From the Department of Hematology, Hôpital Purpan, Toulouse, France; and Department of Hematology, Hôpital Saint-Louis, Paris, France
Authors’ disclosures of potential conflicts of interest are found at the end of this article.
Address reprint requests to Françoise Huguet, MD, Department of Hematology, Hôpital Purpan, Place du Docteur Baylac, 31059 Toulouse cedex 9, France; e-mail: huguet.f{at}chu-toulouse.fr
Overview: Although prognosis of acute lymphoblastic leukemia in children has strikingly improved over the last decades, it remains less favorable in adults. Distinct biologic features, but also differences in treatment design, care providing, and tolerance to therapy, are responsible for these discrepancies. Because of the referral patterns and lack of specific clinical trials, adolescents have been treated either with adult or pediatric protocols. Their outcome has proven to be better with pediatric protocols, which are now recommended in these patients. In young adults, allogeneic stem-cell transplantation has thus far been proposed at least to high-risk or even to all patients. In the future, this policy might be challenged by broader indications of chemotherapy, thus reducing treatment burden, under two conditions. First, more accurate risk stratification is necessary to select good candidates for the chemotherapy option, with the cornerstone of minimal residual disease as in children. Second, chemotherapy needs to be improved. The option of treating adults according to unmodified pediatric protocols is not yet fully evaluated. Promising results are obtained from pediatric-inspired regimens, delivering high doses of nonmyelotoxic drugs along sequential phases of intensive chemotherapy. The thresholds of age, having driven assignation of treatment thus far, will have to be revisited according to efficacy and tolerance of such strategies.
