Pediatr Blood Cancer

Long-Term Results of the AIEOP LNH-97 Protocol for Childhood

Lymphoblastic Lymphoma

Marta Pillon, MD,1* Maurizio Arico, MD,2 Lara Mussolin, PhD,3 Elisa Carraro, BS,1 Valentino Conter, MD,4

Alessandra Sala, MD,4 Salvatore Buffardi, MD,5 Alberto Garaventa, MD,6 Paolo D’Angelo, MD,7 Luca Lo Nigro, MD,8

Nicola Santoro, MD,9 Matilde Piglione, MD,10 Alessandra Lombardi, MD,11 Fulvio Porta, MD,12 Simone Cesaro, MD,13

Maria L. Moleti, MD,14 Fiorina Casale, MD,15 Rossella Mura, MD,16 Emanuele S. G. d’Amore, MD,17

Giuseppe Basso, MD,1 and Angelo Rosolen, MD1,†

INTRODUCTION

Non-Hodgkin lymphomas (NHL) represent approximately 10–

15% of childhood and adolescence high-grade tumors according

to the National Cancer Institute (NCI) Working Formulation

[1–2]. They comprise the B-cell types Burkitt lymphoma and

large cell lymphoma, T-cell anaplastic large cell lymphoma, and

lymphoblastic lymphoma (LBL). In Europe and the United States,

about 30% of all pediatric NHL are LBL, most of them have a

precursor T-cell immunophenotype and present at an advanced

stage.

During the last 30 years, NHL are among pediatric malignancies

that have benefited the most from advances in treatment, largely due

to the use of sequential protocols with increasingly intensive

chemotherapy regimens, tailored according to clinical stage and

immunohistochemistry [3–5]. Contemporary regimens offer to at

least 75% of children with advanced-stage LBL the opportunity to

be cured. This has been achieved largely thanks to the great amount

of research and subsequent advances made in the field of acute

lymphoblastic leukemia (ALL) [6]. In a prospective Children’s

Cancer Group trial, a comparison of two pioneer regimens, COMP

based on use of cyclophosphamide and the 10-drug LSA2L2 (used

for ALL) showed the superiority of the LSA2L2 regimen [7]. Taking

into account these results, subsequent LBL chemotherapy treat-

ments were designed including new drugs, optimization of central

nervous system (CNS) prophylaxis, and intensification of treat-

ment [8–10].

Between 1992 and 1997 the Italian cooperative study group

“Associazione Italiana Ematologia Oncologia Pediatrica”

(AIEOP) conducted its first trial for treatment of childhood LBL,

named “AIEOP LNH-92,” based on the LSA2-L2 backbone.

The outcome of this study was comparable to that of contemporary

studies, with a 5-year event free survival (EFS) of 69% and, in

particular, of 65% for patients with stages III and IV [11]. The main

cause for treatment failure in that study was disease relapse,

Background. Treatment intensification was considered a suitable

strategy to increase the cure rate of lymphoblastic lymphoma (LBL) in

children. Procedure. The AIEOP LNH-97 trial was run between 1997and 2007 for newly diagnosed LBL in patients aged less than 18 years.

Treatment schedule was based on the previous, LSA2-L2 derived,

AIEOP LNH-92 protocol. Modifications included: increased dose of

upfront cyclophosphamide and methotrexate, use of L-Asparaginaseduring induction therapy, intensive block therapy for slow respond-

ers, and late intensification (“Reinduction”) for patients with

advanced stage disease. Total therapy duration was 12 months for

stage I and II, and 24 months for stage III and IV. Central nervoussystem prophylaxis did not include cranial irradiation. Results. 114

eligible patients were enrolled, 84 males and 30 females; median age

was 9 years. Complete remission was obtained in 98% of patients.

After a median follow-up time of seven years, 29 patients failed due

to progression of disease (n¼2), relapse (n¼25), or second

malignancy (n¼2). The 7-year overall survival was 82% (standarderror [SE] 4%) and the 7-year event-free survival was 74% (SE 4%).

No subgroup showed significantly different event free survival. None

of the patients died of front line chemotherapy-related toxicity.

Conclusions. Treatment intensification was associated with goodoutcome in children and adolescents with LBL, with limited toxicity.

Prognosis after relapse was better for patients who underwent

allogeneic hematopoietic stem cell transplantation. Measurements of

biological markers and treatment response are necessary forachieving further improvement through more accurate identification

and stratification of patients at risk of disease relapse. Pediatr Blood

Cancer # 2015 Wiley Periodicals, Inc.

Key words: childhood; long-term outcome; lymphoblastic lymphoma; non-Hodgkin lymphoma; treatment

1Clinic of Pediatric Hemato-Oncology, Department of Women’s and

Children’s Health, University of Padova, Padova, Italy; 2Azienda

Sanitaria Provinciale, Ragusa, Italy; 3Istituto di Ricerca Pediatrica,

Fondazione Citta, della Speranza, Padova, Italy; 4Clinica Pediatrica,

Universita degli Studi di Milano-Bicocca, Azienda Ospedaliera San

Gerardo, Monza, Italy; 5Pediatric Oncology Department, Santobono-

Pausilipon Hospital of Napoli, Napoli, Italy; 6Department of

Hematology-Oncology, Istituto Giannina Gaslini, Genova, Italy;7Department of Oncology, Pediatric Hematology and Oncology Unit,

A.R.N.A.S. Ospedali Civico Di Cristina e Benfratelli, Palermo, Italy;8Pediatric Hematology-Oncology, Policlinico di Catania, Catania,

Italy; 9Division of Paediatric Haematology-Oncology, Department of

Pediatrics, Bari, Italy; 10Division of Pediatric Onco-Hematology,

Regina Margherita Children’s Hospital, Torino, Italy; 11Dipartimento di

Onco-Ematologia Pediatrica, Ospedale Bambino Gesu, Roma, Italy;12Oncology-Haematology and BMT Unit, Ospedale dei Bambini,

Spedali Civili, Brescia, Italy; 13Pediatric Hematology-Oncology,

Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy;14Hematology, Department of Cellular Biotechnologies and Hematol-

ogy, Roma, Italy; 15Pediatric Oncology Service,, Pediatric Department,

Second University of Napoli, Napoli, Italy; 16Pediatric Hematology-

Oncology, Ospedale Pediatrico Microcitemico, Cagliari, Italy; 17De-

partment of Pathology, San Bortolo Hospital, Vicenza, Italy

† Deceased in December 2013.

Conflict of interest: Nothing to declare.

�Correspondence to: Marta Pillon, Clinic of Pediatric Hemato-

Oncology, Department of Women’s and Children’s Health, University

of Padova, Via Giustinani 3, 35128 Padova, Italy.

E-mail: marta.pillon@unipd.it

Received 16 September 2014; Accepted 2 October 2014

C 2015 Wiley Periodicals, Inc.DOI 10.1002/pbc.25469Published online in Wiley Online Library(wileyonlinelibrary.com).

occurring in 24% of patients, often during the first phase of

maintenance therapy. By the time these data became available,

preliminary results of some ongoing studies suggested that

treatment intensification might contribute to reduce the risk of

treatment failure, as in the Berlin–Frankfurt–Muenster (BFM)

experience [12].

Based on this background, in the following AIEOP LNH-97

study, treatment was intensified by the following changes: earlier

exposure to native L-asparaginase (the Escherichia coli product

was used in most patients), increased dose of cyclophosphamide,

and use of high dose of methotrexate (MTX) during induction

therapy. Patients with slow response at the end of induction were

treated with six courses of high-risk ALL type blocks [8].

Moreover, a late intensification (Reinduction) with a BFM-type

protocol II [12] was introduced for patients with more advanced

(stage III and IV) disease. A simplified continuation therapy was

applied for a total duration of treatment of 12 months in stages I

and II, or 24 months in stages III and IV. We report the long-term

treatment outcome of patients with LBL treated in this trial.

PATIENTS AND METHODS

Patients

From October 1997 to August 2007, children and adolescents

aged less than 18 years with newly diagnosed LBL, were

eligible for the AIEOP LNH-97 trial. Exclusion criteria were:

bone marrow (BM) massive involvement (�25% of blasts),

pre-existing severe congenital or acquired immunodeficiency,

previous cytostatic treatment, NHL as a second malignancy, post-

transplantation lymphoma, and any other condition prohibiting

chemotherapy. The study was approved by local institutional

review boards and written informed consent was obtained for

every patient enrolled.

Diagnosis and Staging

The diagnosis was established by analysis of lesional tissue,

obtained by lymph node or tumor biopsy, or malignant effusion.

All cases with available tissue underwent central pathology

review by two independent pathologists to confirm the diagnosis

and the cell lineage (precursor T or precursor B). Formalin-fixed

paraffin-embedded tumor biopsies were analyzed by immuno-

histochemistry using a wide panel of antibodies including T- and

B-lineage markers (TdT, CD1a, CD2, CD3, CD4, CD5, CD7,

CD8, CD10, CD19, CD20, CD43, CD79a, m heavy chain, and k

and l light chains). In selected cases, additional immunostains

were used (myeloperoxidase, CD33, CD123, CD68, CD163,

and CD11c). Cases were classified according to the WHO

classification [13].

Disease stage was defined according to the Murphy modified

system, [14] including physical examination, computed tomogra-

phy or magnetic resonance imaging, bone scan, complete blood

count, BM examination, cerebrospinal fluid (CSF) cell count, and

lactate dehydrogenase (LDH) level. CNS involvement was defined

as >5 cells/ml with lymphoblasts in the CSF, and/or CNS mass

lesion. BM involvement was considered as the presence of blasts

between 5% and <25%.

Treatment and Response Criteria

All patients received the same induction therapy, based on the

LSA2-L2 strategy, largely derived from the previous AIEOP LNH-

92 study [11]. The outline of the protocol and the treatment

elements are summarized in Figure 1 and Table I. While patients in

stage I or II received Induction followed by Consolidation and

Maintenance part I and II, patients in stages III or IValso received a

Reinduction after Consolidation. Patients with CNS involvement

received intensified therapy with high-dose cytarabine during

Consolidation, additional intrathecal therapy and cranial radiother-

apy (CRT) at the end of reinduction therapy in children�1 year old

(18 Gy in children <2 year old, 24 Gy in those aged�2 years). The

total therapy duration was 12 months for stages I and II, and

24 months for stages III and IV.

Early response to treatment was evaluated on day 15. The time

points for complete remission (CR) assessment were the end of

Induction and the end of Consolidation. CR was defined as the

absence of any residual mass and no blasts in the BM and in the

CSF. Patients in partial remission (PR), defined as a residual mass

<30% of the initial volume at the end of Induction, remained in the

same treatment group. Patients with residual tumor mass >30% at

the end of Induction received intensified chemotherapy with six

Figure 1. Treatment schema of AIEOP LNH-97 protocol.

Pediatr Blood Cancer DOI 10.1002/pbc

2 Pillon et al.

courses of high-risk ALL blocks, instead of Consolidation; if CR

was achieved, they completed the treatment program with

Reinduction and Maintenance; on the contrary, in case of

incomplete response, a second line treatment including allogeneic

hematopoietic stem cell transplantation (HSCT) was indicated.

Statistical Analysis

Analyses of overall survival (OS) and EFS were performed

using the Kaplan–Meier method, with differences compared by the

log-rank test [15,16]. OS was calculated from the date of diagnosis

to death from any cause or to the date of last follow-up. EFS was

calculated from the date of diagnosis to the first event (induction

failure, relapse, second malignancy, or death from any cause) or to

the date of last follow-up. Disease free survival (DFS) was defined

as the time from CR until tumor relapse or death from any cause or

to the last follow up. Patients lost to follow-up were censored at the

time of their withdrawal. Statistical analysis was carried out by

using the SAS statistical program (SAS-PC, version 9.3, SAS

Institute, Inc., Cary, NC).

TABLE I. Treatment Schedule

Phase Dose Administration route Days

Induction

Cyclophosphamide 1,000 mg/m2/day in 1 hr i.v. 1

Cyclophosphamide 600 mg/m2/day in 1 hr i.v. 8

Asparaginasea 5,000 U/m2/day i.m. 15, 18, 21, 24, 27, 30, 33, 36

Prednisone 60 mg/m2/day Orally 1–36

Vincristine 1.5 mg/m2/day i.v. 8, 15, 22, 29, 36

Daunorubicin 30 mg/m2/day in 4 hr i.v. 15, 22, 29, 36

HD-MTX 5 g/m2/day in 24 hr i.v. 36b

MTXþAra-CþPdn 12 mgþ30 mgþ10 mgc IT 1, 3d, 8, 15d, 22, 29d, 36

Consolidation

Mercaptopurine 25 mg/m2/day Orally 1–42

Ara-C 100 mg/m2/day i.v. 1–4, 8–11

HD-Ara-Ce 3 g/m2/every 12 hr in 3 hr i.v. 4, 5

Etoposide 100 mg/m2/day in 1 hr i.v. 1–4

HD-MTX 3 g/m2/day in 24 hr i.v. 1f, 22f, 36f

MTXþAra-CþPdn 12 mgþ 30 mgþ 10 mgc IT 1, 22, 36

Cranial RTg 2,400 cGyh At the end of Consolidation

Reinductioni

Cyclophosphamide 600 mg/m2/day in 1 hr i.v. 1

Doxorubicin 30 mg/m2/day in 4 hr i.v. 1, 8, 15

Dexamethasone 6 mg/m2/day Orally/i.v. 1–15

Asparaginasea 5,000 U/m2/day i.m. 8, 11, 14, 17

Vincristine 1.5 mg/m2/day i.v. 1, 8, 15, 22

Ara-C 100 mg/m2/day i.v. 29–32, 36–39

HD-MTX 3 g/m2/day in 24 hr i.v. 29f, 43f

Thioguanine 75 mg/m2/day Orally 29–43

MTXþAra-CþPdnj 12 mgþ 30 mgþ10 mgc IT 1, 15, 29, 43

Maintenance part I 2 cycles of 22 days each

Cyclophosphamide 600 mg/m2/day in 1 hr i.v. 1

Thioguanine 60 mg/m2/day Orally 1–7

MTX 40 mg/m2/day Orally 10

Vincristine 1.5 mg/m2/day i.v. 10

Prednisone 60 mg/ m2/day Orally 10–14

Ara-C 100 mg/m2/day i.v. 18–21

Etoposide 100 mg/m2/day in 1 hr i.v. 18–21

MTXþAra-CþPdnj 12 mgþ 30 mgþ 10 mgc IT 10

Maintenance part II k Time

MTX 20 mg/m2/week i.m. Weekly

MTXþAra-CþPdnl 12 mgþ 30 mgþ 10 mgc IT Every 8 week

Mercaptopurine 50 mg/m2/day Orally Daily

i.v., intravenously; HD, high-dose; MTX, methotrexate; Ara-C, cytosine arabinoside; Pdn, prednisolone; IT, intrathecal therapy; i.m.,

intramuscularly; RT, radiotherapy. aNative Escherichia coli Asparaginasi. bL-leucovorin rescue was administered at 42 hr (15 mg/m2 i.v.), at 48 and

54 hr (7.5 mg/m2 i.v.) from the beginning of HD-MTX infusion and subsequently every 6 hr till serum MTX values <0.25 mmol/L. cDose of IT

therapy was adjusted for children <3 years. dOnly if CNS positive. eHD-Ara-C only in CNS positive patients instead of low-dose Ara-C. fL-

leucovorin rescue, 7.5 mg/m2 i.v., was administered at 42, 48, and 54 hr from the beginning of HD-MTX infusion and subsequently every 6 hr till

serum MTX values<0.25 mmol/L. gCranial RTonly for CNS involvement. hCranial RT dose was adjusted for children>1 year and<2 years (1,800

cGy), but not administered in children<1 year. iOnly for stages III and IV. jIT not administered in children treated with cranial RT. kFor stages I and

II, up to 12 months of therapy; for stages III and IV, up to 24 months of therapy. lOnly for patients with CNS involvement but not irradiated.

Pediatr Blood Cancer DOI 10.1002/pbc

AIEOP LNH-97 Protocol Results 3

RESULTS

Diagnosis and Clinical Features

Of the 131 patients registered in the study, 17 were not eligible

because of age>18 years (n¼ 1), pre-treatment (n¼ 5), blasts in the

BM �25% (n¼ 6), other diagnosis at central review (n¼ 2),

treatment with another protocol (n¼ 2), and NHL as second

malignancy (n¼ 1). Thus a total of 114 patients were eligible. Their

median age at diagnosis was 9 years (range, 1.3–16.6). Central review

of the histological diagnosis was obtained in 90% of the cases;

immunophenotype analysis showed T-cell lineage in 88 cases (77%),

B-lineage in 26 cases. One patient was in stage I, 10 in stage II, 71 in

stage III, and 32 in stage IV (one due to isolated CNS involvement).

Median serum LDH value was 635 IU/L (range, 146–4,441). The

tumor involved a single site in 63 patients: mediastinum (n¼ 47),

lymph node (n¼ 7), parotid gland (n¼ 3), tonsil (n¼ 2), bowel

(n¼ 2), or skin (n¼ 2). In the remaining 51 patients (43%), multiple

sites were involved: in 29 cases mediastinal mass was combined with

other localization (BM, n¼ 16; lymph nodes, n¼ 10; tonsil, n¼ 2;

kidney, n¼ 1); in 15 cases BM involvement was combined with

lymph node (n¼ 9), skin (n¼ 2), bone (n¼ 2), kidney (n¼ 1), or

nasopharynx (n¼ 1); in 7 cases the disease involved lymph node and

testis (n¼ 1), or orbit (n¼ 2), or kidney (n¼ 3), or CNS (n¼ 1).

Response to Treatment and Outcome

Overall, CR was achieved in 112 patients (98%), in 19 already

on day þ15, in 46 at the end of Induction, in the remaining 46 only

at the end of Consolidation; one patient, with a residual mass>30%

at the end of Induction, received six courses of high-risk ALL

blocks (instead of Consolidation), achieving the first CR after the

third block therapy, and completed the scheduled chemotherapy.

Due to the late CR, this patient received an unrelated donor HSCTas

intensification therapy, by local treating physician decision, and

remains alive and disease free at last follow up. No statistically

significant difference in DFS was observed between patients who

obtained early CR (at dayþ15) or late CR (P¼ 0.36). Two patients

failed to achieve CR because of refractory disease and died of

progressive disease (PD), in one case after autologous HSCT.

Twenty-five patients (22%) developed a single site (n¼ 12) or

combined (n¼ 13) relapse at a median time of 14 months (range,

1.7–78 months) from CR, including nine patients who relapsed after

a median time of 14 months (range, 11–61 months) from completion

of therapy. Of the 25 patients who relapsed, 21 (84%) had a T-lineage

LBL (2 stage II, 12 stage III, 7 stage IV CNS negative) while four

patients (16%) had a B-lineage LBL (three stage III, one stage IV

CNS negative). Median time from diagnosis to relapse for T-LBL

patients was 1.3 years (range, 0.3–6.4 years) while median time for

B-lineage LBL was 3.1 years (range, 1.7–7.0). Twelve patients had an

isolated relapse in BM (n¼ 6), mediastinum (n¼ 2), skin (n¼ 2), and

CNS (n¼ 2, both in stage III at diagnosis), whereas 13 experienced a

combined relapse in mediastinum and lymph node (n¼ 2),

mediastinum and BM (n¼ 4), mediastinum plus BM and lymph

node (n¼ 4), BM and lymph node (n¼ 2), BM and testis, BM and

lymph node, thyroid and lymph node (n¼ 1), respectively.

Only seven patients with relapse (28%) survived after second line

chemotherapy and HSCT, either autologous (n¼ 1) or allogeneic

(n¼ 6). The remaining 18 patients died, eight of PD after second line

chemotherapy, and 10 after HSCT, due to: PD (n¼ 4), multiple

organ failure (MOF) (n¼ 2), cytomegalovirus pneumonia (n¼ 1),

adenovirus pneumonia (n¼ 1), sepsis of unknown etiology (n¼ 1),

and gram negative septicemia in second relapse (n¼ 1). Two

patients developed a second malignant neoplasm as their first

adverse event: one patient developed thyroid carcinoma 24 months

after the end of treatment and is still alive after surgical resection; the

second patient had M5 acute myeloid leukemia seven months after

completion of therapy and is in CR after allogeneic HSCT (Table II).

At a median follow-up of seven years (range, 0.7–12.4 years), OS

(standard error [SE]) and EFS (SE) were 82% (4%) and 74% (4%),

respectively (Fig. 2A). The 7 year EFS was 82% (12%) for stage I–II,

74% (5%) for stage III, and 72% (8%) for stage IV, P¼ 0.76

(Fig. 2B). Of note, the late events were three relapses: one in stage II

and two in stage III, at 6.4, 5.5, and 7 years, respectively. The 5-year

OS for the 27 patients who suffered relapse or PD was 24% (9%).

Univariate analysis of age, gender, tumor lineage, LDH value, BM

involvement, mediastinal mass, and stage, early response did not

show any subgroup at significantly different EFS (Table III).

Toxicity

Grade III/IV cytopenia was observed in all treatment phases: in

40% of patients during induction, in 57% during consolidation, in

TABLE II. Treatment Results and Outcome of 114 Children and Adolescents With Lbl, According to Immunophenotype and Disease Stage

Immunophenotype

TotalPre-B T

114 26 88

I II III IV I II III IV

Stage 114 1 6 8 11* 0 4 63 21

Early toxic death 0 0 0 0 0 0 0 0 0

Remission failure 2 0 0 0 0 0 0 2 0

CR 112 1 6 8 11 0 4 61 21

Alive in first CR 85 1 6 5 10a 0 2 48 13

Death in first CR 0 0 0 0 0 0 0 0 0

Second malignancy 2 0 0 0 0 0 0 1 1

Relapses 25 0 0 3 1 0 2 12 7

Alive after relapse 7 2 1 0 2 1 1

CR, complete remission. aIncluding one patient with CNS involvement.

Pediatr Blood Cancer DOI 10.1002/pbc

4 Pillon et al.

52% during reinduction and in 58% during maintenance therapy.

Liver toxicity episodes, mainly transaminase elevation, were

reported in 39% of patients; gastrointestinal toxicity episodes,

mainly due to stomatitis, occurred in 41% of patients; 21% of patients

developed clotting abnormalities, including two cases of thrombosis.

No toxic deaths were reported during first line treatment; six

study patients (5%) died after relapse, during salvage therapy, soon

after HSCT performed as consolidation of second remission, due to

multiorgan failure (n¼ 2) or septicemia (n¼ 4).

DISCUSSION

The main aim of this study was to increase the cure rate in

children with LBL, and particularly in those with advanced disease,

Figure 2. A: 7-year overall survival (OS; OS� standard error [SE], 82� 4%) and 7-year event-free survival (EFS; EFS�SE, 74� 4%) for the

entire study cohort. B: Seven-year EFS according to disease stage (EFS� SE), stage I–II, 82� 12%; stage III, 74� 5%; stage IV, 72� 8%; P: 0.76.

Pediatr Blood Cancer DOI 10.1002/pbc

AIEOP LNH-97 Protocol Results 5

who in the previous study had an EFS of 62% in stage III, and 75%

in stage IV [11]. To achieve this goal, late intensification

(“Reinduction”) was introduced for stage III and IV patients,

based on the favorable impact of this modification made by the

BFM group in their BFM-ALL-86 trial [10]. Also, initial

chemotherapy was intensified for all patients by increasing the

doses of cyclophosphamide (1,000 mg/m2 in 1 hr infusion on day

one, and 600 mg/m2 in 1 hr infusion on day 8 vs. 600 mg/m2/every

12 hr) and of MTX (5 g/m2 over 24 hr, vs. 3 g/m2 over 3 hours). L-

Asparaginase was administered in the induction phase, instead of

consolidation phase, to allow an earlier exposure. Comparative

analyses of AIEOP LNH-92 and AIEOP LNH-97 studies show that

treatment intensification was associated with a higher proportion of

cases achieving survival and EFS at 5 years (from 74% to 83%, and

from 69% to 77%, respectively) although this difference did not

reach statistical significance (P¼ 0.11 and P¼ 0.33, respectively).

These results are comparable with those achieved by major

cooperative groups in contemporary international studies in Europe

and North America [3–7,17–20]. The treatment intensification

applied was not associated with an increase of toxicity, in particular

we did not observe any toxic or infectious deaths.

The main cause for treatment failure was LBL relapse, observed

in 22% of patients. Unfortunately, the majority of them could not be

rescued by second line therapies; remarkably, all the patients still

alive received an allogeneic HSCT as part of their retreatment. This

is in keeping with the report of significantly lower progression rate,

and improved EFS, in patients with LBL after allogeneic HSCT

compared to autologous [21]. An older study had failed to

demonstrate the superiority of allogeneic versus autologous HSCT

for LBL [22]. However, in that study fewer than 20% of the study

population was aged �18 years. The outcome of patients who

failed, due to PD (rarely) or relapse was very poor, with a survival of

only 24%. As in our previous study, AIEOP LNH-92, and despite

the good results, the current analysis of presenting features was not

able to identify any prognostic factors associated with a higher risk

of treatment failure, that is, of lymphoma relapse. Thus, additional

tools for better stratification of patients with LBL still represent an

unmet need. Recent availability of molecular or flow-cytometry

markers could represent a critical tool to detect minimal residual

disease (MRD) with potential to predict clinical relapse, suitable for

therapeutic intervention. To this issue, Coustan-Smith et al.[23]

reported that flow cytometry and real-time quantitative PCR for T-

cell receptor rearrangements could identify submicroscopic BM

involvement associated with inferior outcome. The BFM Study

Group found a clear association between LOH at chromosome 6q,

seen in 19% of T-lineage LBL, and an increased risk of relapse [24].

More recently, Callens et al.[25] showed that NOTCH1/FBXW7

mutations, found in 55% of T-lineage LBL, were associated

with improved EFS and OS. Thus, molecular screening at the

diagnosis and timely evaluation of MRD during the early phase of

treatment should be major components of any future study design in

childhood LBL.

In summary, the long-term results of the AIEOP LNH-97

protocol show that treatment intensification was associated with a

good outcome in children and adolescents with LBL, stratified

according to Murphy system, and that allogeneic HSCT is strongly

indicated for relapsed patients. A combination of clinical and

biological parameters is in the pipeline of current international

collaboration to achieve refined stratification and further improve-

ment in treatment results.

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TABLE III. Univariate Analysis of Risk Factors

Patients

No.

7-year EFS

% (SE) Events P value

Gender

Male 84 73 (5) 22 0.69

Female 30 76 (8) 7

Median age at diagnosis

< 9 years 57 71 (6) 16 0.49

� 9 years 57 77 (6) 13

Immunophenotype

T 88 71 (5) 25 0.17

Pre-B 26 83 (8) 4

LDH

<500 IU/L 43 69 (7) 13 0.56

�500 IU/L 71 77 (5) 16

Bone marrow involvement

Yes 31 71 (8) 9 0.61

No 83 75 (5) 20

Mediastinal mass

Yes 76 75 (5) 19 0.91

No 38 72 (8) 10

Stage

Iþ II 11 82 (12) 2 0.48

IIIþ IV 103 73 (4) 27

Early response

CR on day þ15 19 83 (9) 3 0.36

CR after day þ15 93 74 (5) 24

EFS, event free survival; SE, standard error; LDH, lactate dehydroge-

nase; CR, complete remission.

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