High-Dose Methotrexate Seems to Benefit Only to Standard-Risk BCP-ALL Patients with Good Early Response to Chemotherapy: Final Analysis of the FRALLE93B Study
Authors: Leblanc Thierry , Landman-Parker Judith , Auclerc Marie-Françoise , Desseaux Krystell , Vermylen Christiane , Schmitt Claudine , Gandemer Virginie , Lejars Odile , Vannier Jean-Pierre , Demeocq François , Berthou Christian , Couillault Gérard , Pautard Brigitte , Berger Claire , De Lumley Lionel , Debré Marianne , Michel Gérard , Perel Yves , Leverger Guy , Baruchel Andre 
Published: April 2020

Abstract
From 06/93 to 12/99, 1395 children and adolescents were included in the FRALLE 93 protocol: group A (Very Low Risk): 182, B (Standard risk): 672 and C (High risk including T-ALL): 541. The median FU is 9.5 yr. Inclusion criterias in group B were: age between 1 and 15 yr, WBC&lt; 100,000, BCP phenotype and no poor-prognosis cytogenetic feature (MLL rearrangement or Ph1). Group B pts were randomised in a 2-steps schedule: at inclusion: daunorubicin (DNR: 40 mg/m2 × 2) vs idarubicin (IDA: 8 mg/m2 × 2), and at consolidation: high-dose IV methotrexate (HD-MTX): 4 × 8g/m2 at D1, D15, D29 and D42, vs low-dose po MTX (LD-MTX): 4 × 25 mg/m2; the number of triple IT was the same for both arms (N = 18). Pts with CNS leukemia were not randomized for MTX. During induction, pts were also classified on D21 bone marrow aspiration according to the level of residual blasts: M1 (&lt; 5%): n=555, M2 (6–25%): n=71 and M3 (&gt; 25%): n=41; M2/M3 pts received 1 more antracyclin infusion at D22 and M3 pts were subsequently treated according to the HR group and not randomized for MTX. Both M1 and M2 pts who reached CR were randomized for MTX. The overall group B EFS, DFS and OS were respectively 80±2, 81±2, and 91±1%. Globally there is no statistically significant impact of 1st or 2nd randomization on the outcome of patients. When we look at the outcome according to the D21 status, the EFS are very different: M1: 84±2%, M2: 63±6% and M3: 74±7%. The very poor EFS of M2 pts, who can not actually be classified as SR pts, and the fact that M1 pts represent 90% of pts randomized for MTX led us to analyse separately M1 pts. For M1 pts there is no interaction between 1st and 2nd randomization for survival, EFS and relapse rate (Gail and Simon test, p = 0.51); therefore pts were pooled for 2nd randomization analysis. Among M1 pts, 271 pts were randomized for HD-MTX and 264 for LD-MTX; there is no difference regarding age or leucocytosis between the 2 arms. Results are as follows:
5-yr EFS Relapses CI iBM relapses CI Other relapses CI 5-yr OS (EFS: event-free survival, CI: cumulative incidence, iBM: isolated bone-marrow, OS: overall survival) HD-MTX 87.82±1.99% 0.12±0.04 7.01±0.02 5.17±0.02 95.20±1.30 LD-MTX 79.92±2.47% 0.20±0.06 10.6±0.03 9.10±0.03 88.64±1.95 Test log-rank Gray Gray Gray log-rank p value 0.028 0.037 0.16 0.18 0.07
At the contrary, among M2 pts there is no difference in EFS for pts treated with HD-MTX (61±7%) and LD-MTX (65±9%)
Conclusion:
HD-MTX seems to benefit to pts with standard-risk BCP-ALL and good early response to chemotherapy, and the benefit is associated with a reduction in the number of relapses. No benefit is demonstrated in M2 pts with SER who have a very poor outcome and do require a more intensive treatment; the better EFS of M3 patients treated with double delayed intensification is in favour of this hypothesis.