Relapsefree Survival

Relapse-free survival is used only for patients who achieve CR and is calculated from the date CR was attained to the time of relapse or death' whichever occurs first. As described above' if the patient is not

Risk factor

Prognostic factors in adult ALL Note

Performance status

Leukocyte count

Immunophenotype

Karyotype

HOX11 oncogenea

Multidrug resistance

Age at diagnosis is one of the most important pretreatment risk factors, with advancing age being associated with a worse prognosis. Chronic and intercurrent diseases impair tolerance to aggressive therapy; acute medical problems at diagnosis may reduce the likelihood of survival.48-58

Performance status, independent of age, also influences the ability to survive induction therapy, and thus respond to treatment.54'57

■ High risk: poor performance status.

A high presenting leukocyte count is an independent prognostic factor; duration of CR is inversely related to the presenting leukocyte count.48-50,53,55,58-61

■ High risk: leukocyte count >30,000/^L in B-lineage disease and >100,000/^L in T-lineage disease

Immunophenotype at diagnosis is an independent prognostic factor. In brief, T-lineage immunophenotype confers better outcome than B lineage and the presence of 6 or more T-cell markers is associated with favorable prognosis.48,54,61-63

Chromosome findings at diagnosis are an independent prognostic factor. In brief, t(9;22), +8, t(4;11), -7, and hypodiploid karyotypes are associated with unfavorable outcome; normal karyotype, +21, and del(9p) or t(9p) confer an intermediate outcome; and del(12p) or t(12p) and t(14q11-q13) may be associated with favorable outcome.48'54'55'61'64-70

■ High risk: t(9;22), +8, t(4;11), -7, and hypodiploid karyotypes

The expression of HOX11 oncogene has a favorable outcome in adult T-lineage ALL.71

■ High risk: lack of HOX11 gene expression

The expression of multidrug resistance proteins is associated with an unfavorable outcome in adult ALL.72-77

■ High risk: expression of multidrug resistance proteins

Bone marrow biopsy morphology

Lactic dehydrogenase (LDH) level

Persistence of normal residual hematopoiesis and intense leukemic cells mitotic activity are associated with favorable outcome.78

High LDH level is associated with poor outcome54 and with CNS disease in some studies.54'79

■ High risk: elevated LDH

Eradication of the leukemic blasts from the peripheral blood or bone marrow at day 7 or day 14 was shown to be associated with a favorable outcome.45-47,53

■ High risk: lack of cytoreduction

In addition to pretreatment variables, achievement of CR correlates with prognosis in ALL.58'61

■ High risk: lack of achievement of CR with the first cycle of chemotherapy aEven though this factor was described only once in adult ALL, several studies described its significance in pediatric ALL and therefore this factor is mentioned herein.

Cytoreduction

Achievement of CR

known to have relapsed, or deceased, relapse-free survival is censored on the date the patient was last seen. Relapse-free survival is not subject to competing risks.

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