How is the survival of children after Salvage with Chemotherapy in ALL with isolated early CNS relapse ? Is HSCT mandatory ? What are the options ?
In general treatment of isolated CNS relapse in children is based on intensive reinduction chemotherapy with intensified intrathecal therapy and CNS radiation. Whether allogeneic SCT is of benefit is still an open question. In the European relapse study children with relapse within 18 months from initial diagnosis are recommended SCT whereas the others mostly receive intensive consolidation therapy followed by maintenance.
A survival rate of 40 to 60% can be achieved by this approach although the prognosis can be worse in very early and/or T ALL relapses.
Dear Doctor,
Thank you for the reply. Are you aware of any RCTs comparing these two options? A POG study published in JCO 2006 by Barredo et al have explored the role of reduced dose Cranial RT in treatment of children with isolated CNS relapse, along with chemotherapy.They concluded that salvage is possible with lower dose CRT (18Gy) especially in children with CR1 > 18 months. May be as you have mentioned, HSCT may be an option for children in CR1
The European intreall trial in relapsed ALL recommends 18 Gy but recognizes that the data behind are week. I know of no randomizef study that looks specifically at CNS relapse. I think it would be difficult to get the patient numbers
@Abrahamsson - When you treat outside a trial and in resource limited settings where HSCT options are limited, a retrospective analysis may help to find enough cases salvaged with high dose chemotherapy rather than a HSCT.
It is true that many groups now try to reduce the use of XRT in frontline ALL therapy. Our Nordic ALL protocol does not give RT to any child during primary therapy. However in CNS relapse I do not know any protocol that does not include RT.
It is interesting to note that none of the patients with ALL receive CRT during primary therapy in Nordic Protocols. Are there any prior studies to support this rationale? What we follow is the BFM approach where we give 12 Gy pre-symptomatic CRT for CNS 1/2 status and 18Gy therapeutic CRT for CNS 3 status in addition to the HDMTx chemotherapy. How are the CNS relapse rates in the Nordic trials after completely avoiding CRT?
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