Implementation of an intensive risk‐stratified treatment protocol for children and adolescents with acute lymphoblastic leukemia in Lebanon

Abstract

With modern risk-adapted therapy, over 80% of children with acute lymphoblastic leukemia (ALL) in highincome countries (HICs) are cured. In countries with limited resources, however, therapy results for pediatric ALL are still not encouraging. We describe our experience in treating children with ALL using a risk-adapted protocol at a tertiary referral center in Lebanon. From May 2002 to August 2009, 111 consecutive patients 1-21 years of age with newly diagnosed ALL received the CCCL ALL protocol which was based on the St. Jude Children's Research Hospital Total XV Study. The median age at diagnosis was 5 years 5 months. The male to female ratio was 1.5. Forty-six patients received the intermediate-/high-risk arm and 65 received the low-risk arm. Only one patient (0.9%) died during induction therapy. Relapse occurred in 8 (7.2%) patients. Eight (7.2%) patients died, 4 of whom were in remission. The median follow-up of the patients was 38 months. The 5-year overall survival and event-free survival were and 88.5% (95% CI: 77.1-94.4) and 78.7% (95% CI: 69.8-88.4), respectively. Our results are comparable to those in HICs in spite of the limited resources and the relatively low socioeconomic status of the Lebanese population. Children treated on this protocol experienced significant toxicity necessitating expert supportive care, but benefited from improved cure rates and prolonged survival. Am. J. Hematol. 87:678-683, 2012. V

Acute lymphoblastic leukemia in low and middle-income countries

“…This was evident in case studies from Brazil, Lebanon and central America. After the establishment of a specialized pediatric oncology center within the same medical center, these results improved to 92.3 and 82.3%, respectively [12]. This unit ensured proper training of and coverage by nurses and physicians, support for families through a nongovernmental organization and the implementation of a uniform treatment protocol.…”

“…TRM in this study was 9.3%, which is significantly higher than the 1-2% reported in HIC. In Lebanon and Jordan, adoption of the St. Jude total XV and XIII protocols led to a significant improvement in survival with low death rates of 1% during induction and 2% during maintenance [12,13]. This trend improved over time but TRM during induction remained around 5%.…”

“…More importantly, there was a significant TRM during maintenance that is a very rare occurrence in HIC. These complications were associated with significant morbidity and their treatment required expertise and resources [12,32]. Infections were the main cause of death during maintenance whereas bleeding and other toxicities were more common during induction.…”

“…The situation, however, is different in resource-poor and middle-income countries (MIC) where 70% of all children live and where four out of five cases of ALL occur today. Concomitantly, studies have been published demonstrating improved survival in LIC and MIC using risk-adapted protocols, more sophisticated risk stratification techniques and protocols adapted to local conditions [12][13][14][15]. Differences between countries are striking as even in MIC that have enough resources to join a sophisticated intercontinental (iBFM) trial, the results remained worse than those observed in the HIC participating in the original BFM trial [11 the work done in the developed countries has shown that the majority of children with ALL can be cured with relatively nonintensive treatment protocols, if their risk status can be accurately determined [1,2 && ,3].…”

Skeletal Manifestations of Acute Lymphoblastic Leukemia in Two Pediatric Cases

“…For example, bone pain, limping, arthritis, osteomyelitis, transient synovitis, and fractures may all present. This can be considered a diagnostic difficulty when both clinical presentations and abnormal radiographic findings are not traditional characteristics of leukemia patients [3]. Acute Lymphoblastic Leukemia (ALL) has a high rate of survival (92+/-7%) if detected early [4].…”