, but additional intrathecal therapy during early induction seemed to contribute to improved CNS control without excessive toxicity for high-risk patients.

Trial registration: ClinicalTrials.gov NCT00274937.

FIG 1.

CONSORT diagram. MRD, minimal residual disease.

FIG 2.

Kaplan-Meier and Kalbfleisch and Prentice analyses of outcomes in children with acute lymphoblastic leukemia. The 5-year and 10-year results are shown on the curves.

FIG 3.

Cumulative risk of (A) any CNS relapse and (B) isolated CNS relapse in the Total Therapy 15 and 16 Studies.

FIG A1.

T1 postcontrast sagittal and coronal images of an 8-month-old girl with KMT2A-rearranged ALL presenting with massive cerebral involvement, scalp lesions and leukocyte count of 31,100/µL. Cytospin on CSF showed 0 RBC/µL and 93 WBC/µL with 99% blasts. Images show an extensive parieto-occipital dural-based tumor involving superior sagittal sinus, bilateral brain parenchyma, and erosion through the skull. Superior sagittal sinus was displaced but not occluded on venogram. There was a smaller scalp lesion (arrow) involving the dura, but not the brain. Lesions resolved completely after 3 months of chemotherapy. She has remained in continuous first remission for 11.3 years.