Assessment of end induction minimal residual disease (MRD) in childhood B precursor acute lymphoblastic leukemia (ALL) to eliminate the need for day 14 marrow examination: A Children’s Oncology Group study.

Pediatric Oncology
Session Type and Session Title: 
Oral Abstract Session, Pediatric Oncology I
Abstract Number: 
J Clin Oncol 31, 2013 (suppl; abstr 10001)
Michael J. Borowitz, Brent L. Wood, Meenakshi Devidas, Mignon L. Loh, Elizabeth A. Raetz, Eric Larsen, Kelly W. Maloney, Andrew J Carroll, Alison M. Friedmann, Julie M Gastier-Foster, Nyla A. Heerema, Leonard A. Mattano, James B. Nachman, Naomi Joan Winick, William L. Carroll, Stephen Hunger; The Johns Hopkins Hospital, Baltimore, MD; University of Washington, Seattle, WA; Children's Oncology Group, Gainesville, FL; University of California, San Francisco, San Francisco, CA; New York University Langone Medical Center, New York, NY; Maine Children's Cancer Program, Scarborough, ME; Children's Hospital Colorado, Aurora, CO; Children's Hospital of Alabama, Birmingham, AL; Massachusetts General Hospital, Boston, MA; Nationwide Children's Hospital, Columbus, OH; The Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, OH; MSU/KCMS, Kalamazoo, MI; The University of Chicago, Chicago, IL; The University of Texas Southwestern Medical Center; Center for Cancer and Blood Disorders, Children's Medical Center Dallas, Dallas, TX; University of Colorado Denver Health Science Center, Aurora, CO

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Abstract Disclosures


Background: Response to initial therapy is a powerful prognostic factor in pediatric ALL. Traditionally, slow early response (SER) has been defined by marrow morphology 8 or 15 days after start of induction therapy. More recently, MRD has been identified as the most important predictor of adverse outcome. The value of morphologic assessment of response in the setting of MRD has not been established. Methods: In COG studies AALL0331 (for NCI Standard Risk (SR) B ALL patients (pts)) and AALL0232 (High Risk (HR) B ALL pts), SER was defined by morphology as either ≥5% blasts in a day 15 marrow, or by flow cytometry as ≥0.1% MRD in a d29 marrow (SER MRD). Assignment to treatment arms also depended upon cytogenetic findings and extramedullary disease; each protocol had randomized treatment questions. SER pts were non-randomly assigned to receive augmented BFM therapy (ABFM) with 2 interim maintenance and delayed intensification phases (and CNS radiation for HR SER pts only). All pt treatment groups were combined for these analyses. Rapid early responders (RER) had a better outcome than SER pts (Table). However, pts who were SER only by morphology had a 5y DFS that was not significantly different from that of RER pts, and superior to that of pts who were SER MRD, or SER by both morphology and MRD. In multivariate analysis, SER by morphology was not an adverse prognostic factor after adjusting for risk group and MRD, or separately in SR or HR pts after adjusting for MRD. However, pts with .01-.1% MRD who were SER by morphology had a better 5y DFS than the.01-.1% MRD pts who were RER (90±6%, n=91 vs 77±3%, n=592). Only the former group received ABFM, suggesting intensification based on response rescues some poor risk pts. We conclude that a day 15 marrow is not needed to assess response if MRD is measured at end induction, provided that SER MRD is defined using a .01% cutoff, the threshold for intensifying therapy in current COG ALL trials. Clinical trial information: NCT00103285, NCT00075725.

Pt group N 5 y DFS P value vs RER
RER 6419 89±1% --
SER all 1011 79±2% <.0001
SER by morphology only 339 91±3% .48
SER MRD only 485 72±4% <.0001
SER by morphology and MRD 187 77±6% <.0001