1. ¹Department of Pediatrics, Children's Hospital of Michigan and Wayne State University, Detroit, MI, USA
2. ²Department of Statistics, University of Florida, Gainesville, FL, USA
3. ³Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
4. ⁴Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
5. ⁵Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
6. ⁶Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
7. ⁷Department of Pediatrics, Midwest Children's Hospital and Medical College of Wisconsin, Milwaukee, WI, USA
8. ⁸Department of Genetics, University of Alabama, Birmingham, AL, USA
9. ⁹Department of Pathology, St Jude Children's Hospital, Memphis, TN, USA
10. ¹⁰Division of Pediatric Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA

Correspondence: Dr Y Ravindranath, Georgie Ginopolis Chair for Pediatric Cancer and Hematology, Wayne State University School of Medicine, Children's Hospital of Michigan-2M34, 3901 Beaubien Boulevard, Detroit, MI 48201, USA. Fax: +313 745 5237; E-mail: ravi@med.wayne.edu

Received 8 February 2005; Accepted 14 April 2005; Published online 1 September 2005.

Abstract

From 1981 to 2000, a total of 1823 children with acute myeloid leukemia (AML) enrolled on four consecutive Pediatric Oncology Group (POG) clinical trials. POG 8101 demonstrated that the induction rate associated with the 3+7+7 combination of daunorubicin, Ara-C, and 6-thioguanine (DAT) was greater than that associated with an induction regimen used to treat acute lymphoblastic leukemia (82 vs 61%; P=0.02). Designed as a pilot study to determine the feasibility of administration of noncross-resistant drug pairs and later modified to assess the effect of dose intensification of Ara-C during the second induction course, POG 8498 confirmed the high initial rate of response to DAT (84.2%) and showed that dose intensification of Ara-C during the second induction course resulted in a trend toward higher event-free survival (EFS) estimates than did standard-dose DAT (2+5) during the second induction course (5 year EFS estimates, 22 vs 27%; P=0.33). Age <2 years and leukocyte count <100 000/mm³ emerged as significantly good prognostic factors. The most significant observation made in the POG 8498 study was the markedly superior outcome of children with Down's syndrome who were treated on the high-dose Ara-C regimen. POG 8821 compared the efficacy of autologous bone marrow transplantation (BMT) with that of intensive consolidation chemotherapy. Intent-to-treat analysis revealed similar 5-year EFS estimates for the group that underwent autologous BMT (364.7%) and for the group that received only intensive chemotherapy (354.5%) (P=0.25). There was a high rate of treatment-related mortality in the autologous transplantation group. The study demonstrated superior results of allogeneic BMT for patients with histocompatible related donors (5-year EFS estimate 635.4%) and of children with Down's syndrome (5-year EFS estimate, 668.6%). The POG 9421 AML study evaluated high-dose Ara-C as part of the first induction course and the use of the multidrug resistance modulator cyclosporine. Preliminary results showed that patients receiving both high-dose Ara-C for remission induction and the MDR modulator for consolidation had a superior outcome (5-year EFS estimate, 428.2%) than did patients receiving other treatment; however, the difference was not statistically significant. These four studies demonstrate the importance of dose intensification of Ara-C in the treatment of childhood AML; cytogenetics as the single most prognostic factor and the unique curability of AML in children with Down's syndrome.