Lazarus H M, Rowe J M
Department of Medicine, Ireland Cancer Center, University Hospitals of Cleveland, Case Western Reserve University, Ohio 44106.
Med Oncol. 1994;11(2):75-88. doi: 10.1007/BF02988834.
Advances in the treatment of childhood acute lymphoblastic leukemia (ALL) have been striking while results have been less impressive in adults who develop this disease. Obvious differences in a patient's ability to withstand cytotoxic therapy may account, in part, for these findings, but the biologic behaviour of the disease in the two age groups appears to be different; relapses are more frequent and cures less common in adults. In fact, age alone appears to be the most important prognostic factor in ALL. The demonstration of the efficacy of bone marrow transplantation in advanced disease as well as the marked improvements in supportive care and the development of effective high-dose cytotoxic preparative regimens, especially those which use total body irradiation, however, have paved the way for transplantation in first complete remission. Formerly, most adult ALL patients who underwent bone marrow transplant did so in relapse, or in second or subsequent remission. In most studies 40-50% of first remission adult patients attain long-term disease-free survival after allogeneic and autologous bone marrow transplant. Relapses are considerably higher in the autologous transplant group when compared to the allogeneic group, but the latter population may experience increased morbidity and mortality due to graft-versus-host disease and opportunistic infection. These differences may reflect the beneficial graft-versus-leukemia effect in the allograft as well as infusion of autologous leukemia cells in the autograft but neither transplant subtype appears superior. Compared to more conventional approaches, however, transplantation may offer improved disease-free survival, although patient selection appears to be significantly influence outcome. These many inherent biases must be noted when comparing markedly different approaches, e.g. transplant versus conventional therapy. The challenge of demonstrating which therapy is superior for adult ALL patients can only be addressed in a well-designed, prospective, randomized trial.
儿童急性淋巴细胞白血病（ALL）的治疗进展显著，而成年ALL患者的治疗效果却不尽如人意。患者耐受细胞毒性疗法的能力存在明显差异，这在一定程度上可以解释这些结果，但该疾病在两个年龄组中的生物学行为似乎有所不同；成人ALL的复发更为频繁，治愈情况则较为少见。事实上，年龄似乎是ALL最重要的预后因素。骨髓移植在晚期疾病中的疗效得到证实，以及支持治疗的显著改善和有效的高剂量细胞毒性预处理方案的发展，尤其是那些采用全身照射的方案，为首次完全缓解期的移植铺平了道路。以前，大多数接受骨髓移植的成年ALL患者是在复发时，或第二次及后续缓解期进行移植的。在大多数研究中，40%-50%的首次缓解期成年患者在接受异基因和自体骨髓移植后可获得长期无病生存。与异基因移植组相比，自体移植组的复发率要高得多，但后者可能因移植物抗宿主病和机会性感染而出现发病率和死亡率增加的情况。这些差异可能反映了同种异体移植中有益的移植物抗白血病效应以及自体移植中自体白血病细胞的输注，但两种移植亚型都没有明显优势。然而，与更传统的方法相比，移植可能会提高无病生存率，尽管患者选择似乎对结果有显著影响。在比较明显不同的方法（如移植与传统疗法）时，必须注意这些许多内在偏差。只有在精心设计的前瞻性随机试验中，才能解决证明哪种疗法对成年ALL患者更优越这一难题。
