**Bone Marrow Transplantation (BMT) in Philadelphia-Positive Acute Lymphoblastic Leukemia (Ph+ ALL)**

Jorge Milone and Enrico Alicia

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/55523

## **1. Introduction**

Ph+ ALL represents approximately about 25 to 40% of adults patients with ALL. In children, Ph+ ALL is much less common. Different breakpoint in the bcr gene, major and minor, produce fusion genes resulting in either a 210 or a 190 KDa protein respectively. It appears that major breakpoint fusion (p210) originates in hematopoietic stem cells whereas minor breakpoint fusion (p190) has a B cell progenitor origin, suggesting that p190 ALL and p210 Ph+ ALL may be distinct biological and clinical entities. [1] BMT is the first option for consolidation the complete remission in this patients. The proportion of patients able to undergo BMT in CR1 (Complete Remission) has increased with imatinib-based induc‐ tion and early post-remission therapy, and there is currently no evidence that imatinib has an adverse effect on transplant-related morbidity or mortality (TMR). In addition, donor availability has benefitted from results showing equivalence of sibling and matched unrelated donors in terms of remission duration, non-relapse mortality and overall survival (OS).[1, 2] Several studies have shown improved post-transplant outcome of patients previously receiving imatinib-based treatment when compared with historic control groups, which have been dealt with in the previous chapter. As a consequence, most ALL study groups currently consider imatinib-based treatment, followed by matched related or unrelated allogeneic SCT (allo-SCT) in CR1, to be the gold standard of first-line therapy for Ph+ ALL. [3], Imatinib-based treatment not followed by SCT has been suggested to achieve OS and Disease Free Survival (DFS) similar to that obtained after SCT in one study, [4] and the results of MDACC study showed only a trend towards better OS in transplant‐ ed patients. [5] It still needs to be determined whether therapy based on second genera‐ tion TKI may be equivalent or superior to BMT in a subset of patients, particularly those at high risk of TRM

© 2013 Milone and Alicia; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

The challenges in the treatment of Ph+ ALL are the selection of appropriate pre-transplantation therapy, the minimization of transplantation toxicity, the correct use of TKIs after transplan‐ tation and the appropriate use of and response to BCR/ABL monitoring.

versus-host-disease), and was higher in patients with more advanced disease. Factors affecting event-free and overall survival likewise included disease status (CR1 vs > CR1) and higher age, with a cutoff at approximately 30 years, at the time of transplantation. [8] The intensified preparatory regimens confer long-term survival in a subset of patients with Ph+ ALL, relapse and TRM remain important causes of treatment failure, making success unlikely in patients with more advanced disease. Interestingly, comparable survival data were reported for patients with high-risk ALL with the Philadelphia chromosome and those with normal cytogenetic; actuarial disease-free survival (DFS) at 5 years was 43% for patients in first remission. Chronic GVHD appears to reduce the risk of relapse without increasing the risk of TRM, whereas severe acute GVHD increases the risk of TRM without diminishing the risk of relapse. Thus, patients who developed extensive chronic GVHD had better survivals, and those who developed grade III-IV acute GVHD had worse survivals than did the others. [8,9]

Bone Marrow Transplantation (BMT) in Philadelphia-Positive Acute Lymphoblastic Leukemia (Ph+ ALL)

http://dx.doi.org/10.5772/55523

267

**3. Reduced-intensity conditioning allogeneic stem cell transplantation**

must be interpreted with caution.

In order to decrease the high TRM associated with myeloablative allogeneic stem cell transplantation but still generate a graft-versus- leukemia effect (GVLE), reduced-intensi‐ ty conditioning (RIC) regimens were developed for patients unlikely to tolerate the toxicities of intensive preparative regimens. Overall, several retrospective analyses and a single prospective study suggest that BMT with RIC is feasible in adult patients with high-risk ALL but associated with a high probability of treatment failure in patients transplanted beyond CR1. [10,11,12,13] Myeloablative BMT carries considerable risk of TRM and is not applicable to older individuals. Opinions vary on the upper age limit for the procedure; in UKALL12/E2993, a very high TRM of nearly 40% was observed in patients older than 35 years of age receiving myeloablative BMT, resulting in a protocol limit of 40 years of age in the current UK NCRI study, UKALL14. In some studies, patients are offered myeloabla‐ tive BMT up to the age of 55 years. [14] There are several studies that show the results of the regimens of reduced intensity but with different results, selection and design which

A comparative study of European Group for Blood and Marrow Transplantation (EBMT) registry report one retrospective study where the outcome of 576 adult acute lymphoblas‐ tic leukemia patients aged > 45 years, and who received a reduced-intensity conditioning (RIC; n=127) or myeloablative conditioning (MAC; n=449) allogeneic stem cell transplanta‐ tion from a human leukocyte antigen-identical sibling while in complete remission is assessed. With a median follow-up of 16 months, at 2 years, the cumulative incidences of non-relapse mortality and relapse incidence were 29% (MAC) versus 21% (RIC), and 31% (MAC) versus 47% (RIC), respectively. In a multivariate analysis, nonrelapse mortality was decreased in RIC recipients, whereas it was associated with higher relapse rate. At 2 years, LFS was 38% (MAC) versus 32% (RIC). In multivariate analysis, the type of conditioning regimen (RIC vs. MAC) was not significantly associated with leukemia-free survival. For this authors the RIC allo-SCT from a human leukocyte antigen identical donor is a potential

#### **2. Allogeneic stem cell transplantation with myeloablative conditioning**

Attempts to improve outcome of Ph+ ALL included intensified conditioning regimens in order to reduce the relapse rate. An intensified preparatory regimen consisting of SCT after fractio‐ nated total body irradiation and Cyclophosphamide with or without etoposide has been explored by different investigation groups. Kröger et al investigated an intensified condition‐ ing regimen including fractionated total body irradiation (TBI) (12 Gy), etoposide (30-45 mg/kg) and cyclophosphamide (120 mg/kg), followed by autologous (n = 5), allo-related (n = 13) or allo-unrelated (n = 6) bone marrow (n = 22) or peripheral stem cell (n = 2) transplantation in patients with Ph+ALL. One patient received busulfan (16 mg/kg) instead of TBI. Nineteen patients were transplanted in 1CR, two in 2CR, one in 1PR and two in relapse. After a median follow-up of 45 months, nine patients (37.5%) remain alive in CR. Nine patients (37.5%) relapsed and eight (33.3%) of these subsequently died. After autologous transplantation, four of five patients (80%) relapsed and died. In terms of late relapse the authors had seen it after allogeneic, as well as autologous transplantation, at 33 and 59 months, respectively. The Kaplan-Meier estimate of leukemia-free survival for all patients was 38% at 3 years and 35% at 5 years. For allogeneic transplants in first CR (n = 15) the estimate of DFS was 46% at 3 years and 34% at 5 years. Patients aged below 30 years had a better estimated OS at 3 years (61% vs 11%, P < 0.001). The bcr-abl fusion transcript (p210 vs p190 vs p210/190) did not affect DFS OR OS. For the authors an intensified conditioning regimen seems to improve the results of bone marrow transplantation in patients with Ph+ acute lymphoblastic leukemia. [6]

In another study Laport et al. evaluated sixty-seven patients with HLA-matched sibling donor who received fractionated total body irradiation (FTBI) and high-dose VP16, whereas 11 patients received TBI/VP16/cyclophosphamide, and 1 patient received TBI/VP16/ busulfan. The median age was 36 years. At the time of BMT, 62% of the patients were in first complete remission and 38% of the patients were beyond CR1 (> CR1). The median follow-up was 75 months The 10-year OS for the CR1 and beyond CR1 patients was 54% and 29%, and event-free survival was 48% and 26%. The authors did not find significant difference in relapse incidence (28% vs 41%, but non relapse mortality was significantly higher in the beyond CR1 patients, (31% vs 54%). In this study the univariate analysis, factors affecting event-free and overall survival were white blood cell count at diagnosis (< 30 \_ 109/L vs > 30 \_ 109/L) and disease status (CR1 vs > CR1). The median time to relapse for CR1 and for beyond CR1 patients was 12 months and 9 months, respectively. These results showed that FTBI/VP16 with or without cyclophosphamide confers longterm survival in Ph+ ALL patients and that disease status at the time of BMT is an important predictor of outcome. [7]

In these and other studies the factors that identify modifications in the transplant outcome have been analyzed. Complications such as TRM was mainly due to infections or GVHD (graftversus-host-disease), and was higher in patients with more advanced disease. Factors affecting event-free and overall survival likewise included disease status (CR1 vs > CR1) and higher age, with a cutoff at approximately 30 years, at the time of transplantation. [8] The intensified preparatory regimens confer long-term survival in a subset of patients with Ph+ ALL, relapse and TRM remain important causes of treatment failure, making success unlikely in patients with more advanced disease. Interestingly, comparable survival data were reported for patients with high-risk ALL with the Philadelphia chromosome and those with normal cytogenetic; actuarial disease-free survival (DFS) at 5 years was 43% for patients in first remission. Chronic GVHD appears to reduce the risk of relapse without increasing the risk of TRM, whereas severe acute GVHD increases the risk of TRM without diminishing the risk of relapse. Thus, patients who developed extensive chronic GVHD had better survivals, and those who developed grade III-IV acute GVHD had worse survivals than did the others. [8,9]

The challenges in the treatment of Ph+ ALL are the selection of appropriate pre-transplantation therapy, the minimization of transplantation toxicity, the correct use of TKIs after transplan‐

**2. Allogeneic stem cell transplantation with myeloablative conditioning**

Attempts to improve outcome of Ph+ ALL included intensified conditioning regimens in order to reduce the relapse rate. An intensified preparatory regimen consisting of SCT after fractio‐ nated total body irradiation and Cyclophosphamide with or without etoposide has been explored by different investigation groups. Kröger et al investigated an intensified condition‐ ing regimen including fractionated total body irradiation (TBI) (12 Gy), etoposide (30-45 mg/kg) and cyclophosphamide (120 mg/kg), followed by autologous (n = 5), allo-related (n = 13) or allo-unrelated (n = 6) bone marrow (n = 22) or peripheral stem cell (n = 2) transplantation in patients with Ph+ALL. One patient received busulfan (16 mg/kg) instead of TBI. Nineteen patients were transplanted in 1CR, two in 2CR, one in 1PR and two in relapse. After a median follow-up of 45 months, nine patients (37.5%) remain alive in CR. Nine patients (37.5%) relapsed and eight (33.3%) of these subsequently died. After autologous transplantation, four of five patients (80%) relapsed and died. In terms of late relapse the authors had seen it after allogeneic, as well as autologous transplantation, at 33 and 59 months, respectively. The Kaplan-Meier estimate of leukemia-free survival for all patients was 38% at 3 years and 35% at 5 years. For allogeneic transplants in first CR (n = 15) the estimate of DFS was 46% at 3 years and 34% at 5 years. Patients aged below 30 years had a better estimated OS at 3 years (61% vs 11%, P < 0.001). The bcr-abl fusion transcript (p210 vs p190 vs p210/190) did not affect DFS OR OS. For the authors an intensified conditioning regimen seems to improve the results of bone

tation and the appropriate use of and response to BCR/ABL monitoring.

266 Clinical Epidemiology of Acute Lymphoblastic Leukemia - From the Molecules to the Clinic

marrow transplantation in patients with Ph+ acute lymphoblastic leukemia. [6]

important predictor of outcome. [7]

In another study Laport et al. evaluated sixty-seven patients with HLA-matched sibling donor who received fractionated total body irradiation (FTBI) and high-dose VP16, whereas 11 patients received TBI/VP16/cyclophosphamide, and 1 patient received TBI/VP16/ busulfan. The median age was 36 years. At the time of BMT, 62% of the patients were in first complete remission and 38% of the patients were beyond CR1 (> CR1). The median follow-up was 75 months The 10-year OS for the CR1 and beyond CR1 patients was 54% and 29%, and event-free survival was 48% and 26%. The authors did not find significant difference in relapse incidence (28% vs 41%, but non relapse mortality was significantly higher in the beyond CR1 patients, (31% vs 54%). In this study the univariate analysis, factors affecting event-free and overall survival were white blood cell count at diagnosis (< 30 \_ 109/L vs > 30 \_ 109/L) and disease status (CR1 vs > CR1). The median time to relapse for CR1 and for beyond CR1 patients was 12 months and 9 months, respectively. These results showed that FTBI/VP16 with or without cyclophosphamide confers longterm survival in Ph+ ALL patients and that disease status at the time of BMT is an

In these and other studies the factors that identify modifications in the transplant outcome have been analyzed. Complications such as TRM was mainly due to infections or GVHD (graft-

## **3. Reduced-intensity conditioning allogeneic stem cell transplantation**

In order to decrease the high TRM associated with myeloablative allogeneic stem cell transplantation but still generate a graft-versus- leukemia effect (GVLE), reduced-intensi‐ ty conditioning (RIC) regimens were developed for patients unlikely to tolerate the toxicities of intensive preparative regimens. Overall, several retrospective analyses and a single prospective study suggest that BMT with RIC is feasible in adult patients with high-risk ALL but associated with a high probability of treatment failure in patients transplanted beyond CR1. [10,11,12,13] Myeloablative BMT carries considerable risk of TRM and is not applicable to older individuals. Opinions vary on the upper age limit for the procedure; in UKALL12/E2993, a very high TRM of nearly 40% was observed in patients older than 35 years of age receiving myeloablative BMT, resulting in a protocol limit of 40 years of age in the current UK NCRI study, UKALL14. In some studies, patients are offered myeloabla‐ tive BMT up to the age of 55 years. [14] There are several studies that show the results of the regimens of reduced intensity but with different results, selection and design which must be interpreted with caution.

A comparative study of European Group for Blood and Marrow Transplantation (EBMT) registry report one retrospective study where the outcome of 576 adult acute lymphoblas‐ tic leukemia patients aged > 45 years, and who received a reduced-intensity conditioning (RIC; n=127) or myeloablative conditioning (MAC; n=449) allogeneic stem cell transplanta‐ tion from a human leukocyte antigen-identical sibling while in complete remission is assessed. With a median follow-up of 16 months, at 2 years, the cumulative incidences of non-relapse mortality and relapse incidence were 29% (MAC) versus 21% (RIC), and 31% (MAC) versus 47% (RIC), respectively. In a multivariate analysis, nonrelapse mortality was decreased in RIC recipients, whereas it was associated with higher relapse rate. At 2 years, LFS was 38% (MAC) versus 32% (RIC). In multivariate analysis, the type of conditioning regimen (RIC vs. MAC) was not significantly associated with leukemia-free survival. For this authors the RIC allo-SCT from a human leukocyte antigen identical donor is a potential therapeutic option for acute lymphoblastic leukemia patients aged > 45 years in complete remission and not eligible for MAC allo. [15]

high relapse rate. This hypothesis was evaluated in another prospective study by Wassmann and al. in 27 Ph+ALL patients that received imatinib upon detection of MRD after SCT. Bcrabl transcripts became undetectable in 52% of the patients, after a median of 1.5 months, (they called earlyCRmol). All patients who achieved an earlyCRmol remained in remission for the duration of imatinib treatment; 3 patients relapsed after imatinib was discontinued. The failure to achieve polymerase chain reaction (PCR) negativity shortly after starting imatinib predicted relapse which occurred in 12 of 13 patients after a median of 3 month. The DFS in early-CRmol patients was 91% and 54% after 12 and 24 months, respectively, compared with 8% after 12 months in patients remaining MRD+. Thus in the post-transplant setting, the molecular response to imatinib discriminates between patients with long-term DFS and patients likely to experience relapse and who therefore should receive additional or alternative antileukemic

Bone Marrow Transplantation (BMT) in Philadelphia-Positive Acute Lymphoblastic Leukemia (Ph+ ALL)

http://dx.doi.org/10.5772/55523

269

Burke et al between 1999 and 2006, in a single-center analysis of 32 patients with Ph+ ALL, including pediatric patients, who underwent allo-HCT and received imatinib in either the preor post-transplant period. The median age at HCT was 21.9 years, of 32 patients, 15 received Imatinib therapy pre- or post-HCT (imatinib group) and 17 patients received either no imatinib (n=11) or only after relapsed (n=6) (non imatinib group) There was a trend towards improved OS, relapse-free survival and relapse at 2 years was, 61%, 67% and 13% for the imatinib group (n = 15) as compared with the 41%, 35% and 35% for the non-imatinib group (n = 17), respec‐ tively. Cardiac toxicity and TRM at 2 years were similar between the groups. [20] Overall, further data is needed to define the optimal use and impact of imatinib in the peri-transplant

 **ALL**

Real-time PCR *BCR-ABL* quantification is often used to monitor minimal residual disease in

while there is considerable standardization of methodology for p210 quantification, there is less standardization than for p190 quantification.[17] There are conflicting reports on the association between an initial decrease in *BCR-ABL* transcript level and long-term outcome. Preudhomme C et al. In the "pre-imatinib" era, have observed a good correlation between *BCR-ABL* transcript levels and the outcome which had been reported in 17 patients with Ph

Ottmann et al. analyzed in elderly patients with de novo Ph+ALL who were randomly assigned to induction therapy with either imatinib Ind(IM)) or multiagent, age-adapted chemotherapy Ind(chemo). Imatinib was subsequently co-administered with consolidation chemotherapy. The *BCR-ABL* transcript levels have also been correlated with response. [22] Unlike in chronic

Lee et al were able to demonstrate that a 3-log reduction in *BCR-ABL* transcripts after 1 month of imatinib treatment strongly predicted a reduced relapse risk. The outcomes were evaluated

myeloid leukemia, there is no consensus on what represents an optimal response.

ALL, but optimal practice and interpretation of results is unclear. In addition,

therapy. [19]

patients with Ph+

+ALL. [21]

management of patients with Ph+ ALL.

**6. Monitoring of** *BCR-ABL* **in Ph+**

The RIC approaches should be vigorously pursued as part of prospective studies in order to define their role in ALL. In Ph+ ALL in particular, inquiry into the role of TKIs after alloHSCT is vital. The forthcoming study from the UK NCRI, UKALL14, assigned all patients with ALL of 40 years of age or more to a nonmyeloablative approach with fludarabine, melphalan, and alemtuzumab in an attempt to obtain good disease control with less GVHD. [14] The incidence of TRM and disease progression in these studies was still substantial, however particularly in patients transplanted beyond first CR. The incidence of acute (grades II-IV) and chronic GVHD (43.2% and 65.6%, respectively) was high, but the significantly lower frequency of disease progression in patients with cGVHD highlights the antileukemic activity of cGVHD [15]

## **4. Autologous stem cell transplantation**

The role of autologous stem cell transplantation (ASCT) was studied most extensively in the pre-imatinib era and has attracted little interest since then. While there are no prospective, randomized trials comparing autologous and allogeneic SCT, treatment outcome with conventional ASCT procedures has consistently been inferior to BMT in several retrospective analyses due to a high relapse rate. More recently, some investigators have reevaluated the therapeutic potential of ASCT when given in conjunction with TKI. Shin et al. describe an approach in which Ph+ ALL patients receive imatinib as interim therapy between chemother‐ apeutic cycles and prior to autologous SCT, followed by maintenance therapy. Small patient numbers and as yet limited duration of follow-up preclude a definite assessment of this strategy, which can be expanded to include the more potent second-generation TKI. [15, 16]

## **5. Imatinib after SCT**

A very important and as yet unanswered question concerns whether TKIs should be admin‐ istered after BMT and under what circumstances. The high risk of relapse in patients who are MRD positive after SCT makes administration of an ABL-directed TKI conceptually attractive as a measure to prevent relapse and reestablish molecular negativity. [17] Administration of imatinib early after HCT was tested by Carpenter et al in 22 patients, 15 with Ph+ ALL and 7 with high-risk chronic myelogenous leukemia, (CML) who were enrolled in a prospective study and given imatinib from the time of engraftment until 365 days after HCT. Before day 90, adults (n =19) tolerated a median average daily imatinib dose of 400 mg/d, and children (n = 3) tolerated 265 mg/m2/d. The most common adverse events described by the authors were related to imatinib administration with grade 1-3 nausea, emesis, and serum transaminase elevations. [18]

The positive minimal residual disease (MRD) after stem cell transplantation: is associated with a relapse probability exceeding 90%. Starting imatinib in the setting of MRD may decrease this high relapse rate. This hypothesis was evaluated in another prospective study by Wassmann and al. in 27 Ph+ALL patients that received imatinib upon detection of MRD after SCT. Bcrabl transcripts became undetectable in 52% of the patients, after a median of 1.5 months, (they called earlyCRmol). All patients who achieved an earlyCRmol remained in remission for the duration of imatinib treatment; 3 patients relapsed after imatinib was discontinued. The failure to achieve polymerase chain reaction (PCR) negativity shortly after starting imatinib predicted relapse which occurred in 12 of 13 patients after a median of 3 month. The DFS in early-CRmol patients was 91% and 54% after 12 and 24 months, respectively, compared with 8% after 12 months in patients remaining MRD+. Thus in the post-transplant setting, the molecular response to imatinib discriminates between patients with long-term DFS and patients likely to experience relapse and who therefore should receive additional or alternative antileukemic therapy. [19]

Burke et al between 1999 and 2006, in a single-center analysis of 32 patients with Ph+ ALL, including pediatric patients, who underwent allo-HCT and received imatinib in either the preor post-transplant period. The median age at HCT was 21.9 years, of 32 patients, 15 received Imatinib therapy pre- or post-HCT (imatinib group) and 17 patients received either no imatinib (n=11) or only after relapsed (n=6) (non imatinib group) There was a trend towards improved OS, relapse-free survival and relapse at 2 years was, 61%, 67% and 13% for the imatinib group (n = 15) as compared with the 41%, 35% and 35% for the non-imatinib group (n = 17), respec‐ tively. Cardiac toxicity and TRM at 2 years were similar between the groups. [20] Overall, further data is needed to define the optimal use and impact of imatinib in the peri-transplant management of patients with Ph+ ALL.

#### **6. Monitoring of** *BCR-ABL* **in Ph+ ALL**

therapeutic option for acute lymphoblastic leukemia patients aged > 45 years in complete

The RIC approaches should be vigorously pursued as part of prospective studies in order to define their role in ALL. In Ph+ ALL in particular, inquiry into the role of TKIs after alloHSCT is vital. The forthcoming study from the UK NCRI, UKALL14, assigned all patients with ALL of 40 years of age or more to a nonmyeloablative approach with fludarabine, melphalan, and alemtuzumab in an attempt to obtain good disease control with less GVHD. [14] The incidence of TRM and disease progression in these studies was still substantial, however particularly in patients transplanted beyond first CR. The incidence of acute (grades II-IV) and chronic GVHD (43.2% and 65.6%, respectively) was high, but the significantly lower frequency of disease progression in patients with cGVHD highlights the antileukemic activity of cGVHD [15]

The role of autologous stem cell transplantation (ASCT) was studied most extensively in the pre-imatinib era and has attracted little interest since then. While there are no prospective, randomized trials comparing autologous and allogeneic SCT, treatment outcome with conventional ASCT procedures has consistently been inferior to BMT in several retrospective analyses due to a high relapse rate. More recently, some investigators have reevaluated the therapeutic potential of ASCT when given in conjunction with TKI. Shin et al. describe an approach in which Ph+ ALL patients receive imatinib as interim therapy between chemother‐ apeutic cycles and prior to autologous SCT, followed by maintenance therapy. Small patient numbers and as yet limited duration of follow-up preclude a definite assessment of this strategy, which can be expanded to include the more potent second-generation TKI. [15, 16]

A very important and as yet unanswered question concerns whether TKIs should be admin‐ istered after BMT and under what circumstances. The high risk of relapse in patients who are MRD positive after SCT makes administration of an ABL-directed TKI conceptually attractive as a measure to prevent relapse and reestablish molecular negativity. [17] Administration of imatinib early after HCT was tested by Carpenter et al in 22 patients, 15 with Ph+ ALL and 7 with high-risk chronic myelogenous leukemia, (CML) who were enrolled in a prospective study and given imatinib from the time of engraftment until 365 days after HCT. Before day 90, adults (n =19) tolerated a median average daily imatinib dose of 400 mg/d, and children (n = 3) tolerated 265 mg/m2/d. The most common adverse events described by the authors were related to imatinib administration with grade 1-3 nausea, emesis, and serum transaminase

The positive minimal residual disease (MRD) after stem cell transplantation: is associated with a relapse probability exceeding 90%. Starting imatinib in the setting of MRD may decrease this

remission and not eligible for MAC allo. [15]

268 Clinical Epidemiology of Acute Lymphoblastic Leukemia - From the Molecules to the Clinic

**4. Autologous stem cell transplantation**

**5. Imatinib after SCT**

elevations. [18]

Real-time PCR *BCR-ABL* quantification is often used to monitor minimal residual disease in patients with Ph+ ALL, but optimal practice and interpretation of results is unclear. In addition, while there is considerable standardization of methodology for p210 quantification, there is less standardization than for p190 quantification.[17] There are conflicting reports on the association between an initial decrease in *BCR-ABL* transcript level and long-term outcome. Preudhomme C et al. In the "pre-imatinib" era, have observed a good correlation between *BCR-ABL* transcript levels and the outcome which had been reported in 17 patients with Ph +ALL. [21]

Ottmann et al. analyzed in elderly patients with de novo Ph+ALL who were randomly assigned to induction therapy with either imatinib Ind(IM)) or multiagent, age-adapted chemotherapy Ind(chemo). Imatinib was subsequently co-administered with consolidation chemotherapy. The *BCR-ABL* transcript levels have also been correlated with response. [22] Unlike in chronic myeloid leukemia, there is no consensus on what represents an optimal response.

Lee et al were able to demonstrate that a 3-log reduction in *BCR-ABL* transcripts after 1 month of imatinib treatment strongly predicted a reduced relapse risk. The outcomes were evaluated for Ph+ ALL in 23 adults patients in remission treated with allogeneic bone marrow trans‐ plantation (BMT) [23]

**7. Resistence**

pressure of TKI treatment.

Approximately 80 %to 90% of patients with Ph+ ALL who relapse while on imatinib are found to have BCR/ABL mutation with predominance of P-loop and T315I mutations. With dasatinib relapse is most frequently associated with T315I mutation, whereas P-loop mutations are less common. [28] With variable frequency, the mutations can be present at the time of diagnose. Pfeifer et al detected low levels of mutations in pretreated patients with imatinib with Ph+ ALL who, at the time of relapse, presented the same mutated dominant clone in most of the cases. Soverini et al also reported a high frequency of BCR/ABL mutations which were lately found at the time of relapse. [25,26] Mutations can also be acquired or emerge under the selection

Bone Marrow Transplantation (BMT) in Philadelphia-Positive Acute Lymphoblastic Leukemia (Ph+ ALL)

http://dx.doi.org/10.5772/55523

271

Other additional mechanisms of resistance to therapy with TKI have also been suggested, such as cytogenetic abnormalities in addition to Ph chromosome which are present in approxi‐ mately one third of cases of adult leukemia and have been associated with inferior outcome. Members of the SRC family of kinase have been implicated in leukemogenesis and in the development of imatinib resistance in BCR/ABL positive ALL, suggesting that simultaneous inhibition of Src and Bcr/Abl kinases may benefit individuals with Ph+ acute leukemia. [29, 30]

Relapsed ALL is a clinical problem, and outcomes are extremely poor. Fielding et al in the UKALL12/ECOG study, examined 609 adults with recurring ALL, where the OS of newly diagnosed patients was 38% at 5 years, OS at 5 years after relapse was 7%. [31] The CR2 is possible in only ∼ 50% of chemotherapy-treated patients. Many young patients with Ph+

will have already received alloHSCT, making salvage harder and with more toxicity, partic‐ ularly if chemotherapy reinduction is under consideration. Nevertheless a phase 2 study of dasatinib 140 mg/d in patients who relapsed after imatinib-containing regimens demonstrated that approximately half of the patients could achieve a CR2 with modest toxicity. However, median remission duration was only 3.3 months. Under these circumstances, a second allo-HSCT might be considered.[32] Ishida et published case report which shows a positive outcome for a patient who received dasatinib followed by a RIC alloHSCT after imatinib and myeloablative allo-HSCT which failed to control the disease. All reports of allo-HSCT show less than an ideal outcome in patients beyond CR1. However, many of these were reported before the advent of TKIs, which might, in selected circumstances, allow for second definitive transplantation procedures [33] Among the strategies to treat Ph + ALL relapse after Allo-SCT we will mention donor lymphocyte infusion. This treatment seems to be effective in CML, but it is less useful in ALL maybe due to the immune escape mechanisms of the blastic cells. Likewise, the addition of chemotherapy to ILD is not associated with a better prognosis.

Immunotherapy with donor lymphocyte infusion (DLI) and imatinib appears to be well tolerated but it is rarely and in general only transiently effective. A rationale for the combined

ALL

**8. Relapses in Ph+ acute lymphoblastic leukemia**

In contrast to the data published by these authors, Yanada et al observed no association between rapid achievement of *BCR-ABL* negativity and long-term outcome after an initial imatinib/chemotherapy induction regimen in 100 patients with Ph+ ALL treated and MRD monitoring [24]

Pfeifer et al examined the prevalence of KD mutations in newly diagnosed and Imatinib-naïve Ph+ ALL patients and assessed their clinical relevance in the setting of uniform frontline therapy with imatinib in combination with chemotherapy. The German Multicenter Study Group for Adult Acute Lymphoblastic Leukemia (GMALL) trial ADE10 for newly diagnosed elderly Ph+ ALL were retrospectively examined for the presence of BCR/ABL KD mutation by denaturing high-performance liquid chromatography (DHPLC),cDNA sequencing and allelespecific polymerase chain reaction (PCR). A KD mutation was detected in a minor subpopu‐ lation of leukemic cells in 40% of newly diagnosed and imatinib naïve patients. At relapse the domin cell clone harbored an identical mutation in 90% of the cases, the overall prevalence of mutations at relapse was 80 %. P loop mutations predominated and were not associated with an inferior hematologic or molecular remission rate or shorter rmission duration compared with unmutated BCR/ABL. BCR/ABL mutations conferring high level imatinib resistance are present in a substantial proportion of patients with de novo Ph+ ALL and eventually give rise to relapse.[25]

Soverini et al. analyzed samples collected at diagnosis from 15 patients with Philadelphiapositive acute lymphoblastic leukemia who subsequently received tyrosine kinase inhibitor therapy (dasatinib) by cloning the BCR-ABL kinase domain in a bacterial vector and sequenc‐ ing 200 independent clones per sample. Mutations at relatively low levels (2-4 clones out of 200) could be detected in all patients--eight who relapsed and seven who achieved persistent remission. Each patient had evidence of two to eight different mutations, the majority of which have never been reported in association with resistance to tyrosine kinase inhibitors. They suggest that the BCR-ABL kinase domain is prone to randomly accumulate point mutations, although the presence of these mutations in a relatively small leukemic subclone does not always preclude a primary response to tyrosine Kinase inhibitor. [26]

So much imatinib or dasatinib regimens can be achieving complete clinical response in 95 -100% of patients.

Eligible patients will be treated with alloHSCT wherever possible, and for these patients, *BCR-ABL* monitoring early in the course of the disease is unlikely to change practice at present. For patients not receiving alloHSCT, serial monitoring during initial therapy is of more relevance because it might prompt a switch of therapy before hematological relapse. [17]

At present, the evidence suggests that *BCR-ABL* by RTQ-PCR should be monitored and must be combined with screening for BCR/ABL domain mutations (in case of suspected resistance) after alloHSCT and that reemergence of *BCR-ABL* is a rational basis for intervention. [27]

## **7. Resistence**

for Ph+ ALL in 23 adults patients in remission treated with allogeneic bone marrow trans‐

270 Clinical Epidemiology of Acute Lymphoblastic Leukemia - From the Molecules to the Clinic

In contrast to the data published by these authors, Yanada et al observed no association between rapid achievement of *BCR-ABL* negativity and long-term outcome after an initial imatinib/chemotherapy induction regimen in 100 patients with Ph+ ALL treated and MRD

Pfeifer et al examined the prevalence of KD mutations in newly diagnosed and Imatinib-naïve Ph+ ALL patients and assessed their clinical relevance in the setting of uniform frontline therapy with imatinib in combination with chemotherapy. The German Multicenter Study Group for Adult Acute Lymphoblastic Leukemia (GMALL) trial ADE10 for newly diagnosed elderly Ph+ ALL were retrospectively examined for the presence of BCR/ABL KD mutation by denaturing high-performance liquid chromatography (DHPLC),cDNA sequencing and allelespecific polymerase chain reaction (PCR). A KD mutation was detected in a minor subpopu‐ lation of leukemic cells in 40% of newly diagnosed and imatinib naïve patients. At relapse the domin cell clone harbored an identical mutation in 90% of the cases, the overall prevalence of mutations at relapse was 80 %. P loop mutations predominated and were not associated with an inferior hematologic or molecular remission rate or shorter rmission duration compared with unmutated BCR/ABL. BCR/ABL mutations conferring high level imatinib resistance are present in a substantial proportion of patients with de novo Ph+ ALL and eventually give rise

Soverini et al. analyzed samples collected at diagnosis from 15 patients with Philadelphiapositive acute lymphoblastic leukemia who subsequently received tyrosine kinase inhibitor therapy (dasatinib) by cloning the BCR-ABL kinase domain in a bacterial vector and sequenc‐ ing 200 independent clones per sample. Mutations at relatively low levels (2-4 clones out of 200) could be detected in all patients--eight who relapsed and seven who achieved persistent remission. Each patient had evidence of two to eight different mutations, the majority of which have never been reported in association with resistance to tyrosine kinase inhibitors. They suggest that the BCR-ABL kinase domain is prone to randomly accumulate point mutations, although the presence of these mutations in a relatively small leukemic subclone does not

So much imatinib or dasatinib regimens can be achieving complete clinical response in 95

Eligible patients will be treated with alloHSCT wherever possible, and for these patients, *BCR-ABL* monitoring early in the course of the disease is unlikely to change practice at present. For patients not receiving alloHSCT, serial monitoring during initial therapy is of more relevance

At present, the evidence suggests that *BCR-ABL* by RTQ-PCR should be monitored and must be combined with screening for BCR/ABL domain mutations (in case of suspected resistance) after alloHSCT and that reemergence of *BCR-ABL* is a rational basis for intervention. [27]

because it might prompt a switch of therapy before hematological relapse. [17]

always preclude a primary response to tyrosine Kinase inhibitor. [26]

plantation (BMT) [23]

monitoring [24]

to relapse.[25]


Approximately 80 %to 90% of patients with Ph+ ALL who relapse while on imatinib are found to have BCR/ABL mutation with predominance of P-loop and T315I mutations. With dasatinib relapse is most frequently associated with T315I mutation, whereas P-loop mutations are less common. [28] With variable frequency, the mutations can be present at the time of diagnose. Pfeifer et al detected low levels of mutations in pretreated patients with imatinib with Ph+ ALL who, at the time of relapse, presented the same mutated dominant clone in most of the cases. Soverini et al also reported a high frequency of BCR/ABL mutations which were lately found at the time of relapse. [25,26] Mutations can also be acquired or emerge under the selection pressure of TKI treatment.

Other additional mechanisms of resistance to therapy with TKI have also been suggested, such as cytogenetic abnormalities in addition to Ph chromosome which are present in approxi‐ mately one third of cases of adult leukemia and have been associated with inferior outcome. Members of the SRC family of kinase have been implicated in leukemogenesis and in the development of imatinib resistance in BCR/ABL positive ALL, suggesting that simultaneous inhibition of Src and Bcr/Abl kinases may benefit individuals with Ph+ acute leukemia. [29, 30]

## **8. Relapses in Ph+ acute lymphoblastic leukemia**

Relapsed ALL is a clinical problem, and outcomes are extremely poor. Fielding et al in the UKALL12/ECOG study, examined 609 adults with recurring ALL, where the OS of newly diagnosed patients was 38% at 5 years, OS at 5 years after relapse was 7%. [31] The CR2 is possible in only ∼ 50% of chemotherapy-treated patients. Many young patients with Ph+ ALL will have already received alloHSCT, making salvage harder and with more toxicity, partic‐ ularly if chemotherapy reinduction is under consideration. Nevertheless a phase 2 study of dasatinib 140 mg/d in patients who relapsed after imatinib-containing regimens demonstrated that approximately half of the patients could achieve a CR2 with modest toxicity. However, median remission duration was only 3.3 months. Under these circumstances, a second allo-HSCT might be considered.[32] Ishida et published case report which shows a positive outcome for a patient who received dasatinib followed by a RIC alloHSCT after imatinib and myeloablative allo-HSCT which failed to control the disease. All reports of allo-HSCT show less than an ideal outcome in patients beyond CR1. However, many of these were reported before the advent of TKIs, which might, in selected circumstances, allow for second definitive transplantation procedures [33] Among the strategies to treat Ph + ALL relapse after Allo-SCT we will mention donor lymphocyte infusion. This treatment seems to be effective in CML, but it is less useful in ALL maybe due to the immune escape mechanisms of the blastic cells. Likewise, the addition of chemotherapy to ILD is not associated with a better prognosis.

Immunotherapy with donor lymphocyte infusion (DLI) and imatinib appears to be well tolerated but it is rarely and in general only transiently effective. A rationale for the combined use of DLI and second-generation TKIs such as nilotinib is suggested by case reports, but prospectively collected data are as yet not available. [34]

kemia in adults: significant roles of total body irradiation and chronic graft-versus-

Bone Marrow Transplantation (BMT) in Philadelphia-Positive Acute Lymphoblastic Leukemia (Ph+ ALL)

http://dx.doi.org/10.5772/55523

273

[9] Doney, K, Hagglun, H, Leisenring, W, et al. Predictive Factors for Outcome of Allo‐ geneic Hematopoietic Cell Transplantation for Adult Acute Lymphoblastic Leuke‐

[10] Martino, R, Giralt, S, Caballero, M. D, et al. Allogeneic hematopoietic stem cell trans‐ plantation with reduced-intensity conditioning in acute lymphoblastic leukemia: a

[11] Arnol, R, Massenkeil, G, Bornhauser, M, et al. Nonmyeloablative stem cell transplan‐ tation in adults with high risk ALL may be effective in early but not in advanced dis‐

[12] Mohty, M, Labopin, m, Reza, T, et al. Reduced intensity conditioning allegeneic stem cell transplantation for adult patients with acute lymphoblastic leukemia: a retro‐ spective study From the Europeasn Group for Blood and Marrow Transplantation

[13] Hamaki, T, & Kami, M. kanda Y reduced intensity stem cell transplantation for adult acute lymphoblastic leukemia a retrospective study of 33 patients. Bone marrow

[14] Fielding, A, & Rowe, M. Richards G prospective outcome data 267 unselected adult patients with Philadelphia chromosome-positive acute lymphoblastic leukemia con‐ firm superiority of allogeneic transplantation over chemotherapy in the pre imatinib

[15] Ottman, O, & Pfeifer, H. Management of Philadelphia chromosome positive acute lymphoblastic leukemia (Ph+ALL) Hematology (2009). ASH Educational , 371-381.

[16] Shin, H, & Chung, J. S. and Cho Imatinib interim therapy between chemotherapeutic cycles and in vivo purging prior to autologous stem cell transplantation, followed by maintenance therapy is a feasible treatment strategy in Philadelphia chromosomepositive acute lymphoblastic leukemia. Bone Marrow Transplant. (2005). Nov;,

[17] Fielding, A. Current Managenemt Issues in Acute Lymphicityc Leukemia. ASH ,

[18] Carpenter, P. A, Snyder, D. S, & Flowers, M. Prophylactic administration of imatinib after hematopoietic cell transplantation for high-risk Philadelphia chromosome-posi‐

[19] Wassmann, B, Pfeifer, H, & Stadler, M. Early molecular response to post transplanta‐ tion imatinib determines outcome in MRD+ Philadelphia-positive acute lymphoblas‐

era: result from the international ALL Trial MCR UKALLXII/ECOG 2993.

mia. Biology of Blood and Marrow Transplantation 9:472-481 ((2003).

host disease Bone Marrow Transplantation ((2005).

feasibility study. Haematologica. (2003). , 88, 555-560.

ease. Leukemia ((2002).

hematologyca , 2008-93.

36(10), 917-8.

2011-231.

transplantation (2005). , 2005, 35-549.

tive leukemia Blood (2007). , 2007, 109-2791.

tic leukemia (Ph- ALL Blood. (2005). , 106, 458-463.

## **Author details**

Jorge Milone and Enrico Alicia

\*Address all correspondence to: enrico@netverk.com.ar

Hematology Area, Hospital Italiano de la Plata, La PLata, Argentina

## **References**


kemia in adults: significant roles of total body irradiation and chronic graft-versushost disease Bone Marrow Transplantation ((2005).

[9] Doney, K, Hagglun, H, Leisenring, W, et al. Predictive Factors for Outcome of Allo‐ geneic Hematopoietic Cell Transplantation for Adult Acute Lymphoblastic Leuke‐ mia. Biology of Blood and Marrow Transplantation 9:472-481 ((2003).

use of DLI and second-generation TKIs such as nilotinib is suggested by case reports, but

[1] Fielding AK; Goldstone AHAllogeneic haematopoietic stem cell transplant in Phila‐ delphia-positive acute lymphoblastic leukemia. Bone marrow transplantation ((2008).

[2] Castor, A, Nilsson, L, et al. distint patterns of hematopoitic stem cell involvement in

[3] Lee, S, & Yoo-jin, K. Cgang Ki M ey al. The effect of first-line imatinib interin therapy on the outcome of allogeneic stem cell transplantation in adult with newly diagnosed

[4] Yanada, M, Takeuchi, J, Sugiura, I, et al. High complete remission rate and promising outcome by combination of imatinib and chemotherapy for newly diagnosed BCR-ABL-positive acute lymphoblastic leukemia: a phase II study by the Japan Adult

[5] De Labarthe, A, Rousselot, P, & Huguet-rigal, F. Imatinib combined with induction or consolidation chemotherapy in patients with de novo Philadelphia chromosomepositive acute lymphoblastic leukemia: results of the GRAAPH-2003 study. Blood.

[6] Kröger, N, & Krüger, W. Wacker-Backhaus G Intensified conditioning regimen in bone marrow transplantation for Philadelphia chromosome-positive acute lympho‐

[7] Ginna, G. Laport, Joseph C. Alvarnas, Joycelynne M. Long-term remission of Phila‐ delphia chromosome-positive acute lymphoblastic leukemia after allogeneic hemato‐ poietic cell transplantation from matched sibling donors: a year experience with the

[8] Yanada, M, Naaoe, T, Iiada, H, et al. Myeloablative allogeneic hematopoietic stem cell transplantation for Philadelphia chromosome-positive acute lymphoblastic leu‐

blastic leukemia. Bone Marrow Transplant. (1998). Dec;, 22(11), 1029-33.

fractionated total body irradiation-etoposide regimen Blood (2008). , 20.

Philadelphia chromosome positive acute lymphoblastic leukemia Blood , 105

acute lymphoblastic leukemia. Nature Medicine, 11.630-637 ((2005).

Leukemia Study Group. J Clin Oncol. (2006). Jan 20;, 24(3), 460-6.

prospectively collected data are as yet not available. [34]

272 Clinical Epidemiology of Acute Lymphoblastic Leukemia - From the Molecules to the Clinic

\*Address all correspondence to: enrico@netverk.com.ar

(2007). Feb 15;, 109(4), 1408-13.

Hematology Area, Hospital Italiano de la Plata, La PLata, Argentina

**Author details**

**References**

Jorge Milone and Enrico Alicia


[20] Burke, J, & Trotz, B. Baker K allohematopoieic cell transplantation for Ph chromo‐ some-positive ALL: impact of imatinib on relapse and survival.Bone Marrow Trans‐ plantation ((2009).

[32] Ottmann, O, Dombret, H, Martinelli, G, et al. Dasatinib induces rapid hematologic and cytogenetic responses in adult patients with Philadelphia chromosome-positive acute lymphoblastic leukemia with resistance or intolerance to imatinib: interim re‐

Bone Marrow Transplantation (BMT) in Philadelphia-Positive Acute Lymphoblastic Leukemia (Ph+ ALL)

http://dx.doi.org/10.5772/55523

275

[33] Ishida, Y, Terasako, K, & Oshima, K. Dasatinib followed by second allegeneic hema‐ topoietic stem cell transplantation for relapse of Philadelphia chromosome-positive acute lymphoblastic leukemia after the first transplantation Int J Hematol (2010).

[34] Tiribelli, M, & Sperotto, A. Candoni A Mario TiribelliAlessandra SperottoAnna Can‐ doniErica SimeoneSilvia ButtignolRenato FaninNilotinib and donor lymphocyte in‐ fusion in the treatment of Philadelphia-positive acute lymphoblastic leukemia (Ph+ ALL) relapsing after allogeneic stem cell transplantation and resistant to imatinib.

sults of a phase 2 study- Blood, (2007). , 2007, 110-7.

Leukemia Research (2009). , 33(2009), 174-177.

Oct,, 92(3), 542-6.


[32] Ottmann, O, Dombret, H, Martinelli, G, et al. Dasatinib induces rapid hematologic and cytogenetic responses in adult patients with Philadelphia chromosome-positive acute lymphoblastic leukemia with resistance or intolerance to imatinib: interim re‐ sults of a phase 2 study- Blood, (2007). , 2007, 110-7.

[20] Burke, J, & Trotz, B. Baker K allohematopoieic cell transplantation for Ph chromo‐ some-positive ALL: impact of imatinib on relapse and survival.Bone Marrow Trans‐

[21] Preudhomme, C, & Henic, N. Cazin B Good correlation between RT-PCR analysis and relapse in Philadelphia (Ph1)-positive acute lymphoblastic leukemia (ALL). Leu‐

[22] Ottmann, O. G, & Wassmann, B. Pfeifer H Imatinib compared with chemotherapy as front-line treatment of elderly patients with Philadelphia chromosome-positive acute

[23] Lee, S, & Kim, D. W. Cho B Risk factors for adults with Philadelphia-chromosomepositive acute lymphoblastic leukaemia in remission treated with allogeneic bone marrow transplantation: the potential of real-time quantitative reverse-transcription

[24] Yanada, M, Sugiura, I, & Takeuchi, J. Prospective monitoring of BCR-ABL1 transcript levels in patients with Philadelphia chromosome-positive acute lymphoblastic leu‐ kaemia undergoing imatinib-combined chemotherapy. Br J Haematol. (2008). Nov;,

[25] Pfeifer, H, & Wassmann, B. Pavlova A Kinase domain mutations of BCR-ABL fre‐ quently precede imatinib-based therapy and give rise to relapse in patients with de novo Philadelphia-positive acute lymphoblastic leukemia (Ph+ ALL). Blood (2007).

[26] Soverini, S, & Vitale, A. Poerio A Philadelphia-positive acute lymphoblastic leukemia patients already harbor BCR-ABL kinase domain mutations at low levels at the time

[27] Nicola Gokbuget Recommendations of the European Working Group for Adult ALL

[28] Soverini, S, Colarossi, S, & Gnani, A. Resistance to dasatinib in Philadelphia-positive leukemia patients and the presence or the selection of mutations at residues 315 and

[29] Hu, Y, Liu, Y, & Pelletier, S. Buchdunger E Requirement of Src kinases Lyn, Hck and Fgr for BCR-ABL1-induced B-lymphoblastic leukemia but not chronic myeloid leuke‐

[30] Li, S. Src-family kinases in the development and therapy of Philadelphia chromo‐ some-positive chronic myeloid leukemia and acute lymphoblastic leukemia. Leuk

[31] Fielding, A. K, Rchards, S. M, & Chopra, R. Outcome of 609 adults after relapse of acute lymphoblastic leukemia (ALL), an MRC UKALL12/ECOG 2993 study Blood

of diagnosis. Haematologica. (2011). Apr;, 96(4), 552-7.

317 in the BCR-ABL kinase domain Hematologica (2007).

mia. Nat Genet. (2004). May;, 36(5), 453-61.

Lymphoma. (2008). Jan;, 49(1), 19-26.

(2007). Feb 1,109 (3) 944-50

lymphoblastic leukemia (Ph+ALL). Cancer. (2007). May 15;, 109(10), 2068-76.

polymerase chain reaction. Br J Haematol. (2003). Jan;, 120(1), 145-53.

plantation ((2009).

143(4), 503-10.

2011- 126

Jul 15;, 110(2), 727-34.

kemia. (1997). Feb;, 11(2), 294-8.

274 Clinical Epidemiology of Acute Lymphoblastic Leukemia - From the Molecules to the Clinic


**Chapter 12**

**Alterations of Nutritional Status in**

Additional information is available at the end of the chapter

spond to a disease or its treatment suitably at a given time. [1]

portant conclusions that have been made with respect to this issue. [2]

Nutritional status is the result of the interaction between environmental and genetic conditions in which a child lives, when these environmental conditions are favorable for life (physical, biological, nutritional and psychosocial), the genetic potential is ex‐ pressed as an ideal state of nutrition, but when conditions are unfavorable such expres‐ sion will be diminished, resulting in altered nutritional status, such as malnutrition, overweight and obesity, which among other things would cause the child did not re‐

In different studies conducted in children with cancer, the authors have evaluated the impact of nutritional status, assuming that if a cancer patient is well nourished, have less toxicity caused by antineoplastic drugs, will have a greater immune resistance to processes serious infectious, and therefore have a better survival and quality of life than the patient who is not well nourished, so in this chapter we will mention the most im‐

Malnutrition is the main nutritional disorder that occurs in children with cancer, and has been defined as a state in which a deficiency of energy, protein, and other nutrients, causes measurable adverse effects on the structure and functioning of organs and body

and reproduction in any medium, provided the original work is properly cited.

© 2013 Maldonado-Alcázar et al.; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

**Childhood Acute Leukemia**

Alejandra Maldonado-Alcázar, Juan Carlos Núñez-Enríquez, Carlos Alberto García-Ruiz, Arturo Fajardo-Gutierrez and Juan Manuel Mejía-Aranguré

http://dx.doi.org/10.5772/52715

**1. Introduction**

**Chapter 12**
