Trial Information

Multicenter Therapy-Optimization Trial AML-BFM 2004 for the Treatment of Acute Myeloid Leukemias in Children and Adolescents

During the last decade, prognosis in acute myelogenous leukemia (AML) in childhood has
improved considerably, but still 30% of the children experience a relapse of disease and
further 10% fail to respond sufficiently to the present therapies. A further intensification
of therapy might improve the overall survival of these children, but possible, implicit side
effects have to be considered carefully. Increase in dose intensification of the proven,
effective anthracyclines will be limited by the risk of cumulative cardiotoxicity. A
liposomal formulation of daunorubicin may offer a possibility to increase dosage, at least
partially, without causing cumulative cardiotoxicity. Objective one of this randomised study
is to ascertain if this dose increase improves therapy response and overall survival at
acceptable toxicity. The previous experiences with liposomal daunorubicin, gathered from the
relapse studies AML-BFM Rez 97 and International Therapy Study Relapsed AML 2001/012 as well
as from the pilot study AML-BFM 2002P, have shown that the induction therapy is feasible in
clinical centers with experience in AML therapy without leading to a marked increase of
toxicity or prolongation of granulocytopenia.

First results of study AML-BFM 98 have shown that the patients of the standard risk (SR)
group did not benefit from an additional, second induction (HAM). On this account we did not
reintroduce this second induction course in the present study AML-BFM 2004. However, SR
patients will take part in the randomisation of initial therapy with a general view to
achieving higher effectiveness.

For patients of the high-risk group, the administration of 2-chloro-2-deoxyadenosine (2-CDA)
will be integrated in the first phase of consolidation to achieve an even higher
intensification. It could be shown that 2-CDA possesses good antileukemic activity in
pediatric and adult AML. In a phase-II study it could also be demonstrated that 2-CDA has
good effectiveness in combination with cytarabine. Results of phase-II studies conducted at
St. Jude Children's Hospital, Memphis, showed that 2-CDA has good effectiveness especially
in children with monoblastic leukemias (FAB M4/M5). Consequently, this intensification for
high-risk patients, who present in more than half of the cases with monoblastic leukemias
(FAB M4/5), may allow further improvement of therapy for this cohort. The pilot study
AML-BFM 2002P confirmed that the study design was practicable without increasing
significantly the risk of higher toxicity. However, median duration of aplasia was
significantly prolonged in comparison to that of the AI (cytarabine, idarubicin)-block.
Objective two of this study is to determine by randomisation if an improvement of efficiency
is possible.

Study AML-BFM 98 has already focussed on the question of whether or not doses of CNS
irradiation of 12 Gy and 18 Gy are equivalent with regard to their capacity of reducing the
risk of relapse. As the results of study AML-BFM 87 confirmed the necessity of CNS
irradiation, but did not reveal the necessary minimum dose, this randomisation has been
implemented in order to prevent, as far as possible, late sequelae of CNS irradiation by
reducing the radiation dose (= objective three).

As the number of patients of study AML-BFM 98 was not sufficient to resolve this question,
this randomised analysis has been extended for a second period and will therefore be
continued in the current study AML-BFM-2004.

Besides the intensification of cytostatic therapy, study AML-BFM 2004 seeks to optimise the
quality of supportive therapy by implementing measures of quality assurance. This demands an
up-to-date, complete documentation of each therapy phase. In studies AML-BFM 93 and 98,
about 12% of deaths were due to primary complications such as leukostasis syndrome,
haemorrhage or severe infections (4%), infections in aplasia before achieving remission (4%)
or infections in remission (4%). Maybe the lives of even more children will be saved in the
future by improved standards for the prevention of primary complications. Further, the
efficacy of chemotherapy could be improved by less delays in therapy which are often due to
infections or other complications.