GENERAL MOTORS CANCER RESEARCH FOUNDATION PRIZES
CHARLES F. KETTERING PRIZE
Acute Leukemia in Children
Model for the Development of Scientific
Methodology for Clinical Therapeutic
Research in Cancer
EMlL FREl 111
P RIOR TO 1947, the median survival from diagnosis
for children with acute lymphocytic leukemia was
2 months. In 1947 Farber and associates, noting the im-
portance of the vitamin folic acid to normal leukocyte
production, administered the antimetabolite of folic acid,
aminopterin, to children with acute leukemia and ob-
served dramatic evidence of clinical and hematologic im-
’
provement. Recognizing the importance of nucleic acid
synthesis to cell turnover, Elion and Hitching synthesized
base analogs and observed that thiopurines were active
in leukemia-bearing mice,’ and Burchenal and coworkers
demonstrated that 6-mercaptopurine was effective in the
treatment of acute leukemia in humans in 1952.3With
the observation that the corticosteroids were lympho-
cytotoxic, cortisone and ACTH were evaluated in children
with acute leukemia (ALL) independently by Pearson
and Farber and found to be capable of producing transient
In 1955, Emil J. Freireich and I decided to perform
therapeutic research in cancer, and specifically in patients
with acute leukemia, for reasons which included the fol-
lowing. Our chief, Dr. C. Gordon Zubrod, came to the
National Cancer Institute (NCI) in 1954 with an absolute
faith that, given the appropriate resources and scientific
talent, both clinical and basic progress could be achieved
in the chemotherapy of cancer. His scientific and ad-
ministrative leadership inspired, guided, and permitted
much of what follows. Some “tools” for the treatment
of acute leukemia, the above-mentioned antitumor agents,
had already been fashioned. Dr. Zubrod, with Dr. James
Holland, who played a major role in what follows, had
already initiated a program in acute leukemia at the Na-
tional Cancer Institute. Experimental in vivo leukemia
models were being intensively studied by several of our
basic science colleagues and subsequent collaborators at
Presented at the 1983 General Motors Cancer Research Foundation
Prizewinners Laureates Lectures, Jack Masur Auditorium, National In-
stitutes of Health, Bethesda, Maryland, June 14, 1983.
2013
the National Cancer Institute. Finally, acute leukemia
had several favorable characteristics, such as easy acqui-
sition of the neoplastic cells from the blood and marrow
for study.
The Scientific Clinical Trial
Many of the therapeutic and other observations with
respect to clinical cancer prior to 1955 were qualitative.
Quantitative studies of the impact of chemotherapeutic
agents on the biology of the disease and response to che-
motherapy were lacking. An essential first step was to
apply quantitative (scientific)methodology to the clinical
trial. Thus in the first study, initiated in 1955, some of
the principles of the controlled clinical trial were devel-
oped, adapted, and applied for the first time to c a n ~ e r . ~
A prospective therapeutic design was constructed, which
included criteria for selection of patients, a quantitative
definition of response to treatment, randomization with-
in stratified subgroups, and other biostatistical method-
010gy.~~~
Complete Remission: Significance
Response to treatment and particularly complete re-
mission was defined in quantitative terms. The central
feature of this definition related to the bone marrow, the
major site of leukemic involvement. Prior to treatment
the cellularity of the bone marrow in patients with ALL
is usually loo%, and over 90% of the cells are leukemic.
With complete remission, recognizable leukemic cells
must no longer be identifiable by microscopy in the mar-
row, and direct and indirect evidence for leukemic infil-
tration in other organs must di~appear.~ Concurrently,
or immediately following this, normal myeloid function
must be re-established, as evidenced morphologically in
the marrow and in the peripheral blood. Utilizing these
criteria, it was found that only a minority of patients
entered complete remission when the above agents were
employed individually.
2014 CANCERMay 15 1984
DAIS
FIG. I . Influence of remission on duration of survival in patients with
ALL. (A) From start of combined therapy to death in patients achieving
antimetabolite remissions. (€3) From start of combined therapy to death
in patients who did not achieve remission. (C) From relapse to death
in patients who achieved antimetabolite remissions. (Reprinted with
permission from: Holland JF. Breaking the cure barrier: Karnofsky Me-
morial Lecture. J Clin Oncol 1983; 1:75.)
In the quantitative study started in 1955, it was observed
that the overwhelmingly most powerful discriminant for
improved survival was the attainment of a complete re-
mission (Fig. 1). Patients who did not respond had a
median survival of 3 months (comparable to that achieved
prior to 1947), patients who achieved partial remissions
did a little better, but patients who achieved complete
remission had median survivals of 10 months (Fig. 1).
The time from relapse to death in patients achieving re-
mission was comparable to that from start of treatment
to death in patients who did not respond, indicating that
the improvement in survival was due to time spent in
complete remission.6 However, in the study presented in
Figure 1, only 15% of patients entered complete remission.
It was subsequently demonstrated that cytogenetic mark-
ers of neoplastic cells, present in approximately 60% of
patients prior to treatment, disappeared when patients
entered complete remission.7s8Thus, instead of the
“pseudo-remissions’’ of chronic myelogenous leukemia,
where the marrow in remission maintains the neoplastic
marker,’ the remissions in ALL were real and represented
a 99% or greater reduction in the leukemia burden. It
has become a principle of chemotherapy for cancer, gen-
MTX@’*)___ -+ 6.Mp‘z”’
R/
/4
ALL (pediatric) ~
R + MTXI”%l
\\
’ ___
l 6 -
6-Mp‘28X’
M P + MTX‘‘rr) __-
FIG.2. Acute lymphocytic leukemia (ALL). First quantitative ex-
+
perimental design for combination chemotherapy. ( ): Complete re-
sponse rate: MTX: methotrexate; 6-MP 6-mercaptopurine.
VOl. 53
erally, that to impact on the disease significantly in terms
of survival, one must first achieve a complete remission.
The logical next step, therefore, was to increase the com-
plete remission rate.
Improving the Complete Remission Rate:
Combination Chemotherapy
Our first attempts to improve the complete remission
rate involved combination chemotherapy. The experi-
mental design of a study started in 1958, and conducted
by the Acute Leukemia Group B, is presented in Figure
2.’’ This design has become prototypical for the evaluation
of combinations and sequences of agents. Thus one can
quantitatively assess the effect of the agents individually
and in combination on complete remission rate and du-
ration. One can assess the effect of prior exposure of one
agent on the second in a cross-over design. The relative
merits of sequential versus concurrent combination che-
motherapy can be determined. Finally, the overall effect
of prior treatment on response can be assessed. This study
was based, in part, on the demonstration by Law that
antipurines and methotrexate (MTX) were moderately
synergistic in L1210 mouse leukemia, and that 6-mer-
captopurine-resistant tumors were collaterally sensitive
to MTX, presumably because such tumors could not
’
salvage purines.’ Therefore, in addition to measuring the
initial complete remission rate, the phenomenon of col-
lateral sensitivity was tested, and the capacity of patients
to respond in a cross-over design was determined. It was
found, in terms of the initial complete remission rate,
that the combination was slightly superior, but that still
only a minority of patients achieved complete remission
(Fig. 2). Because for both 6-mercaptopurine (6-MP) and
MTX myelosuppression was dose limiting, it was nec-
essary to decrease the doses of each agent, when used in
combination, to 50% to 60% of that employed for the
agent used alone. It was essential, therefore, to determine
the dose effect, that is, how much of a sacrifice in effec-
tiveness such a dose reduction would render.
Controlled studies of the dose effect were initiated in
patients with Hodgkins and non-Hodgkin’s lymphoma
with MTX and with the alkylating agent thiotepa (Table
I). Patients were randomly allocated to (1) full, or standard
dose; or (2) half of that dose. It was found that there was
a very substantial reduction in toxicity with lower doses
but also that the therapeutic effect was largely lost, with
only a 50% reduction in d ~ s e ’ ~(Table
. ’ ~ 1). Thus com-
bination chemotherapy was much more likely to prove
effective if doses of the individual agents could be main-
tained, a situation made possible where qualitatively dif-
ferent dose-limiting toxicity obtained for the individual
agents. Thus for prednisone and 6-MP, full doses of the
individual agents could be delivered, and a response rate
No. 10 ACUTELEUKEMIA
IN CHILDREN * Frei 2015

of 82% was achieved (Table 2). The vinca alkaloid, vin- TABLE1. Effect of Dose on Tumor Response and Toxicity in
Patients With Hodgkin’s Disease and Lymphosarcoma
cristine, was introduced into the clinic by Dr. Myron
Karon at NCI in 1962 and was found to be highly effective Objective Significant
in producing complete remissions in patients with ALL, response toxicity*
Patients
without producing bone marrow depre~si0n.l~ Therefore Dose (no.) No. % No. %
prednisone and vincristine could be combined at full doses
and would not have to be modified downward because Thiotepat
of the myelosuppression intrinsic to the disease during 0.2 9 1 11 2 22
0.4 22 13 59 12 55
remission induction. An 84% complete remission rate Folic acid antagonists4
was achieved. This was considered to represent synergism, Low dose 16 3 19 3 19
since the complete remission rate observed was greater High dose 30 I5 50 17 68
than that assuming independent drug action (Table 2).12*15 * Decrease in white blood cells to less than 3000 cells/mm’ and decrease
Thus, the essential, initial step in the treatment of in platelets to less than 75,000/mm3.
ALL-complete remission-could be achieved in close f Dose in mgjkgjday X 4, then weekly, all intravenously.
4 Low dose: MTX (methotrexate) 0.075 or DCM (dichlorometho-
to 90% of patients. The insights and science leading to trexate) 0.375 mgjkgjday for 42 days: high dose: MTX 0.15 or DCM
and deriving from the progress in increasingthe complete 0.75 mg/kg/day for 42 days. All folk acid antagonists given orally.
remission rate, as demonstrated in Table 2, had a major
and lasting effect on cancer chemotherapy generally. First
is the pragmatic fact that essentially all highly effective which characterized the onset of the disease in the in-
and curative chemotherapeutic regimens for human can- dividual patient. Subsequently, with increasing pertur-
cer involve combinations of two, and usually three to bation of the disease by treatment, altered relapse patterns
four agents. A major basic science rationale for combi- occurred (see below), Cytogenetic studies indicated that
nation chemotherapy is tumor cell heterogeneity. This is some 60%of patients with ALL had clonal disease initially,
evident from cytokinetic and cytogenetic studies, antigen as evidenced by specific aneuploidy and markers which
expression, hormone receptor expression, and most par- characterized the majority of metaphases. While these
ticularly in terms of variability in response to chemo- disappear during remission, the same abnormality re-
therapeutic agents on the part of tumor stem cells isolated turned with relapse,'^^ indicating that relapse was due to
from a given human tumor.I6 Such heterogeneity implies recurrent disease emerging from a microscopic tumor
multiple targets, and therefore the necessity for multi- burden, and not due to re-induced (new) disease. The
targeted (combination) therapy.” This heterogeneity is generally exponential distribution of the relapse curve
probably the primary basis for the selection of drug-re- was also consistent with this position. Therefore a series
sistant cell lines and, experimentally, such resistance can of hypotheses concerning microscopic disease were de-
be markedly reduced by the use of combination che- veloped and clinical studies were conducted to define and
motherapy. Parenthetically the same problems and ra- control microscopic disease (Fig. 3).
tionale for combined systemic treatment do, or almost The first question was whether, once patients achieved
certainly will, apply to immunotherapy and hormone
therapy. Other rationales for combination chemotherapy
TABLE2. Combination Chemotherapy In Acute Lymphatic
include combined sequential or concurrent attack on bio- Leukemia of Childhood*
chemical pathways; the manipulation of drug transport;
the use of metabolites to rescue normal, and hopefully Complete remission
No. of
not tumor, cells from antimetabolite effect; other a p Agent patients No. % Year started
proaches to metabolic modulation; and cytokinetic ap-
proaches involving cell synchrony and recruitment. The MTX 48 10 21% 1958
6-MP 43 I2 21% 1958
many and developing rationales for combination che- VCR 81 38 47% 1961
motherapy at a basic and clinical level have been re- Pred 72 41 57% 1960
viewed.’* MTX + 6-MP 39 17 45% (42%)f 1958
Pred + 6-MP I54 127 82% (69%) 1961
Pred + VCR 63 53 84%(77%) 1963
Prolonging the Duration of Complete Remission
Data from Leukemia Chemotherapy Group 8.
In spite of the achieving high complete remission rates, ?The figure in parenthesis is the complete remission rate (CRR)
all patients with ALL eventually relapsed, usually within calculated assuming independent drug action: CRRA + = CRRA
a matter of a few months. The nature of relapse was + CRRs ( 100 - CRR,)
100
studied. It usually involved the bone marrow, and was MTX: methotrexate; 6-MP: 6-mercaptopurine; VCR vincristine; Pred:
often associated with symptomatology comparable to that prednisone.
2016
7 Effective
/ 6-MP
VP +CR R
/ MTX dahl
Effect of Schedule VP +CR R
\ MTX 2 timeslwk
Effect of Dose
CR R / Fu'l'
induction
Numerous
studies
Effect of Combinations Best as of
1970
+
A) MTX every wk MP every day
E) A) t CPA
C) Either A) or 8 ) + intermittent VP ("rdnforcemnt')
FIG. 3. Acute lymphocytic leukemia. Treatment during remission
(maintenance treatment): Key clinical trials (R: randomization). *Com-
bined MTX, 6-MP, CPA. CPA: cyclophosphamide; V P vincristine
+ prednisone; MTX: methotrexate; 6-MP mercaptopurine; CR: com-
plete response.
a complete remission, an active agent continued during
remission, would, in fact, prolong the duration of re-
mission. We found that 6-MP was markedly superior to
a placebo in prolonging the duration of complete remis-
sions, and thus was active against microscopic disease
(Fig. 3).19 That study was the first quantitative "adjuvant"
study wherein complete remission was produced, either
by chemotherapy or by surgical removal of the primary,
and systemic treatment employed to control microscopic
disease.
Several quantitative studies conducted in patients in
complete remission indicated that MTX was probably
the best single agent. Experimental studies, particularly
by Dr. Abraham Goldin and associates in transplanted
mouse leukemia, indicated that for many agents, and
particularly for MTX, intermittent treatment was superior
to continuous treatment.20 We were also influenced by
the studies in choriocarcinoma,where intermittent courses
of MTX were curative.2' Accordingly, in the study in-
volving complete remission induction with vincristine
and prednisone, patients, once in complete remission,
were randomly allocated to MTX twice weekly, versus
daily MTX, at doses which produced comparable toxicity
(Fig. 3). The former was significantly superior. Subsequent
studies did not demonstrate a significant dose schedule
effect for cyclophosphamide and 6-MP. The basis for the
superiority of intermittent MTX was thought at the time
to be cytokinetic, but recent studies involving induction
CANCERMay 15 1984 VOl. 53
Duration CR
(median in mo.)
of resistance to MTX in mammalian cells suggest that
resistance can be produced more readily by continuous,
7 as compared to intermittent, exposure.
The dose effect of antitumor agents in lymphoma has
p = 0.01
already been empl-asized. Such has also been demon-
1 .s
strated in two comparative studies of combination che-
4 motherapy in patients with acute lymphocytic leukemia
in remission (Fig. 3).21a*22In the dose study presented in
p = 0.01
Figure 3, the interpretation was complicated by the fre-
9
quency with which meningeal leukemia was responsible
15 for relapse.
p = 0.01
Finally, as with complete remission induction, com-
bination chemotherapy delivered during remission was
6 found to be superior in prolonging the duration of re-
mission. The combination of 6-MP given daily with MTX,
given twice weekly or once weekly, was found to sub-
stantially prolong the duration of systemic remission."
It was observed that the best agents for complete re-
mission induction differed from the agents which were
most effective for treatment during remission. Thus vin-
cristine plus prednisone was the optimal combination of
two agents for complete remission induction, but these
agents continued in remission did not prolong such re-
missions (median, 2-3 months). In contrast, the com-
bination of 6-MP and MTX was not particularly effective
in inducing complete remissions, but when employed
during remission, it did substantially prolong the duration.
This was the first demonstration that sequencing treat-
ment provided improved therapeutic results, presumably
by suppressing the emergence of drug resistant clones.
The superiority of combination chemotherapy in pre-
venting the emergence of drug resistance was found orig-
inally in the study of infectious diseases. For example,
combinations of anti-tuberculous agents are superior to
single agents in terms of markedly delaying or preventing
the emergence of drug-resistant tubercule bacilli.23
A number of additional approaches, including rota-
tional chemotherapy, intermittent "reinforcement" of
antimetabolite chemotherapy by vincristine and pred-
nisone, and the sequencing of multiple drugs, were em-
ployed in an effort to further prolong remission^^^-^'
(Fig. 3).
However, while the application of optimal dose, sched-
ule and combination chemotherapy strategiessignificantly
prolonged the duration of complete remission (the control
of systemic microscopic disease), another obstacle to cure
was emerging.
Meningeal Leukemia
Meningeal leukemia was a rare event prior to 1955,
but as the proportion of patients entering complete re-
mission increased substantially and the duration of sys-
temic complete remission lengthened, the incidence of
No. 10 ACUTE LEUKEMIA
IN CHILDREN
meningeal leukemia as the initial manifestation of relapse
increased to the point where it occurred in 50% to 60%
of the patients.27aMeningeal leukemia consists of sheets
of leukemic cells lining the meninges of the central ner-
vous system, impeding egress of spinal fluid and thus
increasing intracranial pressure, with resultant headaches,
changes in vital signs, and cranial nerve palsies. This
occurred at a time when the patient was systemically in
complete remission, as evidenced by a normal bone mar-
row. It could be proven, unequivocally, by the demon-
stration of leukemia cells within spinal fluid obtained by
lumbar puncture. At about this time, Drs. Rall and as-
sociates demonstrated in pharmacologic studies that many
of the anti-leukemic agents were largely excluded from
the central nervous system; that is, they did not pass the
blood-brain barrier.28Methotrexate injected intrathecally
had been demonstrated to be effective in decreasing pleo-
cytosis, cerebrospinal fluid pressure, and in improving
symptoms in such patients, for a relatively brief period
of time.29Clinically evident meningeal leukemia was usu-
ally followed shortly by systemic relapse, suggesting that
drug-resistant clones, selected in low drug concentrations
in the central nervous system and capable of adapting to
higher concentrations in the systemic circulation, were
responsible for the sequence from meningeal to systemic
relapse.
An elegant experimental model of meningeal leukemia
in the mouse was developed, and provided supporting
evidence to its pathogenesis and treatment.29aThis was
as follows: Early in the development of the leukemia
process before treatment is initiated, microscopic in-
volvement of the central nervous system has occurred in
the majority of patients. With the exhibition of systemic
treatment, the systemic leukemia burden is controlled
and the patient enters complete remission. However, the
microscopic burden in the central nervous system is in
a pharmacologic sanctuary and progresses to the point
where eventually the clinical syndrome of meningeal leu-
kemia emerges. This is consistent with the fact that the
risk of developing meningeal leukemia increases linearly
with time spent in complete remi~sion.~’
This suggested that therapeutic approaches conducted
early in complete remission designed to eradicate micro-
scopic leukemic involvement of the central nervous sys-
tem would decrease the risk of development of overt
meningeal leukemia. In a quantitative study, it was dem-
onstrated that intrathecal MTX, given early in complete
remission, significantly decreased the risk of meningeal
le~kemia.~’ However, pharmacologic studies in primates
demonstrated that the lumbar intrathecal administration
of drugs, while providing good concentrations over the
lower reaches of the central nervous system, failed in
many instances to achieve cytotoxic concentrations over
the cerebral hemi~pheres.’~ Accordingly, in a series of
- Frei 2017
elegant studies at St. Jude Children’s Cancer Research
Hospital by Aur and associates and Pinkel, it was dem-
onstrated that brain irradiation at relatively low doses,
combined with lumbar intrathecal MTX, reduced the
incidence of meningeal acute leukemia to less than 10%!3-35
The Curative Treatment of
Acute Lymphocytic Leukemia
The above sequence of studies, as well as the following
cytokinetic modeling, suggested that the cure of ALL in
children might be within reach, and the first prospectively
designed curative intent studies were undertaken. The
first of these was the VAMP program, introduced in
1961 .12936The four-drug combination involved vincristine
and prednisone, given at full doses, with amethopterin
(MTX) and 6-meraptopurine. Each course lasted 10days;
there was a 2-week interruption; and a total of 5 courses
were given. Improved supportive care in the form of
platelet transfusions, antibiotics, and granulocyte trans-
fusions was employed. The VAMP program incorporated
and extended many of the previously mentioned strat-
egies, including maintenance of the steep individual drug
dose effect; moving the combination of a sequence of two
and two to the concurrent use of four agents (intensive
combined “up-front” therapy) in an attempt to maximize
the rate of cytoreduction and to minimize the potential
for the emergence of drug resistant cells; and a sufficient
interval between courses to allow for host recovery. Vari-
ations on this theme included the same agents given in
sequential rather than concurrent combination and longer
durations of treatment (BIKE and POMP program^)."^
Of the 66 patients treated with these regimens, 4 were
cured. 12,36-37a
The impact of these trials and the previously mentioned
strategic principles on cancer chemotherapy generally was
major (see below). However, the failure to include central
nervous system (CNS) prophylaxis (not critical for the
treatment of Hodgkin’s disease, for example, but essential
for the treatment of ALL) limited the cure rate of the
VAMP and related programs. However, the optimal use
of the above three principles-complete remission in-
duction with vincristine and prednisone; CNS prophy-
laxis, with intrathecal MTX and cranial irradiation; and
treatment during complete remission with intermittent
MTX and daily 6-MP-led to cure rates approaching
40%. This was demonstrated most convincingly initially
, ~ ~ et ul.33v34at St. Jude, by Holland and
by P i r ~ k e lAur
the Cancer and Leukemia Group B,27 and by Clarkson
and his associates at Memorial Sloan-Kettering. While
there have been a number of tactical variations and finally
improvements on this theme, the essential strategy re-
mains intact. Progress in curative treatment is presented
in Figures 4 and 5 .
2018 CANCERMay IS 1984 VOl. 53

1983 such patients.4043 The same or a slightly modified pro-

gram was also curative for patients with diffuse histiocytic
DFCl 1981 (n=128) lymph0ma.4~The CMFV program (cyclophosphamide,
BFM 1976 (n=158) MTX, 5-fluorouracil, and vincristine) was introduced at
NCI in 1963, found to be active in breast cancer, but like
St. Jude 1970 (n.76)
t-----. the "lost colony," was not pursued after 1965 and was
n I- DFCl 1973 (n.129)
2 .4 reported belatedly by the Eastern Cooperative Oncology

-
n
Group in 1972.44aThe vincristine, actinomycin D, cy-

\
.2
Tivey 1954 (n.218) clophosphamide (VAC) programs have proven curative
of! 2 3 4 5 6 '10 II 12 for children with solid tumors, particularly in a multi-
Years disciplinary ~etting.4~ All three agents are active, and one
FIG.4. Acute lymphocytic leukemia. Improved survival as indicated is nonmyelosuppressive. The cisplatin, bleomycin, and
by selected studies. The date indicates the time the study was started. vinblastine program, which has revolutionized the treat-
Taken from references 35, 68, 70, 72. ment of testicular cancer,46 is based on the previously
mentioned principles, as is the more recent development
Acute Lymphocytic Leukemia: The Stalking Horse of highly effective therapy for a common epithelial tumor,
squamous cell carcinoma of the head and neck.47
The development of the above scientific strategies and
tactics for the curative treatment of ALL suggested that, Cytokinetic Models: Experimental
given the tools (e.g.,three to four active agents) for other
neoplastic diseases, curative treatment might be possible; Application to ALL
and indeed, subsequent experience has proved this to be In the early 1960s, Dr. Howard E. Skipper and his
the case. associates initiated a series of studies addressed to the
By 1963, four active agents for Hodgkin's disease had quantitative biology of leukemia in mice and its pertur-
been identified: mustargen, Oncovin (vincristine), MTX, bation by ~hemotherapy.~~ These studies have had a pro-
and prednisone (MOMP);13.39two of them were non- found impact on our understanding of, and approaches
myelosuppressive. An intensive intermittent "up front" to, therapeutic research in the clinic, initially with respect
combination program (MOMP) was developed.@In 1964, to ALL, and subsequently with respect to all cancer. The
MTX was replaced by procarbazine (the MOPP program). first generalization, which he derived and demonstrated
In contrast to previous experience with single agents, these in a number of experimental in vivo studies, was the
combinations produced rapid, complete and durable re- phenomenon of the first-order kinetic effect of chemo-
missions in the majority of patients, which with subse- therapeutic agents. In summary, this states that for a
quent extensive follow-up has proven curative in 50% of given treatment it is the fractional reduction of tumor
cells which is constant, and not the absolute reduction.
This constant fractional kill is independent of tumor
burden.48
Figure 6 represents that generalization adapted to the
clinic. Employing the Chalkley count technology and ap-
propriate calculations, it was determined that patients
with clinically overt ALL have a body burden of leukemia
cells in the range of a trillion ( 10I2).I2It is assumed that
curative treatment requires the elimination by chemo-
therapy directly (presumably with some host help) of the
entire leukemia burden. This is consistent with some of
the transplanted mouse leukemias, where a single cell is
capable of ascending to overt disease.49Complete remis-
sion induction therapy destroys 1 kg of tumor (Fig. 6)
YEARS F R O M ONSET OF PROTOCOL and eliminates all clinical and laboratory evidence of leu-
---56Ol N . 39 Mid. 6 m a -----6801 N . 4 5 2 Mr4:33mo> kemia. While this involves a 99% (2 log) or greater re-
-5702 N . 3 0 1 Ned. 8 -7111 hz617Yta:5l .
-6005Ns 15IYid*I3 ---I411 N-482Miar69 . duction in the number of leukemia cells, it is only the
-6313 N. 113Yd.I8 -7611 N.582Yide-
"""'"66OI W. 265Yd.28 beginning of successful treatment ("tip of the exponential
iceberg") considering the first-order kinetic concept. Thus,
FIG. 5. Acute lymphocytic leukemia in children younger than age 20
years. Cancer and Leukemia Group B experience, 1956- 1980 (reference it takes just as much treatment to effect a 99% reduction
38). from lo'* to 10'O cells, (1 kg of tumor) as it does to effect
No. 10 ACUTELEUKEM~A
I N CHILDREN
a 99% reduction from lo6to lo4(less than 1 mg of tumor).
Hence the achievement of a complete remission represents
the initial step only, and continued treatment after re-
mission for a significant period of time is essential for
leukemia cell eradication. The fundamental truth of this
model remains intact, even though neoplastic cell het-
erogeneity and chemotherapeutic selection pressures
modify the curve in a complex variety of ways.
A major need in evaluating treatment is a method for
determining the magnitude of cytoreduction during re-
mission. For this we turned to experimental models.
Skipper had demonstrated, again for L1210 mouse leu-
kemia, that time to death was not only a precise measure
of the leukemia cell inoculum, but that time to death
following treatment was also a precise measure of the
number of leukemia cells persisting at the end of treat-
ment.".48 This suggested that the duration of complete
remission following cessation of therapy (duration of un-
maintained remission) might correlate inversely with the
number of leukemia cells persisting at the end of treatment
and thus provide an estimate of the magnitude of leukemia
cytoreduction. In order to apply this more quantitatively
to the clinic, it was necessary to know the doubling time
of leukemia cells after cessation of treatment. In a study
of I7 patients evaluated through early and late bone mar-
row relapse following unmaintained remission, it was
found that the median doubling time of leukemia cells
in the marrow was 4 days." This was reasonably consistent
with tritiated thymidine studies of the kinetics of human
ALL cells.50 Thus in the hypothetical situation, where
the leukemia burden was reduced to one cell, the time
to relapse was calculated as 1 X 2N = 1 X 1OI2 (number
of leukemia cells at relapse): N = 41 (number of dou-
blings); 41 X 4 (doubling time in days) = 164 days to
relapse from a single cell.I2 The initial application of this
program suggested consistent results. After the induction
of complete remission with vincristine or prednisone (no
maintenance treatment), relapse occurred in 40 to 50
days, suggesting a 2- to 4-log reduction in the leukemia
burden. With the VAMP program, the median time to
relapse after cessation of treatment was 140 days, which
was consistent with a 10-logreduction in leukemia burden,
and 3 of the 17 patients had long-term disease-free sur-
vival. However, subsequent studies involving longer du-
rations of treatment (for example, the POMP program
involved 12 months of four-drug treatment) produced a
duration of unmaintained remission of 220 days. This
problem, which presumably related to leukemia cell het-
erogeneity, plus the emergence of meningeal leukemia,
which when controlled was followed by a substantial in-
crease in cure rate, diverted our attention from this ap-
proach. However, several years later, when cure rates in
the range of 50% were established, the general truth of
the above model re-emerged.
- Frei 2019
-rlKQ
2)CNS Prophylaxis -10qrn
a
8
3) Treotment During Remission
- -100rnq Q
4) Csssotion of 2
Treatment -ImQ 4
3
4
-1Op'l ul
B
-0IPP 2
0 1 0
Time (from stort of treatment)
FIG.6. Acute lymphocytic leukemia. Cytokinetic model and treatment
categories.
While treatment prior to 1963 was often continued
indefinitely in remission, it became apparent, particularly
when cure rates were achieved, that such was not only
not practicable but not reasonable, considering the pre-
viously mentioned cytokinetics. Also, drug resistance
studies indicated that this was a ubiquitous problem and
that it was likely, particularly with the antimetabolites,
that drug-resistant clones would emerge by 3 years of
treatment, if not substantially before. As a result, in the
curative regimens indicated above, treatment was dis-
continued at 2 to 3 years, and such was not associated
with an increase in relapse rate.51It was found for patients
in continuous complete remission and cessation of treat-
ment at 3 years that 20% to 30% would subsequently
relapse. Eighty per cent of those destined to relapse did
so within 1 year, the majority of these within the first 6
months. Indeed, the median time to relapse in that setting
was 5 to 6 months." Assuming that the patients who did
not relapse had no leukemic cells and that the small pro-
portion who did had a marked reduction in the number
of leukemia cells, the time to relapse in such patients is
reasonably consistent with the aforementioned cytokinetic
model.
The Skipper models48provided a number of additional
observations with relation to drug resistance, combina-
tions, and cycling of chemotherapeutic agents, and in-
terpretations of the duration of response which were and
remain of major heuristic value and provide a frame of
reference for the construction of clinical treatment strat-
egies.
The Biology of Leukemia: Lessons from
Treatment Research
Up to 1970, the therapeutic approach to ALL centered
around improving the master protocol. Thus a prospective
therapeutic plan (a protocol) was designed for all patients,
with the implied assumption that ALL was homogeneous.
However, by the late 1950s there was evidence that the
2020 CANCERMay 15 1984
assumption of homogeneity was incorrect, and progressive
and more sophisticated analyses of the correlation of pre-
treatment variables with response frequency and duration,
as well as “analysis of failure” studies, confirmed the fact
that ALL was indeed a heterogeneous disease. The influ-
ence of these variables on remission rate and duration
varied over time as different and progressively improved
treatment was introduced, so that precise quantification
of their prognostic influence independent of treatment
was difficult.52
It was noted in the late 1950sthat high leukocyte counts
(for example, greater than 25,000 mm3)prior to treatment
and extensive extramedullary infiltration (liver, spleen,
lymph nodes) were adverse prognostic factors. Age youn-
ger than 2 and older than 9 years was also adverse, as
was the presence of a mediastinal mass. It was also noted
that patients who entered remission quickly-within the
first 30 days-had a better prognosis than those who en-
tered complete remission after 30, but before 60, days.
Since this suggested that the rapidity of reduction of leu-
kemia cells might be a measure of the magnitude of the
reduction, and also that rapid reduction might decrease
potential for the emergence of resistant daughter cells,
attempts were made to evaluate the rate of cytoreduction
during the first 5 days by studying the rate of decrease
in absolute leukemic infiltration in the marrow. While
several of these studies suggested a correlation between
cytoreduction over the first 5 days and cure rates, the
results varied depending on the treatment program, and
definitive conclusions could not be d r a ~ n . ’ ~
As a result of the sheep red blood cell rosetting tech-
nique, it became possible to identify normal T-cells and
T-cell leukemias, and the studies by Borella and Sen,54
were the first to provide a more pathogenetically rational
explanation for heterogeneity with respect to response.
This was amply confirmed by subsequent definitive studies
involving monoclonal antibodies. Many of the above
prognostic factors were covariables. Thus mediastinal
mass particularly, but also magnitude of leukocyte count
and extramedullary infiltration, including CNS infiltra-
tion, is more common in patients with T-cell disease.
Tritiated thymidine studies of the rate of DNA synthesis
in the bone marrow prior to treatment correlated nega-
tively with duration of remission, and was significantly
higher in patients with T-cell disease.”
At the other end, analysis of failures was providing
similar insights. With CNS prophylaxis, meningeal leu-
kemia remained a problem for T-cell disease, but prac-
tically disappeared for non-T-cell disease. Also for most
treatment programs, late relapses, often after cessation of
treatment, occurred in the testes.52
The experimental basis for understanding the heter-
ogeneity of acute leukemia has been markedly improved
in recent years, particularly as a result of immunologic,
Vol. 53
cytogenetic, and histochemical studies. The differentiation
of normal human T-cells within the thymus has been
defined by the development of one or more monoclonal
antibodies for the various differentiation and functional
steps. These antibodies, applied to T-ALL, indicate that
most human T-cell ALL derives from immature T-cells
in the thymus and are consistent with monoclonal origin.56
Conversely, lymphoblastic lymphoma derives from T-
cells of the intermediate stage of differentiation, whereas
the cutaneous lymphomas more commonly derive from
mature helper T-cells. Subcategorization on the basis of
normal differentiation pathways is in process for the non-
T-cell lymphomas, most of which almost certainly rep-
resent derivations from the B-cell lineage. The normal
B-cell differentiation pathway is in the process of being
defined.57A common acute leukemia-associated antigen
(CALLA) is the current major segregant of this category
of patients. Thus, in the late 1970s, about 20% of patients
with ALL were known to have T-cell disease. and a poor
prognosis; 5% had B-cell Burkitt’s leukemia and an ex-
tremely poor prognosis; and the remainder had so-called
non-T/non-B with a substantially better prognosis, par-
ticularly those who were CALLA-positive.
The Last Ten Years
While the cure of ALL in major centers approached
50% by the early 197Os, a further increase in cure rate
was delayed, and it is only in the last few years that there
is compelling evidence that a substantial further increase
in cure rate has been achieved. Approaches and contri-
butions to this success will be summarized.
While 90% of patients could achieve complete remis-
sion with vincristine and prednisone, that figure a p
proaches 100%with the addition of asparaginase and/or
doxorubicin. Moreover, intensive combined (all “ u p
front”) chemotherapy resulted in the more rapid and
extensive cytoreduction, with an associated reduced op-
portunity for the selection of drug resistant clones. Thus,
in several studies, the addition of doxorubicin and/or
asparaginase not only increased the complete remission
rate, but particularly increased the proportion of patients
who entered complete remission early (first 30 days) and
perhaps increased the rate of marrow leukemia cytore-
duction within the first 5 days. Consistent with this was
the fact that several such studies demonstrated that the
addition of a third and/or fourth agent during remission
induction increased the duration of remission.
CNS prophylaxis was also addressed. While there is
controversy concerning the magnitude of the effect, it is
the consensus that the brain irradiation employed in CNS
prophylaxis has an adverse effect on cerebral function.
In a minority of patients, computed tomography (CT)
scans may show minor degrees of brain atrophy.’* Ex-
No. 10 ACUTE LEUKEMIA
IN CHILDREN*
tensive controlled psychometric studies suggest a 5% to
10%deficit in almost all aspects of cerebral function, with more effectiveand less toxic than low-dose MTX (Table
the effect being somewhat greater in subjects younger
than 6 years of age. While the acute effects abate, long-
term effects persist, and are presumably irre~ersible.~~-~’ added to the myelosuppressive BACOP program (bleo-
Accordingly, alternative approaches to CNS prophylaxis
have been sought, and one such approach will be pre-
sented.
While a great deal of progress in cancer treatment has
derived from ALL, the reverse occurred with respect to
high-dose MTX with rescue. This program illustrates how
clinical investigation can extend the therapeutic spectrum
of an agent. Methotrexate was the first drug introduced
for the treatment of acute leukemia in 1947, and for 10
years was thought to be effective only in patients with
ALL. By progressively more sophisticated studies, em-
ploying variations of dose, schedule, combinations, mod-
ulations, rescue, and analogs, accompanied often by par-
allel pharmacologic studies, the clinical usefulness of
MTX has been substantially extended. This has been true
for a number of other chemotherapeutic agents as well.
The demonstration by Jaffe and associates that high-dose
MTX with leucovorin rescue (HDMTX) was effective,
with minimal toxicity, in osteogenic sarcoma6Ia led to
broad spectrum Phase I1 studies. It was quickly found,
particularly in subjects older than age 40 years, that a
substantial proportion of patients had significant and often systemic and testicular relap~e.~’
severe toxicity. Accordingly, in a series of pharmacologic
studies, this toxicity and the risk factors were explained, duces the intended decrease in meningeal leukemia (suc-
and primary approaches to preventing the toxicity were
developed. In addition, toxicity could be predicted on
the basis of pharmacologic and serum creatinine studies.
When such perturbations were found at 24 to 36 hours,
adjustment in the leucovorin rescue dose provided a sec-
ondary approach to preventing toxicity. This clinical in-
vestigation resulted in the ability to deliver high or in-
termediate doses of MTX with leucovorin with safety-
indeed, toxicity occurred in less than 10%of treatments.
The Phase I1 studies were completed, and HDMTX was
found to be as active as full doses of MTX against all
tumors responsive to MTX.62-64 However, there were two
compellingly important advantages: ( I ) the antitumor ac-
tivity was achieved without significant myelosuppression
or other toxicity (it became another active agent in the
important nonmyelosupressive category and therefore
ideal for use in combination); and (2) it provided ther-
apeutic concentrations of MTX in the central nervous
system.62While at equilibrium the concentration of MTX
in the cerebrospinal fluid (CSF), compared to plasma, is
only I%, the concentration in the CSF provided when
very high systemic doses of MTX are administered, will
be cytotoxic. It was found that HDMTX was highly ef-
fective and minimally toxic in refractory patients with
non-Hodgkin’s lymph~ma.~’ It was as effective as stan-
Frei 202 1
dard-dose MTX in previous studies and substantially
1). Moreover, it was active in patients with meningeal
lymphoma (comparable to meningeal When
mycin, Adriamycin [doxorubicin], cyclophosphamide,
Oncovin [vincristine], prednisone) for diffuse histiocytic
lymphoma, no compromise of the dosage was necessary.
The resultant M-BACOP program produced a substantial
increase in the rate of complete response and the disease-
free survival plateau.66
Accordingly, following preliminary studies by Freeman
and associates, intermediate dose MTX with rescue, plus
intrathecal MTX, has been employed for CNS prophylaxis
of ALL.67 A quantitative comparative study was con-
ducted to determine the relative efficacy of cranial irra-
diation and intrathecal MTX, and intermediate-dose
MTX with leucovorin rescue. This study indicated that
intermediate-dose MTX with leucovorin rescue was not
as effective as cranial irradiation and intrathecal MTX
in reducing the incidence of meningeal leukemia, although
the incidence of meningeal leukemia in both treatment
arms was substantially less than that which occurred in
the absence of CNS prophylaxis. However, in this con-
trolled study the intermediate dose methotrexate rescue
program early in remission decreased the frequency of
Thus high- or inter-
mediate-dose MTX with leucovorin rescue not only pro-
cessful CNS prophylaxis), but will, as in lymphoma, pro-
vide an added systemic effect, as evidenced by a decrease
in bone marrow relapse. Current work in this area focuses
on the importance of MTX dose, duration prior to leu-
kovorin rescue, and number of courses required to op-
timize systemic and CNS effect.
Treatment during remission has been investigated dur-
ing the past 10 years. The HDMTX approach properly
belongs here as well and has already been discussed. In
1973, investigators at the Farber Institute initiated a study
where doxorubicin replaced MTX for the first 9 to 12
months of remission. Methotrexate with 6-MP, along with
vincristine and prednisone, were employed in the second
12 months. This was done because of the evidence that
12 months of MTX might provide the maximum effect
that can be achieved with this agent, and particularly
because doxorubicin had substantial activity in lympho-
cytic neoplasms in humans (for example, non-Hodglun’s
lymphoma). This study provided a cure rate in the range
of 40% to 50% (Figure 4), which was not superior to
previous studies following established principles. It did,
however, establish that the most important agent em-
ployed during remission, MTX, could be replaced by
doxorubicin, indicating the effectivenessof doxorubich6*
Asparaginase is one of the more effective agents for
2022 CANCERMay 15 1984 Vol. 53

TABLE
3. AML Key Studies in Improving CR Rate standard remission induction, CNS prophylaxis, and
CR duration treatment during remission programs, have resulted in a
Treatment CR (a) (median in mo.) References substantial improvement in disease-free survival, as il-
lustrated in Figure 4.69-7’ Similarly, the German group
Ara-C every day 14 6 Ellison et a/.
CALGB74 has observed that protocols involving several courses of
Ara-C 2-day infusion 16 5 combination chemotherapy applied intensively early
every 2-3 wks during treatment of ALL produced 90% disease-free sur-
Ara-C 5day infusion 38 11 Bodey SW0G7’ vival at 3 years by actuarial estimate.72
every 2-3 wks
Adnamycin or 35-40 - General
Acute Myelogenous Leukemia in Children
daunorubicin
Ara-C 5-day infusion 55 - CALGB76
every 2-3 wks* Widely The progressive success in the treatment of ALL was
confirmed not realized in the other common form of acute leukemia;
Ara-C 7-day infusion 70
that is, acute myelogenous leukemia (AML). However,
every 2-3 wks* significant progress began approximately 10 years ago
with the identification of two active chemotherapeutic
* Plus anthracycline. agents for AML. Arabinosyl cytosine (Ara-C) is a cell-
R: randomized study; C R complete response; CALGB: Cancer and
Leukemia Group B SWOG: Southwest Oncology Group. cycle-specific agent. In experimental models, based on
kinetic and pharmacologic studies, it has been found that
the dose, and particularly the schedule, of Ara-C may
remission induction in ALL and when added to standard markedly influence its therapeutic index. This was found
remission induction programs will, in comparative studies, also to be true when such studies were extrapolated to
improve the disease-free survival plateau. However, in the clinic (Table 3). Ara-C is a cell cycle specific agent,
the past, because of the perceived problem of rapid de- and substantial studies and experimental models in clin-
velopment of resistance, and particularly immunogenicity, ical and experimental pharmacology, as well as clinical
asparaginase was limited to short-term treatment. In a investigation and trials were required to maximize its
pilot study, it was demonstrated that patients in secondary effectiveness (Table 3). Used optimally, Ara-C produces
remission could be treated with weekly intramuscular a 40% complete remission rate, and when combined with
asparaginase safely for months, and that such patients an anthracycline such as daunarubicin or doxorubicin,
have prolonged durations of remission. Asparaginase and complete remission rates approaching 70% are now reg-
doxorubicin are synergistic in experimental systems. Ac- ularly achieved (Table 3).73Thus, the stage was set for
cordingly, studies involving the addition of long-term as- maximizing leukemia cytoreduction during remission.
paraginase (the first 8 or 9 months of remission) with While a number of sophisticated studies have been per-
doxorubicin in high-risk patients, with otherwise relatively formed in this area, I will focus on one that followed
some of the important principles of therapeutic research,
as mentioned above, and which were crowned with a
measure of success.
Potential obstacles to cure were identified. The first
was inadequate leukemia cytoreduction. Since in ho-
- mogeneous systems this follows first order kinetics, and
gn 4- since for most chemotherapeutic agents there is a linear
log relationship between dose and leukemia cytoreduc-
E
a ti0x-1,~~this obstacle was approached by employing early
intensification (increased doses) of Ara-C in combination
with doxorubicin. Four such courses were d e l i ~ e r e d . ’ ~ , ~ ~
2/ The second obstacle to cure was considered to be the
emergence of drug resistant cell lines. The kinetics of
initial response and the nature of the relapse curves sug-
0 1 2 3 4 5 6 7 8
gested that drug-resistant cell lines were in the ascendancy
Years
after 4 months of treatment. In an effort to prevent this
AGE CCR FAIL TOTAL MEDIAN and achieve stepwise cytoreduction (“switch at the nadir”),
-0-I’IYRS 25 20 45 UNDEF treatment during remission was cycled at 3- to 4-month
FIG.7. Acute myelogenous leukemia in children. Disease-free survival intervals. Thus, after 4 courses of intensification, treat-
curve for patients entering complete remission. ment was cycled to 4 courses of azacytidine, followed by
No. 10 IN CHILDREN
ACUTELEUKEMIA
four courses of POMP, returning finally to 4 courses of
Ara-C, for a total of 14 months of treatment. The third
obstacle, particularly in younger patients with AML, was
the CNS pharmacologic sanctuary. Since Ara-C crosses
the blood-brain barrier reasonably well,79the intensifi-
cation with Ara-C early in remission was expected to
eradicate microscopic disease at that site. Our study was
initiated in 1976, and therefore has a 7-year maximum
follow-up. The data for children are presented in Figure
7. Seventy-five per cent of the patients entered complete
remission. As with other highly effective programs, the
risk of relapse (hazard function) decreases with time. In
Figure 7 disease-free or continuous complete remission
survival curves are plotted for those patients entering
complete remission. The data are sufficiently mature to
indicate a disease-free survival plateau at 50% to 60%.78
Concluding Remarks
Thirty-five years ago, Dr. Sidney Farber lit a candle,
both scientifically and attitudinally, with respect to the
treatment of acute leukemia in children. Today, the cure
rate for all patients with chemotherapy on modern pro-
tocols is probably 75% and will approach 100%in stan-
dard-risk patients, and 80% in high-risk patients in the
near future. Figures 4 and 5 indicate graphically the prog-
ress that has been achieved in the treatment of acute
lymphocytic leukemia in children over the past 35 years.
Additional evidence for progress is the fact that therapeutic
research is increasingly focusing on the quality of life.
Thus, shorteningthe duration of treatment and decreasing
the use of cardiotoxic agents and treatments that might
affect the central nervous system should diminish the
long-term side effects of treatment. Of major interest is
the fact that, inspite of increasing long-term follow-up in
cured patients, there has not been a significant increase
in second primaries, which has occurred in patients with
Hodgkin's disease. The major mutagens and carcinogens
employed in the treatment of Hodgkm's disease are pro-
carbazine and the alkylating agents and large-field radio-
therapy. On the other hand, the chemotherapeutic agents
for the treatment of ALL have limited, if any, mutage-
nicity and carcinogenicity in experimental systems.
Moreover, such agents have not been clearly identified
as carcinogens in clinical cancer chemotherapy trials.
Another important strategy for the curative treatment
of acute leukemia, which is not the subject of this pre-
sentation, is bone marrow transplantation. Thus ALL
patients who fail initial chemotherapy may be candidates
for curative intent treatment with bone marrow trans-
plantation using either matched allogeneic marrow, or,
more experimentally, autologous marrow which has been
immunologicallyprocessed to remove leukemia cells. Al-
logeneic bone marrow transplantation employed during
Frei 2023
first remission in pediatric patients with AML have pro-
duced results comparable to those reported for the che-
motherapy trial presented in Figure 4.
While basic science has contributed importantly to the
above progress, it should be emphasized that clinical sci-
entists were in the vanguard and that basic science has
been profoundly influenced by the biological insights and
therapeutic successes of the above programs for acute
leukemia. The progress that has been achieved in ALL
has provided many of the strategic principles for the suc-
cessful treatment of other tumors such as lymphomas,
testicular cancer, and pediatric solid tumors in the ad-
juvant treatment of important tumors such as breast can-
cer and osteogenic sarcoma. Such progress may be ongoing
in some of the common epithelial tumors in adults, such
as head and neck cancer. While the initial and major
progress in the curative treatment of acute leukemia has
occurred in pediatric patients, more recent studies indicate
that such programs, appropriately modified, provide
compelling evidence that 20% to 40%of adults with acute
leukemia can be cured with these strategies.*'B8'
Finally, progress in cancer treatment should be more
rapid in the immediate future. For those of us privileged
to work in cancer research environments, the rapidity
with which new knowledge and technology, particularly
at a basic level, is being acquired is a most compelling
reality. A progressively stronger scientific base for tumor
biology generally, and for cancer chemotherapy specifi-
cally, should provide further improvement in treatment
in the form of agents with greater specificity for tumor
as compared to normal host cells.
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