1. Tata Memorial Hospital
Childhood Acute Lymphoblastic Leukemia: Risk Stratification in Developing Countries
Shripad Banavali
MD(Med;Bom), BC(Ped;USA), BE(Hem-Onc;USA)
Tata Memorial Hospital

2. Acute Lymphoblastic Leukemia
Most common form of childhood cancer.
Treatment of ALL is true success story of modern oncology.

4. Key Components of Successful Therapy
Clinical trials; Co-operative groups
Empiric multi-agent CNS therapy
Pre-symptomatic CNS therapy
Post-induction intensification
Anti-metabolite therapy
Re-induction/re-consolidation
Risk adapted therapy

5. ALL: L1, L2, L3, PAS

9. Multiplex RT-PCR in B lineage ALL

12. MORPHOLOGICAL REMISSION (98%)
Morphology cannot discriminate between patients with HR or LR of relapse.
More sensitive techniques needed to detect small numbers of malignant cells during and after treatment.
Detection of MRD (IP and RT-PCR).
MOLECULAR REMISSION (?%)

13. What is detection of MRD

14. What is detection of MRD
It is nothing but detection of the clones of cells resistant to the chemotherapy given.

15. MRD: Study of Resistance in ALL
Resistance can also be studied by:-
(1) MTT in-vitro Assay
Pred + Asp + VCR Drug resistance profile
3 yr DFS 100% Most sensitive profile (20% pts)
84% Inter. sensitive profile (40% pts)
43% Least sensitive profile (40% pts)

16. MRD: Study of Resistance in ALL
Resistance can also be studied in-vivo by:-
(2) D7 blast count post exposure to
Pred + 1 dose of IT-MTX
(3) D 15 BM blast %

18. Estimation of MRD
Flow cytometry :
(2) RT-PCR:

22. Treatment of Childhood ALL
TOP PRIORITY
PREVENTION OF RELAPSE

23. ALL-Challenges For Developed Countries Clinical trials
Despite success, 25% of children relapse. Intensify therapy for those who need or will benefit from it.
Many of those who are cured are over-treated Minimize side effects
Little progress has been made in the treatment of certain very high risk groups (Ph+, infants and relapse)
Develop new treatment options

26. PEDIATRIC ONCOLOGY : FACTS
India U.S.A.
New cases / yr , ,400
Rx, curative intent <25% %
Cure rate, adequ. Rxed % %
Overall cure rate % %
Rxed on Co-op Groups % %

27. Hematological cancers in India Average Annual Age standardized incidence rate per 100,000 persons ( )
Region Lymphoid leukemia Myeloid leukemia
M F M F
Delhi
Mumbai
Bangalore
Chennai
Bhopal
Barshi
Medical Oncology, vol. 19, , 2002

28. Rx of ALL: THE TMH EXPERIENCE
V+P %
V+P+Doxo or L-Asp %
VACP %
1. Advani et al: Am J Hematol 15:35,1983
2. Advani et al: Ind J Cancer 26:180,1989
3. Advani et al: Am J Hematol 39:242, 1992
4. Advani et al: Ann Onc 10:167,1999

30. Advani et al. Ann Oncol 1999

31. Advani et al. Ann Oncol 1999

32. Clinical characteristics in relationship to event free survival by participating center. Results of multi-variate analysis.
Characteristic
DELHI
P-Value
CHENNAII
MUMBAI
Number accrued
228
168
652
Age
0.20
0.033
0.74
WBC count
0.0005
0.080
0.002
Platelet count
0.025
0.059
0.011
Hemoglobin
0.94
0.38
0.79
LDH --
0.47
0.39
Immunophenotype
0.99
0.13
0.17
Lymphadenopathy
0.66
0.83
0.49
Hepatosplenomegaly
0.58
0.92
Mediastinal mass
0.32
0.10

33. CALLA + ACUTE LYMPHOBLASTIC LEUKEMIA CHANGING INCIDENCE OVER 3 DECADES

34. T- ACUTE LYMPHOBLASTIC LEUKEMIA CHANGING INCIDENCE OVER 3 DECADES

35. Frequencies of the major subgroups of Precursor B cell ALL in Indian children differ from the rest. Siraj AK, et al. Leukemia 2003; 17:
n= 259
India (%) USA (%) Europe (%)
TEL-AML
mBCR-ABL*
ELA-PBX
MLL-AF
*Guiterrez MI, et al. J Mol Diagnostics 2005; 7:40-47

36. x MUMBAI
DELHI
CHENNAI

37. Childhood Acute Lymphoblastic Leukemia Results of MCP-841 in other Centres
Bangalore
Trivandrum
Jaipur
Total number
127 66 49
CR (%) 96 83 90
TRM(%)
2.4
24.2
16.3
Relapse(%) -
21.8
22.4
CCR(%) 53 57
F Up(months) 36 38

38. ALL : FUTURE PLANS CLINICAL
New ALL protocol
Collaboration with INCTR
Salient features
More Continuous CT
More Chemo in 1st year
Both Inj. & oral CT during Maintenance
Less RT (1260 cGy)

39. THE PROBLEM Limited Resources Lack of Appropriate
(Financial and Human Capital) Research
High
Low capacity to treat Poor Access to therapy Mortality Rate
Late Presentation
&
Late Detection

40. THE SOLUTION Limited Resources Appropriate
(Financial and Human Capital) Research
Best
Low capacity to treat Rx Pts. ĉ Best Prognosis Value for Money
Low Intensity Rx

41. Appropriate Rx ALL Rx Outcome Pharmacogenetics Pharmakokinetics
SEED
Biology of
Leukemic cells
ALL Rx
Outcome
Pharmacogenetics
Pharmakokinetics
SOIL
Genotype
Nutrition
Supportive
care
Compliance
Drug quality

42. What is detection of MRD
It is nothing but detection of the clones of cells resistant to the chemotherapy given.
“Functional Assay”

43. Appropriate Rx ALL Rx Outcome Pharmacogenetics Pharmakokinetics
SEED
Biology of
Leukemic cells
ALL Rx
Outcome
Pharmacogenetics
Pharmakokinetics
SOIL
Genotype
Nutrition
Supportive
care
Compliance
Drug quality

44. Estimation of MRD
Flow cytometry : 2-3 laser Flow-cytometer many antibodies
time consuming expensive
(2) RT-PCR: by TCR receptor; Ig gene rearrangements; known translocations. Individual primers.
Expertise not available at all centres.

46. Can there be a simple way to estimate MRD?

47. TDT expression by all ALL blasts Not expressed normally in PB
Real Time Analysis of Terminal Deoxy Transferase Gene Expression: A convenient marker for Minimal Residual Leukemia Bu R, Belgaumi A, Timson G, Banavali S, Al Mahir, Bhatia K, Gutierrez MI.
TDT expression by all ALL blasts
Not expressed normally in PB
Estimation of TDT in PB by Real time PCR

50. ALL: “Core Biology” Lab Assessment Of Components Of Cure In Developing Countries
Real time reference laboratory system for risk based classification.
MRD studies : using single parameter, e.g. TDT
Using PB
At diagnosis ; At week 4 & 6 (8)

51. ALL: “Core Biology” Lab Assessment Of Components Of Cure In Developing Countries
All samples to be sent to a central lab by courier.
MRD studies based on single parameter, e.g. TDT.
5-7 day turnaround time.
Results sent by .
Remaining sample to be stored for future studies.

54. What Is The Best Way To Risk Stratify Children With ALL In Developing Countries?
One parameter
(Not multiple like clinical, IP, DI, Cytogen, Mol, MRD)
MRD Estimation
Simplest version using single parameter
Functional assay

55. Management of Childhood ALL
Common Standard Rem. Ind Protocol
Estimation of MRD at D29/D43
> 1 %
< 0.01 %
< 0.1 %
? Less intensive Rx
? Shorter duration
D. D. I
Allo. BMT
Investigational Therapies  

56. CURABLE Childhood Cancers are PROVIDED THEY ARE…. diagnosed early
diagnosed properly
treated appropriately

57. ALL TEAM Clinical Lab Studies INCTR Collaboration
Dr. S.D.Banavali Dr.C.N.Nair Dr. Ian Magrath
Dr. P.A.Kurkure Dr. Ashok Kumar Ms. Melissa Adde
Dr. B.Arora Mr. Sashikant Dr. Kishore Bhatia
Dr. S.K.Pai Dr. A.Chougule Dr. Marina Gutierrez
Dr. P.M.Parikh Dr. P.M. Parikh
Dr. R.Bhagwat Dr.S. Barbhaya MSW Dept.
Dr. A.Vora Dr.S.Kamath Mr.M.A. Patil
Sister Asha Dr.P. Kadam Amre Ms. Neelima Dalvi
Ms. A. Paes
Dr. S.Chiplunkar Data Managers
Radiotherapy Dr.J.Khode Ms. B.Kolhatkar
Dr.M.A.Muckaden Ms.M.Patkar Ms.R.Hawaldar
Dr.S.Lashkar Ms. B.Tambe
Dr. N.Nair Mr.R.Kadam
Surgery Dr. S.Goswami
Dr. R.Mistry Dr.N.Merchant