Acute lymphoblastic leukemia:
Patients are treated according to modified St. Jude total
XV7 protocol. We propose:
1-Giving granulocyte colony stimulating factors (GCSFs) during induction
chemotherapy if BMA at D19 is in complete remission and after induction
chemotherapy before consolidation.
2-Delaying consolidation and giving weekly methotrexate (MTX)/
6-mercaptopurine (MP) for 2 weeks as interim continuation if BMA at the
end of induction is MRD negative
3-During consolidation, reduction of the 6 MP dose by 50% with close
assessment of total leucocytic counts.
4- During continuation: for low risk patients, omitting vincristine
(VCR)/dexamethasone (DEX) pulses and use only MTX/ 6MP in the addition
to re-induction weeks and for high risk patients, no change
L-asparaginase and reinduction weeks, omitting weeks of
cyclophosphamide/cytarabine and use MTX/6MP alternating with VCR/DEX.
These modifications are based on randomized controlled study by Felice
et al8. Felice et al., performed a randomized controlled study comparing between continuation regimens consisting of MTX/6MP or rotating pairs of drugs in low risk ALL patients and continuation regimens consisting of MTX/6MP alternating with VCR/DEX or rotating pairs of drugs for SR/HR ALL patients. They found no statistically significant difference in outcome between arms of maintenance for both risk groups. They also found that rotating drug pairs regimen was associated with significantly more febrile neutropenia episodes and prolonged hospitalization . These modifications allow less clinical visits to hospital by extended dispensing of continuation chemotherapy