Chemotherapy

Chemotherapy is the main treatment for ALL. The phases of treatment include the following:

Induction Therapy

The first phase of chemotherapy is called “induction therapy.” Induction therapy

  • Includes a multi-drug regimen based on the patient’s age, subtype and overall health. Drugs used in induction therapy can include
    • Vincristine
    • Pegaspargase
    • Dexamethasone or prednisone
    • Daunorubicin or doxorubicin (high-risk groups)
  • Lasts 4 weeks
  • Includes staying at the hospital
  • Has a goal of remission, meaning that leukemia cells are no longer found in bone marrow samples and blood counts are normal

Children with Philadelphia chromosome-positive (Ph+) ALL are also given additional medications.

Over 95 percent of children achieve a remission at the end of induction therapy. However, remission does not mean that your child is cured. Your child still needs more treatment to ensure that the disease does not come back (relapse).

Minimal Residual Disease (MRD). Even when a complete remission is achieved, some leukemia cells that cannot be seen with a microscope may remain in the body. The presence of these cells is referred to as minimal/measurable residual disease (MRD). Patients who have achieved remission after initial treatment but have MRD are at increased risk of disease relapse. Testing for MRD can help your child’s doctor re-evaluate your child’s ALL risk category and determine whether your child may benefit from further intensified therapies.

If your child is in remission but tests positive for MRD, the doctor may prescribe a drug called blinatumomab (Blincyto®).

Central Nervous System (CNS)-Directed Therapy. Childhood regimens for ALL typically include treatment to stop the spread of leukemia cells to the central nervous system which includes the brain and spinal cord. CNS-directed therapy is given throughout the entire course of treatment.

Central nervous system-directed therapy may include:

  • Intrathecal chemotherapy, in which anti-cancer drugs are injected into the fluid-filled space between the thin layers of tissue that cover the brain and spinal cord.
  • High-dose systemic chemotherapy, in which anti-cancer drugs are injected into a vein and travel through the blood to cells throughout the body.
  • Radiation therapy to the brain
    • Cranial radiation is no longer routinely used in children with ALL, except in those with leukemia cells in their cerebrospinal fluid at the time of diagnosis or those with CNS relapse.

For information about the drugs listed on this page, visit Drug Listings.

 

Consolidation Therapy

Consolidation (intensification) therapy begins after induction therapy. Consolidation therapy

  • Involves higher doses of chemotherapy than those used during the induction phase. Drugs used in the consolidation phase can include:
    • Cytarabine
    • Vincristine
    • 6-mercaptopurine (6-MP)
    • Cyclophosphamide
    • Pegaspargase
  • Lasts 4-8 weeks
  • Does not usually require a hospital stay, but children may be admitted for complications, such as fever and infections
  • Has the goal of killing any remaining leukemia cells in the body that could cause a relapse 

For children who are MRD-positive after induction, blinatumomab (Blincyto®) may be recommended. Blinatumomab is a liquid administered slowly into a vein by IV as a continuous infusion over a period of 28 days for each cycle. 

As part of consolidation, some children in remission may receive an allogeneic stem cell transplant. Doctors usually recommend allogeneic stem cell transplantation for children who have a particularly high risk of relapse due to high-risk genetic features or for children who have very high levels of MRD after induction and/or consolidation.

Interim Maintenance

After consolidation therapy, there is a recovery period called “interim maintenance.” Interim Maintenance

  • Involves chemotherapy that does not cause decreased blood cell counts
  • Usually includes methotrexate combined with other chemotherapy agents
  • May be given in an outpatient clinic or may require a short hospital stay
  • Has the goal of maintaining remission and allowing bone marrow to recover from effects of therapy

Delayed Intensification

The phase referred to as “delayed intensification”

  • Involves chemotherapy combinations that may include
    • Vincristine
    • Dexamethasone
    • Pegaspargase
    • Doxorubicin
    • 6-mercaptopurine
    • Cyclophosphamide
    • Cytarabine
  • Lasts about 8 weeks
  • Usually does not require a hospital stay, but children may be admitted for complications, such as fever and infections
  • Has the goal of eliminating residual, drug-resistant leukemia cells from the body

Maintenance

The final phase of treatment is called “maintenance.” Maintenance

  • Regimens include
    • Oral 6-mercaptopurine
    • Oral methotrexate
    • Vincristine and prednisone or dexamethasone
    • CNS-directed chemotherapy
  • Lasts 2 years from the start of interim maintenance 
  • Includes medications that are taken orally at home and tend to cause less-severe side effects
  • Has the goal of preventing disease relapse

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