Single-Institution Experience with HyperC-VAD Protocol for Adult Acute Lymphoblastic Leukemia

Acute lymphoblastic leukemia (ALL) is much rarer in adult age than in childhood, accounting for less than a quarter of acute leukemias, and with an overall survival rate at 5 years below 38%. The authors report the group experience in the treatment of adult ALL with HyperC-VAD protocol. From 2004 to 2007, 21 patients with adult ALL (15 male/6 female), with a median age at diagnosis of 29 years [18;58], were treated: four with ALL-L3/Burkitt lymphoma, six with T cell ALL/lymphoblastic lymphoma, eight with B cell ALL/lymphoblastic lymphoma, and three with ALL with t(9;22). The protocol consists of 4 courses of HyperC-VAD (cyclophosphamide 300mg/m2 IV q12h, on days 1–3; vincristine 2mg IV qd, on days 4 and 11; doxorubicin 50mg/m2 IV, on day 4; dexamethasone 40mg IV/PO qd, on days 1–4 and 11–14) that alternate with 4 courses of HD MTX-ARAC (methotrexate 1g/m2 IV, on day 1; cytarabine 3g/m2 IV q12h, on days 2–3). Those patients with ALL with t(9;22) received imatinib 400mg IV qd, on days 1–14 of each course; and CD20-positive cases received rituximab 375mg/m2 IV qd, on days 1 and 11 (odd courses) or on days 1 and 8 (even courses) of the first 4 courses. All patients received central nervous system prophylaxis in each course with methotrexate 12mg intrathecal on day 2 and cytarabine 100mg intrathecal on day 8. All patients (21/21) achieved complete remission after the first course of chemotherapy. Two patients abandoned the protocol due to neurologic and hematologic toxicity. The relapse rate was 47.6% (10/21), and the overall survival was 61.9% (13/21) – all deaths were due to disease progression. Overall, 131 courses were completed (69 odd courses/62 even courses). The most frequent complication was febrile neutropenia (32.8% - 18 in odd courses; 25 in even courses). The most severe complications were gram-negative septic shock (2 in even courses) and severe axonal polyneuropathy (1 in an odd course; 1 in an even course). Although these results are consistent with the literature, a longer follow up is needed to draw definitive conclusions.