Treatment of childhood acute lymphoblastic leukemia in Jakarta: Result of modified Indonesian National Protocol 94

  • Djajadiman Gatot
  • Endang Windiastuti
Keywords: acute lymphoblastic leukemia, childhood, survival


Background Before 1990, the survival rates of childhood acute
lymphoblastic leukemia (ALL) patients remained low. In 1994, the
Hematology Oncology Working Group of the Indonesian Pediatric
Association constructed a national protocol based on standard in-
ternational protocol. As the outcome was still not promising, in 1998
the protocol was modified by introducing low dose MTX infusion for
CNS prophylaxis.
Objective To analyze the survival of pediatric ALL patient treated with
the modified protocol in Cipto Mangunkusumo Hospital, Jakarta.
Methods A prospective study was carried out to all newly diag-
nosed and relapsed children with ALL from January 1998 through
December 2004. Patients were stratified into standard risk group
(SRG) and high risk group (HRG). HRG met with one of these
criteria: WBC >50 000/ìl, the presence of CNS involvement, medi-
astinal mass, relapse, or L 3 morphology. After completing induc-
tion therapy, all patients received low-dose MTX (LDMTX) infusion
(500 mg/m 2 ), especially for those aged less than 3 years. If the
patient could not afford LDMTX, cranial irradiation (CRT) was given.
Results There were 309 patients, consisted of 190 SRG and 119 HRG
patients. Male to female ratio was 1.8:1. Complete remission was
achieved in 86.3% SRG patients compared with 63.8% in HRG pa-
tients (P<0.05). Event-free survival (EFS) rate in SRG and HRG were
65.9% (95%CI 59.8; 71.9%) and 40.4% (95%CI 32.5; 48.4%), respec-
tively. The overall survival (OS) rates in SRG was 81.2% (95%CI 76.3;
86.2%) and in HRG was 56.0% (95%CI 47.8; 64.2%). The overall OS
and EFS for both groups were 71.6% (95%CI 67.0; 76.2%) and 59.6%
(95%CI 54.5; 64.7%), respectively. Failure of therapy was mostly due
to severe aplasia resulted in bleeding and severe infection. CNS re-
lapse was rare in both groups, i.e. 3.1% in SRG and 0.8% in HRG.
Conclusion Treatment of ALL using modified national protocol for
SRG shows promising results. However, the outcome of HRG pa-
tients is still inferior to those reported elsewhere. The use of low-
dose MTX infusion can replace the role of cranial irradiation as
CNS prophylaxis measure.

Author Biographies

Djajadiman Gatot
Department of Child Health, Medical School, University of
Indonesia, Jakarta, Indonesia.
Endang Windiastuti
Department of Child Health, Medical School, University of
Indonesia, Jakarta, Indonesia.


1. Rocha JCC, Cheng C, Liu W, Kishi S, Das S, Cook
EH, et al. Pharmacogenetics of outcome in children
with acute lymphoblastic leukemia. Blood 2005;105:-
2. Shing MMK, Li CK, Chik KW, Lam TK, Lai HDH,
Ling Ng MH, et al. Outcomes and prognostic factors
of chinese children with acute lymphoblastic leuke-
mia in Hongkong: Preliminary results. Med Pediatr
Oncol 1999;32:117-123.
3. Ribeiro RC, Pui CH. Saving the children-improving
childhood cancer treatment in developing countries.
N Engl J Med 2005;352:2158-60.
4. Howard SC, Pedrosa M, Lins M, Pedrosa A, Pui CH,
Ribeiro RC, et al. Establishment of a pediatric oncol-
ogy program and outcomes of childhood acute lym-
phoblastic leukemia in a resource-poor area. JAMA
5. Laosombat V, Wongchanchailert M, Sattayasevana B,
Wiriyasateinkul A, Watana-Arepornchai S. The treat-
ment of children with acute lymphoblastic leukemia
in Thailand. Med Pediatr Oncol 2002;38:266-8.
6. Campbell M, Salgado C, Quintana J, Becker A, Vargas
L, Cabrera ME, et al. Improved outcome for acute lym-
phoblastic leukemia in children of a developing coun-
try: Results of the Chilean National Trial PINDA 87.
Med Pediatr Oncol 1999;33:88-94.
7. LeClerc JM, Billett AL, Gelber RD, Dalton V, Tarbell
N, Lipton JM, et al. Treatment of childhood acute lym-
phoblastic leukemia: Results of Dana-Farber ALL con-
sortium protocol 87-01. J Clin Oncol 2001;20:237-46.
8. Schrappe M, Reiter A, Ludwig WD, Harbott J,
Zimmermann M, Hiddemann W, et al. Improved outcome
in childhood acute lymphoblastic leukemia despite re-
duced use of anthracyclines and cranial radiotherapy:
Results of trial ALL-BFM 90. Blood 2000;95:3310-22.
9. Kamps WA, Bokkerink JPM, Hahlen J, Riehm H,
Gadner H, Schrappe M, et al. Intensive treatment
of children with acute lymphoblastic leukemia ac-
cording to ALL-BFM-86 without cranial radio-
therapy: Results of Dutch childhood leukemia study
group protocol ALL-7 (1988-1991). Blood 1999;94:
10. Arico M, Valsecchi MG, Conter V, Rizzari C, Pession
A, Messina C, et al. Improved outcome in high-risk
childhood acute lymphoblastic leukemia defined
by prednisone-poor response treated with double
Berlin-Frankfurt-Muenster protocol II. Blood
11. Ishii E, Eguchi H, Matsuzaki A, Koga H, Yanai F, Kuroda
H, et al. Outcome of acute lymphoblastic leukemia in
children with AL90 regimen: Impact of response to
treatment and sex difference on prognostic factors. Med
Pediatr Oncol 2001;37:10-9.
12. Reiter A, Schrappe M, Ludwig WD, Hiddemann W,
Sauter S, Henze G, et al.Chemotherapy in 998
unselected childhood acute lymphoblastic leukemia
patients: Results and conclusions of the multicenter
trial ALL-BFM 86. Blood 1994;84:3122-33.
13. Abdulsalam M, Gatot D. The development of treat-
ment of childhood acute lymphoblastic leukemia in
Jakarta. Presented in the ESO-SIOP Pediatric Oncol-
ogy Course. Surabaya, Indonesia 2003.
14. Freeman AI, Boyett JM, Glicksman AS, Brecher ML,
Leventhal BG, Sinks LF, et al. Intermediate-dose meth-
otrexate versus cranial irradiation in childhood acute
lymphoblastic leukemia: A ten-year follow- up. Med
Pediatr Oncol 1997;28:98-107.
15. Riehm H, Gadner H, Henze G, Kornhuber B,
Lampert F, Niethammer D, et al. Results and signifi-
cance of six randomized trials in four consecutive
ALL-BFM studies. Haematol Blood Transfus
How to Cite
Gatot D, Windiastuti E. Treatment of childhood acute lymphoblastic leukemia in Jakarta: Result of modified Indonesian National Protocol 94. PI [Internet]. 18Oct.2016 [cited 28May2024];46(4):179-4. Available from:
Received 2016-10-15
Accepted 2016-10-15
Published 2016-10-18