Remission Induction

O The initial treatment for acute leukemias is called induction. The purpose of induction is to induce a remission, a state where there is no identifiable leukemic cells in the bone marrow or peripheral blood with light microscopy. This definition may change as more sensitive techniques come into play.19 The current induction therapy for ALL typically consists of vincristine, asparaginase, and a steroid (prednisone or dexamethasone). An anthracycline is addedfor higher-risk patients. Adults, unlike children, are universally considered to be at high risk for relapse, thus their induction regimens include an anthracycline (daunorubicin or doxorubicin) in addition to the standard steroid and vincristine treatment that have been the backbone of treatment for this disease for the last 40 years.5 Dexamethasone is often replacing prednisone as the steroid of treatment because of its longer half-life and better CNS penetration.6,20 Even though dexamethasone possesses more favorable pharmacologic characteristics than prednisone, its use may be associated with more aseptic osteonecrosis of the femoral and humoral heads as well as an increase in life-threatening infections and 20

septic deaths. CNS Prophylaxis

Leukemic invasion of the CNS is considered to be an almost universal event in patients, even in those whose CSF cytology shows no apparent disease. Thus, all patients with ALL and AML leukemia receive intrathecal (IT) chemotherapy. Although this is often referred to as "prophylaxis," it more realistically represents treatment6 CNS prophylaxis relies on IT chemotherapy (e.g., methotrexate, cytarabine, and corticost-eroids), systemic chemotherapy with dexamethasone and high-dose methotrexate, and craniospinal irradiation (XRT) in selected high-risk patients.11 Cranial radiation was once a common intervention, but it is now reserved for only high-risk patients in whom IT treatment is inadequate. Its use has diminished substantially once the efficacy of IT treatment was evident, and the toxicities associated with radiation, learning disabilities, growth retardation, and secondary malignancies, were recognized. IT therapy has replaced cranial XRT as CNS prophylaxis for all except the very high-risk patients.

Inexplicably, the treatment of CNS leukemia has not had the same remarkable impact on the OS of adults as it has for childhood ALL. Although it reduces the incidence of CNS relapse in adults, it has not been associated with a measurable effect on survival.11

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