The more uniform approach to risk-based treatment assignment and to collection of specific prognostic factors should increase the efficiency of future ALL clinical research.

The goal of this prospective randomized clinical trial was to compare 2 cohorts of standardized cleft patients with regard to functional speech outcome and the presence or absence of palatal fistulae. The 2 cohorts are randomized to undergo either a conventional von Langenbeck repair with intravelar velarplasty or the double-opposing Z-plasty Furlow procedure. A prospective 2 × 2 × 2 factorial clinical trial was used in which each subject was randomly assigned to 1 of 8 different groups: 1 of 2 different lip repairs (Spina vs. Millard), 1 of 2 different palatal repair (von Langenbeck vs. Furlow), and 1 of 2 different ages at time of palatal surgery (9-12 months vs. 15-18 months). All surgeries were performed by the same 4 surgeons. A cul-de-sac test of hypernasality and a mirror test of nasal air emission were selected as primary outcome measures for velopharyngeal function. Both a surgeon and speech pathologist examined patients for the presence of palatal fistulae. In this study, the Furlow double-opposing Z-palatoplasty resulted in significantly better velopharyngeal function for speech than the von Langenbeck procedure as determined by the perceptual cul-de-sac test of hypernasality. Fistula occurrence was significantly higher for the Furlow procedure than for the von Langenbeck. Fistulas were more likely to occur in patients with wider clefts and when relaxing incisions were not used.

Intensification with repeated i.v. MTX in the setting of low-dose LCV rescue was associated with a higher risk for acute NT and LE, especially in patients who received concomitant TIT. The long-term consequences for affected patients remain unknown.

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Children with Down syndrome and ALL had a low frequency of adverse clinicobiologic features at diagnosis. However, these findings did not translate into a superior outcome, apparently because of treatment-related toxicity in this group. Future trials should focus on pharmacokinetics and other strategies to reduce toxicity in these compromised patients.

Use of the DNA index, leukocyte count, and age--data that are relatively inexpensive and simple to obtain--may be sufficient to stratify patients with B-progenitor cell ALL for risk-directed therapy. Patients at an extremely low risk of failing therapy (approximately 20% of cases in this study) can thus be identified and spared the toxic short-term and late effects of more intensive therapies that may be needed for children with less favorable clinical and biologic features.

This study shows an outcome interaction among sex, time, and commonly used prognostic variables. The important sex difference observed at 2 and 5 years suggests that more intensive consolidation and/or maintenance therapy in some boys with B-precursor ALL should be investigated.

Cytogenetic and DNA flow cytometric analyses of leukemic cells from 2,184 children with newly diagnosed acute lymphoblastic leukemia (ALL) identified 27 cases (1.2%) that had a hypodiploid line with fewer than 45 chromosomes per cell. Had cytogenetic techniques been used alone, seven cases would have been missed, compared with five if only flow cytometry had been used. For comparative purposes, the 27 cases were divided into three groups: near-haploid (n = 10), hypodiploid 30–40 (n = 9), and hypodiploid 41–44 (n = 8). Blast cells from patients with near-haploid ALL lacked structural chromosomal abnormalities; showed nonrandom retention of two copies of chromosomes 8, 10, 14, 18, 21, and the sex chromosomes; and had a second leukemic line with exactly twice the number of chromosomes or DNA content. Karyotypic analysis of the hypodiploid 30–40 and hypodiploid 41–44 groups disclosed structural abnormalities in the stemline or sideline of most of the well-banded cases; those in the latter group were similar to findings in cases with 45 chromosomes. As in the near-haploid group, chromosome 21 and the sex chromosomes were preferentially retained in the hypodiploid 30–40 and 41–44 cases. Except for a slight excess of female patients in the near- haploid group and an older age at diagnosis in the hypodiploid 30–40 cases, there were no initial clinical features that distinguished these patients from the general ALL population. Despite intensive treatment and short follow-up, 17 of the 27 patients have relapsed. This study suggests that the poor treatment responsiveness of hypodiploid ALL is not limited to the more than 80% of the patients who have 45 chromosomes per leukemic cell and demonstrates that cytogenetic and flow cytometric analyses are complementary in the evaluation of children with ALL.