CLINICAL OBSERVATIONS, INTERVENTIONS, AND THERAPEUTIC TRIALS

Comparison of Escherichia coli–asparaginase with Erwinia-asparaginase in the

treatment of childhood lymphoid malignancies: results of a randomized European
Organisation for Research and Treatment of Cancer—Children’s Leukemia Group
phase 3 trial
Michel Duval, Stefan Suciu, Alina Ferster, Xavier Rialland, Brigitte Nelken, Patrick Lutz, Yves Benoit, Alain Robert,
Anne-Marie Manel, Etienne Vilmer, Jacques Otten, and Noël Philippe, for the European Organisation
for Research and Treatment of Cancer—Children’s Leukemia Group

Asparaginase is an enzyme used in the domized 700 children with acute lympho- The estimate of event-free survival rate (SE)
treatment of acute lymphoblastic leuke- blastic leukemia or lymphoblastic lymphoma at 6 years was 59.8% (2.6%) versus 73.4%

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mia and lymphoblastic lymphoma in chil-
dren. It has minimal bone marrow toxicity.
Its major side effects are anaphylaxis,
pancreatitis, diabetes, coagulation abnor-
malities, and thrombosis, especially intra-
cranial. It is derived from 2 different sources:
Escherichia coli and Erwinia chrysan-
themi. Nonrandomized clinical studies
have suggested a similar efficacy of these
2 types of asparaginases and a lower
toxicity for Erwinia-asparaginase. The Eu-
ropean Organisation for Research and
Treatment of Cancer–Children’s Leuke-
mia Group (EORTC-CLG) 58881 trial ran-
to either E coli– or Erwinia-asparaginase
at the same dosage of 10 000 IU/m2 twice
weekly to compare toxicity and efficacy.
Coagulation abnormalities were more fre-
quent in the E coli–asparaginase than in
the Erwinia-asparaginase arm of the study
(30.2% versus 11.9%, P < .0001). The inci-
dence of other toxicity was not signifi-
cantly different. In the Erwinia-asparagi-
nase arm, more patients failed to achieve
complete remission (4.9% versus 2.0%;
P ⴝ .038) and the relapse rate was higher,
leading to shorter event-free survival (haz-
ard ratio,1.59; 95% CI, 1.23-2.06; P ⴝ .0004).
(2.4%). Overall survival rate at 6 years
was also lower in the Erwinia-asparagi-
nase arm at 75.1% (2.3%) versus 83.9%
(2.0%), P ⴝ .002. With the dose schedul-
ing used in this protocol, E coli–asparagi-
nase induced more coagulation abnor-
malities but was superior to Erwinia-
asparaginase for the treatment of childhood
lymphoid malignancies. (Blood. 2002;99:
2734-2739)
© 2002 by The American Society of Hematology

Introduction
The enzyme L-asparaginase has been used in the treatment of
lymphoblastic malignancies in children since 1970.1-6 Its antileuke-
mic effect is believed to result from the depletion of circulating
asparagine, which is not essential for normal cells but essential for
most malignant lymphoblastic cells. Asparaginase has minimal
bone marrow toxicity. Its main side effects are anaphylaxis,
pancreatitis, diabetes, and coagulation abnormalities that may lead
to intracranial thrombosis or hemorrhage.7-12
Clinically available asparaginase is derived from 2 sources:
Escherichia coli and Erwinia chrysanthemi. In many countries,
asparaginase from only one of these sources is available for
front-line therapy of lymphoblastic malignancies. In 1990, when
the study reported here was started, the 2 types of asparaginase
were used as if they were one and the same drug. Doses and
schedule, although variable from one protocol to another, were
defined without consideration for the source of the enzyme. One
clinical study using a historical comparison had in fact suggested
that Erwinia-asparaginase was as effective as E coli–asparaginase
but was less toxic.11 To get a clearer view on the relative efficacy
and toxicities of the 2 drugs, we conducted the first randomized
trial to compare them in front-line chemotherapy in children with
newly diagnosed acute lymphoblastic leukemia (ALL) and lympho-
blastic non-Hodgkin lymphoma.
Patients and methods
Patients
Patients were enrolled in 28 pediatric centers in Belgium, France, and
Portugal in trial 58881 of the European Organisation for Research and
Treatment of Cancer—Children’s Leukemia Group (EORTC-CLG).13,14 To
be eligible for the trial, patients less than 18 years of age had to be

From service d’Hémato-Immunologie, Hôpital Robert-Debré, Paris, France;
European Organisation for Research and Treatment of Cancer, Brussels,
Belgium; Centre Hospitalier Universitaire, Reine Fabiola, Brussels, Belgium;
Centre Hospitalier Universitaire, Angers, France; Centre Hospitalier
Universitaire, Lille, France; Centre Hospitalier Universitaire, Strasbourg,
France; Gent University Hospital, Gent, Belgium; Centre Hospitalier
Universitaire, Toulouse, France; Centre Hospitalier Universitaire, Lyon, France;
and Akademisch Ziekenhuis, Vrije Universiteit Brussel, Brussels, Belgium.
Submitted March 27, 2001; accepted December 10, 2001.
Supported by grants 5U10-CA11488-20 through 5U10-CA11488-30 from the
National Cancer Institute and by Ipsen. Its contents are solely the responsibility
of the authors and do not represent the official view of the National Cancer
Institute or Ipsen.
M.D. and S.S. contributed equally to this work.
Reprints: Michel Duval, Service d’Hémato-Oncologie, Hôpital Sainte-Justine,
3175, chemin Côte-Sainte-Catherine, Montréal, QC, Canada, H3T 1C5; e-mail:
michel.duval@umontreal.ca.
The publication costs of this article were defrayed in part by page charge
payment. Therefore, and solely to indicate this fact, this article is hereby
marked ‘‘advertisement’’ in accordance with 18 U.S.C. section 1734.
© 2002 by The American Society of Hematology

2734 BLOOD, 15 APRIL 2002 䡠 VOLUME 99, NUMBER 8

BLOOD, 15 APRIL 2002 䡠 VOLUME 99, NUMBER 8 E coli– VERSUS Erwinia-ASPARAGINASE 2735

diagnosed with ALL according to French-American-British L1 or L2 Table 1. EORTC-CLCG 58881: treatment protocols for low- and high-risk
cytomorphology or lymphoblastic non-Hodgkin lymphoma. Patients previ- patients
ously treated with corticosteroids for more than 7 days were excluded. Days of
Patients were considered to have central nervous system (CNS) Drug Dose administration*
involvement if they had cranial nerve palsy or at least 5 leukocytes/␮L Induction: protocol IA
cerebrospinal fluid with leukemic cells seen on cytocentrifuged prepara- Prednisolone (PO) 60 mg/m2 1-28
tions. Immunophenotype was determined using standard techniques, and Vincristine (IV) 1.5 mg/m2 8, 15, 22, 29
positivity for each marker was defined as more than 20% of leukemic cells (max. 2.5
expressing that marker. Chromosome analysis used standard techniques. mg)
Bone marrow smears, immunophenotypes, and cytogenetics were reviewed Daunorubicin (IV) 30 mg/m2 8, 15, 22, 29
centrally. Methotrexate (intrathecal) 12 mg† 1, 8, 22, 38, 52
According to randomization
E coli–asparaginase (IV) or 10 000 IU/m2 12, 15, 18, 22, 25, 29,
Treatment
32, 35
Patients were randomized to Erwinia-asparaginase (Erwiniase, Ipsen, Erwinia-asparaginase (IV) 10 000 IU/m2 12, 15, 18, 22, 25, 29,

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Maidenhead, United Kingdom) or E coli–asparaginase (Paronal, Medac, 32, 35
Hamburg, Germany for the Belgian centers, or Kidrolase, Bellon, Consolidation: protocol IB
Montrouge, France for the French and Portuguese centers, both pro- Cyclophosphamide (IV) 1 000 mg/m2 36, 63
duced by Kyowa Hakko, Tokyo, Japan). Physicians had to switch to the Cytarabine (IV) 75 mg/m2 38-41, 45-48, 52-55,
other asparaginase in case of allergy grade 1 or higher. In case of 59-62
pancreatitis or thrombosis, asparaginase was eliminated from the 6-Mercaptopurine (PO) 60 mg/m2 36-63
treatment. Informed consent was required before entry, in accordance Interval therapy
with the Helsinki protocol. The trial also randomized patients to receive 6-Mercaptopurine (PO) 25 mg/m2 1-56
additional monthly intravenous mercaptopurine during maintenance Methotrexate (24 h IV infusion 5 000 mg/m2 8, 22, 36, 50
therapy, and high-risk patients (see below) to receive high-dose with leucovorin rescue)
cytarabine during interval therapy. Methotrexate (intrathecal) 12 mg† 9, 23, 37, 51
Protocol design was similar to that of the BFM-90 protocol.15 Patients According to randomization for high-risk patients
were stratified into low- and high-risk categories according to their risk Cytarabine (IV) 1 000 mg/m2 9, 10, 23, 24, 37, 38,
factor calculated as a function of blood blast count, hepatomegaly, and 51, 52
splenomegaly.14,15 A very-high-risk group was defined by the presence of at Reinduction: protocol II
least one of the following criteria regardless of risk factor: more than 1000 Dexamethasone (PO) 10 mg/m2 1-21
blasts/␮L in the blood after 7 days of prednisolone and intrathecal Vincristine (IV) 1.5 mg/m2 8, 15, 22, 29
methotrexate on day 1, translocation t(9;22) or t(4;11), near-haploidy, (max. 2.5
undifferentiated immunophenotype, or complete remission (CR) not achieved mg)
after protocol IA for leukemia patients or after protocol IB for lym- Doxorubicin (IV) 30 mg/m2 8, 15, 22, 29
phoma patients. Methotrexate (intrathecal) 12 mg† 38
Strategy for low- and high-risk patients was based on induction- Cyclophosphamide (IV) 1 000 mg/m2 36
consolidation, CNS-directed therapy with high-dose methotrexate, and Cytarabine (IV) 75 mg/m2 38-41, 45-48
then reinduction, followed by maintenance therapy for a total treatment 6-Thioguanine (PO) 60 mg/m2 36-49
duration of 2 years (Table 1). CNS-directed therapy consisted of According to randomization
high-dose intravenous methotrexate and 10 intrathecal injections of E coli–asparaginase (IV) or 10 000 IU/m2 8, 11, 15, 18
methotrexate; cranial irradiation was not given even for patients with Erwinia-asparaginase (IV) 10 000 IU/m2 8, 11, 15, 18
CNS involvement at diagnosis. The latter received an additional 10
Maintenance therapy was a combination of daily oral mercaptopurine adjusted to
intrathecal injections of methotrexate and during maintenance 5 high- maintain leukocytes between 2000 and 3000/␮L and methotrexate 20 mg/m2 once a
dose methotrexate infusions. Asparaginase was administered intrave- week. According to randomization, some patients received intravenous mercaptopu-
nously twice weekly. A total of 12 doses of 10 000 IU each was planned, rine 1000 mg/m2 every 4 weeks.
8 during protocol I and 4 during protocol II. No study for asparaginase *Adjustments were made for clinical condition and marrow recovery.
pharmacokinetics was planned because no laboratory of our group had †Doses were adjusted for children under age 3 years.
that expertise at the time the trial started.
Treatment of very-high-risk patients called for rotating chemotherapy
courses and also for allogeneic bone marrow transplantation for patients of protocol I. Relapse was defined as the reappearance of more than 25%
with an HLA-identical sibling. After completion of protocol IA, very-high- leukemic cells in the bone marrow or of any leukemic cell at another site.
risk patients received consolidation therapy of 6 weeks’ duration consisting Coagulation abnormalities were defined as any clinical or biologic abnor-
of cyclophosphamide, asparaginase, oral mercaptopurine, and high-dose mality requiring a modification of chemotherapy or supportive care.
methotrexate and cytarabine (IB⬘ protocol). They then received a combina- Investigators were advised to consider such a modification for hypofibrino-
tion of oral dexamethasone, high-dose cytarabine, mitoxantrone, etoposide, genemia below 0.5 g/L. Allergy, neurotoxicity, liver toxicity, and infection
and asparaginase (“VANDA” block).16 VANDA was followed by interval were graded according to World Health Organization (WHO) criteria.18 To
therapy with only 3 administrations of high-dose methotrexate, combined ensure comparability with other studies, National Cancer Institute (NCI)
with high-dose cytarabine. Then 2 sequences of 3 R-blocks were adminis- risk groups for leukemia patients were used according to consensus
tered according to the BFM relapse protocol,17 followed by maintenance conference recommendations: NCI standard-risk group consisted of pa-
therapy. Cranial radiotherapy was not given. Total duration of treatment was tients aged 1 to 9 years at diagnosis with an initial white blood cell (WBC)
also 2 years. count less than 50 ⫻ 109/L. Other patients were considered as having NCI
high-risk leukemia.19

Definitions
Complete remission was defined as cellular bone marrow with fewer than
5% leukemic cells and no evidence of leukemia or lymphoma at any other
site. Remission failure was defined as failure to reach CR at the completion
Statistical methods
Randomization was done centrally (EORTC Data Center, Brussels) and was
stratified according to center, disease (leukemia versus lymphoma), risk
2736 DUVAL et al BLOOD, 15 APRIL 2002 䡠 VOLUME 99, NUMBER 8

factor (⬍ 0.8, 0.8-1.19, ⱖ 1.2), and immunophenotype (B versus T lineage) Table 2. Patient characteristics by arm
for leukemia patients, and by Murphy stage (stage I-II versus III-IV) for E coli–asparaginase Erwinia-asparaginase
lymphoma patients. Randomization was not stratified by the presence of no. (%) of patients no. (%) of patients
t(9;22). Subsequent randomizations were stratified according to treatment N ⫽ 354 (100%) N ⫽ 346 (100%)
arm and initial risk factor or Murphy stage. Sex
The primary end point was event-free survival calculated from the Male 206 (58) 202 (58)
date of CR to the date of first relapse or death. For patients who failed to Female 148 (42) 144 (42)
reach CR by the end of protocol I, the failure was considered as an event Age (y)
at time 0. The secondary end points were the rate of CR after induction Younger than 1 10 (3) 11 (3)
and consolidation, disease-free survival (time from CR until relapse or 1 through 9 282 (80) 275 (80)
death), and survival (time from randomization until death, whatever the 10 through 17 62 (17) 60 (17)
cause). Actuarial curves were computed using the Kaplan-Meier tech- ALL 334 (94) 319 (92)
nique, and the SEs of the estimates were obtained using the Greenwood WBC count (109/L)
formula.20 To summarize the overall treatment difference, the hazard Less than 25 215 (64) 201 (63)
ratio for the daily risk of event in Erwinia-asparaginase arm versus the 25 to 100 66 (20) 69 (22)
one in E coli–asparaginase arm and its 95% CI was estimated using the

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At least 100 53 (16) 49 (15)
Cox proportional hazards model.21 This model was also used to adjust CNS involvement 17 (5) 15 (5)
the treatment difference for several prognostic factors. A total of 750 Immunophenotype
patients were initially planned to detect a significant (␣ ⫽ 5%) differ- B lineage 289 (87) 267 (84)
ence of 10% in event-free survival rate at 5 years (from 65% to 75%) T lineage 45 (13) 52 (16)
with a statistical power of 85%. The Peto stopping rule was adopted: a Karyotype
comparison yielding a log-rank P ⬍ .001 was considered sufficient to Successful examinations 261 (78) 235 (74)
stop enrollment. All analyses were performed according to the intention- Hyperdiploidy 70 [27]* 52 [22]*
to-treat principle. t(9;22) 3 [1]* 11 [5]*
The Fisher exact 2-tailed test was used (StatExact) to compare the rates t(4;11) 5 [2]* 6 [3]*
of complete remission after induction and consolidation. The odds ratio Near-haploidy 1 [⬍ 1]* 1 [⬍ 1]*
estimates and their exact 95% CIs were used to express the results. The Normal and others 182 [70]* 165 [70]*
same methods were used for treatment comparisons of the incidence of Response to prephase:
grade 3 to 4 toxicity during the induction period. blasts (/␮L) on D8
Less than 1000 292 (87) 278 (87)
1000 42 (13) 41 (13)
Initial very-high risk
features 47 (14) 54 (17)
Results NCI risk groups
Patient characteristics NCI standard risk 212 (63) 203 (64)
NCI high risk 122 (36) 116 (36)
Between November 1990 and October 1993, 702 patients were Lymphoblastic lymphoma 20 (6) 27 (8)
enrolled. Seven hundred were considered eligible for entry into the Murphy stage III or IV 20 (100) 23 (85)

study, 354 in the E coli–asparaginase arm and 346 in the T lineage 19 (95) 22 (81)

Erwinia-asparaginase arm. Two patients with Burkitt lymphoma,
one in each arm, initially erroneously diagnosed and subsequently
treated with another protocol were excluded from the analysis.
Enrollment was stopped early because the treatment difference in
terms of event-free survival yielded a P ⬍ .001.
Patient characteristics according to treatment arms are shown in
Table 2. A total of 653 patients (93%) had ALL. The 2 arms were
comparable for usual prognostic factors, except for a slight
imbalance in the incidence of t(9;22). Forty-seven patients with
lymphoblastic lymphoma were randomized and the 2 arms were
also comparable at presentation.
Protocol compliance and toxicity
During protocol IA, 81% of the patients in the E coli–
asparaginase and 88% of the patients in the Erwinia-
asparaginase arm received 8 doses of the asparaginase they had
been randomized to receive (Table 3). Coagulation abnormali-
ties were more often observed in the E coli–asparaginase arm:
30.2% versus 11.8%; odds ratio, 3.20; P ⬍ .0001 (Table 4). The
incidence of other grade 3 or 4 toxic effects observed during
protocol IA was low and comparable in the 2 arms. Three
patients died before reaching CR. Grade 3 or 4 allergy had a low
incidence in the 2 groups: 2.5% versus 2.6%.
During protocol IIA a similar proportion of patients in the 2
arms received the planned asparaginase treatment: 66% versus
69% (Table 3). Twenty-nine percent of patients in each arm
*Percentages were computed on successful cytogenetic examinations. NCI risk
groups were as defined by the consensus conference.
received at least one dose of the asparaginase they had not been
randomized to. Such a proportion did not allow comparison of
toxicity in protocol IIA.
Efficacy
After induction (protocol IA), 335 leukemia or lymphoma patients
(94.5%) reached CR in the E coli–asparaginase arm and 315
(91.0%) in the Erwinia-asparaginase arm (Table 5). Four leukemia
patients (1.2%) never achieved CR at the completion of protocol I
in the E coli–asparaginase arm and 12 (3.8%) in the Erwinia-
asparaginase arm: odds ratio, 3.23; P ⫽ .042 (Table 6). Three
patients with lymphoblastic lymphoma in the E coli–asparaginase
arm and 5 in the Erwinia-asparaginase arm did not achieved CR.
For the whole group, the estimated odds ratio for remission failure
was 2.56, P ⫽ .038 (Table 5).
Median follow-up was 6.9 years (range, 4.8-9.0 years). Relapse
rate was approximately 1.5 times higher in the Erwinia-
asparaginase arm, regardless of the site, in leukemia (Table 6) and
in lymphoma patients (2 versus 5 relapses). The rate of death in CR
was similar: 11 patients (3.2%) versus 8 (2.4%). Event-free
survival was shorter in the Erwinia-asparaginase arm (P ⫽ .0004;
Figure 1A). Its rate at 6 years (SE) was 59.8% (2.6%) versus 73.4%
BLOOD, 15 APRIL 2002 䡠 VOLUME 99, NUMBER 8 E coli– VERSUS Erwinia-ASPARAGINASE 2737

Table 3. Evaluation of compliance with allocated asparaginase Table 5. ALL and lymphoblastic lymphoma patients: short-term
outcome by arm
E coli–asparaginase Erwinia-asparaginase
no. (%) of patients no. (%) of patients Erwinia-
E coli–asparaginase asparaginase Odds ratio
During IA 354 (100) 346 (100)
N ⫽ 354 (100%) N ⫽ 346 (100%) (95% CI) (P)*
Patients received all
planned doses 287 (81) 303 (88) CR not reached 19 (5.4) 31 (9.0) 1.74 (0.93, 3.32)

Patients switched to after induction (.078)

other asparaginase* 39 (11) 24 (7) Remission failure 7 (2.0) 17 (4.9) 2.56 (0.99, 7.39)

During IIA 300 (100) 277 (100) (.038)

Patients received all Remission failure means patient never achieved CR at the end of
planned doses 198 (66) 190 (69) induction-consolidation.
Patients switched to *Fisher exact test.
other asparaginase* 86 (29) 80 (29)

*Switch denotes a patient who received at least one injection of asparaginase he

was not randomized to receive. Some patients did not receive all planned doses but
comparison yielded a similar result when adjusted for NCI risk

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were not switched to the other asparaginase. group and sex, and, for leukemia patients, for very-high-risk
features or for t(9;22) in those with a successful cytogenetic
examination.
(2.4%) in the E coli–asparaginase arm, and the estimated hazard
ratio for remission failure, relapse, or death was 1.59 (95% CI,
1.23-2.06). For leukemic patients the estimated hazard ratio for
remission failure, relapse, or death was 1.60 (95% CI, 1.22-2.09) Discussion
after adjustment for NCI risk group, very-high-risk features, and
sex, which appeared to be independent strong prognostic factors. Seven hundred children with ALL or lymphoblastic lymphoma
When restricted to leukemia patients with a successful cytogenetic were randomized to receive either E coli– or Erwinia-asparaginase.
examination, the comparison adjusted for the presence of t(9;22) Median follow-up was 6.9 years. Two main conclusions can be
yielded similar results. drawn from the results of this randomized trial. First, E coli–
The effects of the other 2 randomizations on the difference asparaginase is more toxic because it induces more coagulation
between outcome for the 2 types of asparaginase were as follows. abnormalities. Second, clinical efficacy of E coli–asparaginase is
First, the addition of high-dose cytarabine during interval therapy superior to that of Erwinia-asparaginase at the dosage of 10 000
had no effect on disease-free survival,22 and it did not interact with IU/m2 twice weekly. The type of asparaginase not only affects early
the difference in outcome between the asparaginase arms. Second, response to treatment but also the risk of relapse, event-free
patients randomized to receive additional monthly intravenous survival, and overall survival.
mercaptopurine during maintenance had a shorter disease-free Overall toxicity of asparaginase was low. The most frequent
survival.23 Among the patients randomized for asparaginase, 638 side effects were coagulation abnormalities, which were more
remained in CR at the beginning of maintenance therapy. A total of frequent in the E coli–asparaginase arm, as previously re-
224 patients were randomized to receive additional monthly ported.11,24,25 Our results confirm a trend toward more neurotox-
intravenous mercaptopurine, 229 were randomized not to receive icity and convulsions with E coli–asparaginase.11 However,
it, and 185 were not randomized. In the 3 subgroups the hazard their frequency (2.5% grade 3 or 4 neurotoxicity, 1.7% convul-
ratio for death or relapse according to the type of asparaginase was sions) remained moderate compared to the rate of relapse
calculated. The three 95% CIs for these hazard ratios were, and death.
respectively, 1.32 to 3.37, 0.65 to 1.92, and 1.02 to 2.98. They all In accordance with previous reports, we found no difference
contained the overall estimate of 1.63 calculated in the 638 between the 2 types of asparaginases in the rates of allergy, liver
patients, so there is no proof so far that addition of monthly toxicity, or insulin-requiring diabetes.5,10-12 Frequency of pancre-
mercaptopurine interacts with the difference in outcome between atitis and severe infections was similar, whereas other reports
the asparaginase arms. concerning these side effects are conflicting.5,11
Estimated overall survival rate at 6 years was 83.9% (2.0%) Three controlled studies have randomized patients to receive
in the E coli–asparaginase arm versus 75.1% (2.3%) in the additional asparaginase during postremission therapy in child-
Erwinia-asparaginase arm (P ⫽ .002; Figure 1B). Estimated hood lymphoid malignancies. In 2 of them, additional E
hazard ratio for death was 1.66 (95% CI, 1.20-2.23). The coli–asparaginase improved outcome for patients with ALL and
advanced stage lymphoblastic lymphoma.1,4 The largest study,
Table 4. Toxicity during induction (protocol IA)
which randomized 1085 patients, administered either E coli– or
Erwinia-asparaginase at equal dosage. It failed to show any
E coli–asparaginase no. Erwinia-asparaginase no.
(%) of patients N ⫽ 354 (%) of patients N ⫽ 346 impact on outcome of additional asparaginase during postremis-
(100%) (100%) sion therapy.15 Although our study closed in 1993, it is still, to
Allergy (WHO 3-4) 9 (2.5) 9 (2.6) our knowledge, the only comparative study of the 2 types of
Coagulation abnormalities 107 (30.2) 41 (11.8) asparaginases during the remission-induction phase in such a
Neurotoxicity (WHO 3-4) 9 (2.5) 5 (1.4) large number of children, and certainly the only large study in
Convulsions 6 (1.7) 1 (0.3) which reliable 6-year survival figures are available. Its results
Pancreatitis 1 (0.3) 3 (0.9) suggest that asparaginase in the remission-induction phase may
Diabetes requiring insulin 5 (1.4) 2 (0.6) still have an impact on final outcome in this era of multi-
Liver toxicity (WHO 3-4) 16 (4.5) 13 (3.8) agent therapies.
Infection (WHO 3-4) 18 (5.1) 16 (4.6)
This difference in efficacy between asparaginases was not
Death 1 (0.3) 2 (0.6)
expected when the trial was begun, but is in keeping with recent
2738 DUVAL et al BLOOD, 15 APRIL 2002 䡠 VOLUME 99, NUMBER 8

Table 6. ALL patients: outcome by arm

E coli–asparaginase Erwinia-asparaginase Odds ratio
N ⫽ 334 (100%) N ⫽ 319 (100%) (95% CI) (P)*

CR not reached after induction 12 (3.6) 21 (6.6) 1.89 (0.87, 4.29)

(.107)
Remission failure 4 (1.2) 12 (3.8) 3.23 (0.96, 13.84)
(.042)
CR reached 330 (98.8) 307 (96.2)
Continuous CR 242 [73] 190 [62]
Death in CR 11 [3] 7 [2]
Relapses 77 [23] 110 [36]
Bone marrow 45 [14] 64 [21]
CNS (isolated) 12 [4] 18 [6]
CNS (combined) 13 [4] 15 [5]
Other isolated 3 [1] 5 [2]

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Other combinations 4 [1] 8 [3]

Remission failure means patient never achieved CR at the end of induction-consolidation.

Parentheses for columns 2 and 3: percentages were computed on all patients included.
Brackets for columns 2 and 3: percentages were computed on patients having reached CR.
*Fisher exact test.

data. The serum half-life of Erwinia-asparaginase activity is
significantly shorter, 0.65 day versus 1.24 days for E coli–
asparaginase.26 Asparagine depletion during reinduction in the
BFM-90 trial was achieved in 26% of patients receiving Erwinia-
asparaginase and in 60% to 90% of the patients receiving E
coli–asparaginase.27 Time to recovery of serum asparagine level
after administration was 4 days for Erwinia-asparaginase versus 11
days for E coli–asparaginase.27
In all treatment protocols so far, the dosing schedule of
asparaginase has been defined regardless of the type of asparagi-
nase used,15 although the regimens have varied considerably from
one protocol to another, from 6000 IU daily to 25 000 IU once a
week. IU is defined by a chemical in vitro activity and not by a
biologic in vivo effect. A recent study suggests that increasing the
dose and decreasing the time interval between Erwinia-asparagi-
nase administrations results in pharmacodynamics similar to that of
lower and less frequent doses of E coli–asparaginase.28 However, it
has not been demonstrated that this strategy leads to the same
clinical outcome, and it may be more toxic. Whether other as yet
unknown qualitative differences between the 2 sources of asparagi-
nases could be responsible for their unequal efficacy cannot be
demonstrated by these studies and remains undecided.
Thus, E coli–asparaginase can be recommended for first-line therapy,
reserving Erwinia-asparaginase for allergic patients, because (1) most
patients allergic to the former are not immediately allergic to the
latter,10,12 (2) our results were analyzed according to the intention-to-
treat principle and 29% of patients in the E coli–asparaginase arm were
actually switched to Erwinia-asparaginase because of allergy, and (3) it
has been demonstrated that this switch does not modify clinical
outcome.29,30 The effect of Erwinia-asparaginase should be monitored
by measuring asparaginase activity or perhaps more simply asparagine
depletion.28,31 Asparaginase linked to polyethylene glycol (PEG-
asparaginase) is now available. Its immunogenicity is lower and its
serum half-life longer. Pharmacokinetic studies suggest that it may be
substituted for E coli–asparaginase, but clinical trials are needed to study
the impact of substitution on clinical outcome.5,32,33
In conclusion, our trial demonstrates the superiority of E
coli–asparaginase compared to Erwinia-asparaginase in lymphoid
malignancies of childhood, when used at the dose of 10 000 IU/m2
twice a week. Our findings underscore the importance of asparagi-
nase in induction therapy of childhood lymphoid malignancies. In
modern multiagent therapies, minor differences in treatment regi-
men may lead to substantial differences in outcome, suggesting the
need for caution when modifying current therapeutic protocols.

Figure 1. Event-free survival and survival for the patient cohort. (A) Event-free survival
for patients randomized to E coli–asparaginase (solid line) or Erwinia-asparaginase Acknowledgment
(broken line). O indicates observed number of events (remission failure, relapse, or death in
CR); N, total number of patients randomized. (B) Survival for patients randomized to E
coli–asparaginase (solid line) or Erwinia-asparaginase (broken line). O indicates observed A complete list of the participating institutions and investigators
number of deaths; N, total number of patients randomized. appears in the Appendix at the end of this article.
BLOOD, 15 APRIL 2002 䡠 VOLUME 99, NUMBER 8 E coli– VERSUS Erwinia-ASPARAGINASE 2739

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Appendix
Participating institutions and investigators of EORTC-CLG: EORTC
Data Center, Gabriel Solbu, Stefan Suciu, Christine Waterkeyn; HU des
Enfants, Bruxelles, Dr Azzi, Dr Ferster, Dr Sariban; CHR Grenoble, Dr
Bachelot, Dr Plantaz; AZK VUB Brussels, Dr Maurus, Dr Otten; Hôpital
Américain Reims, Dr Behar, Dr Munzer; UZ Gent, Dr Benoit, Dr
Dhooge, Dr Laureys; Hopital Debrousse Lyon, Dr Bertrand, Dr Manel,
Dr Philippe, Dr Souillet; CHU Angers, Dr Blanchet, Dr Dautel, Dr
Gamelin, Dr Le Moine, Dr Pein, Dr Pellier, Dr Rialland; CHU
Strasbourg, Dr Babin-Boilletot, Dr Falkenrodt, Dr Lutz; CHU Caen, Dr
Boutard, Dr Minckes; UZ Gasthuisberg Leuven, Dr Brock, Dr Uyttebro-
eck; CHR Citadelle Liège, Dr Chantraine, Dr Dresse, Dr Hoyoux;
Hôpital Edouard-Herriot Lyon, Dr Charrin, Dr Magaud; CHU Toulouse,
Dr Dastugue, Dr Robert, Dr Rubie; Hôpital Saint Antoine Lille, Dr
Demory; Fondation Lenval Nice, Dr Deville, Dr Soler; Institut Curie,
Paris, Dr Fagnou, Dr Michon, Dr Pacquement; CHU Lille, Dr Fournier,
Dr Mazingue, Dr Nelken; CH St-Joseph-l’Espérance, Montegnee, Dr
Francotte, Dr Hainaut, Dr Philippet; Hôpital Robert-Debré, Paris, Dr
Duval, Dr Fenneteau, Dr Grandchamp, Dr Lescoeur, Dr Rohrlich, Dr
Vilmer; AK Antwerpen, Dr Gyselinck; CHU Nantes, Dr Harousseau, Dr
Méchinaud; CHU Montpellier, Dr Margueritte; CHU La Timone,
Marseille, Dr Michel; CHU Poitiers, Dr Millot; Hopital Cimiez, Nice,
Dr Monpoux; Hospital S. Joao, Porto, Dr Norton; CH Verviers, Dr Bitar, Dr
Paulus; Clinique de l’Esperance, Montegnée, Dr Philippet; CHU Reims, Dr
Pignon; CHU Besançon, Dr Plouvier; Centre Lacassagne, Nice, Dr Thyss.