[Treatment of acute lymphoblastic leukemias in adults]

Acute lymphoblastic leukemia (ALL) is one of the few malignant disease for which substantial improvement was achieved during the last two decades. The complete remission (CR) rate is about 80% but the long-term remission rate is only 25-35%. Independent poor-prognostic factors include older age, presenting leukocyte count greater than 25-35 x 10(9)/l, cytogenetic abnormalities, egPh+/bcr-abl+, t(4;11), specific immunophenotype (pre-T, "mature" B) and longer time to achieve remission. Randomized studies show that the addition of anthracyclines to vincristine and prednisone improve the CR rates. Attempts to further intensify induction treatment have been limited to severe toxicity. There is evidence from trials with a variety of schedules that consolidation and maintenance therapy does improve the outcome. Hematologic toxicity is an important limitation in the treatment of adult with ALL. Whether the use of growth factors might improve outcome with chemotherapy requires long-term follow-up of large randomized studies. To reduce the risk of central nervous system (CNS) leukemia early intrathecal chemotherapy is necessary. Concomitant use of high-dose systemic chemotherapy or radiotherapy is useful in prophylaxis CNS leukemia in some studies but a risk oriented approach is needed. Allogenic bone marrow transplantation (BMT) in first CR is recommended for high-risk patients and is appropriate after relapse in all patients less than 55 years old. Autologus BMT in first and next CR as well as methods for purging malignant cells from procured marrow are potential use but require further clinical trials.