Measurement of Residual Leukemia during Remission in Childhood Acute Lymphoblastic Leukemia

William Mark Roberts, M.D., Zeev Estrov, M.D., Maia V. Ouspenskaia, M.S., Dennis A. Johnston, Ph.D.,
Kenneth L. McClain, M.D., Ph.D., and Theodore F. Zipf, Ph.D., M.D.

N Engl J Med 1997; 336:317-323January

Hematologic remission in acute lymphoblastic leukemia (ALL) is defined as fewer than 5 percent
lymphoblasts in a light-microscopical examination of the bone marrow. However, in patients
cured of childhood ALL, leukemia cells could persist even when no lymphoblasts are visible in
the marrow.
Our data imply that more than 10,000 leukemia cells may persist in a patient who remains in long-term
remission (the approximate equivalent for the threshold of PCR positivity)21 and that the cure of ALL
may not require the elimination of all leukemia cells. (LOE 2b)

Review article Acute Lymphoblastic Leukemia (NEJM)

The current rate of cure of nearly 80 percent in children attests to remarkable progress in the
development of effective treatments for resistant subtypes of the disease.1B

With improvements in chemotherapy and supportive care, the rate of complete remission now ranges
from 97 to 99 percent in children 1B

Nonetheless, attempts are being made to intensify induction therapy, especially for patients with
standard-risk or high-risk disease, on the premise that more rapid and complete reduction of the
leukemic-cell burden may forestall drug resistance in leukemic cells, leading to improvements in long-
term outcome. Indeed, intensive induction regimens with four or more drugs have been credited with
improving outcomes in several trials in children.1B