By using rapid flow cytometric techniques capable of detecting one leukemic
cell in 10(4) normal cells, we prospectively studied minimal residual dise
ase (MRD) in 195 children with newly diagnosed acute lymphoblastic leukemia
(ALL) in clinical remission. Bone marrow aspirates (n = 629) were collecte
d at the end of remission induction therapy and at 3 intervals thereafter.
Detectable MRD (ie. greater than or equal to 0.01% leukemic mononuclear cel
ls) at each time point was associated with a higher relapse rate (P < .001)
; patients with high levels of MRD at the end of the induction phase (<grea
ter than or equal to> 1%) or at week 14 of continuation therapy (greater th
an or equal to 0.1 %) had a particularly poor outcome. The predictive stren
gth of MRD remained significant even after adjusting for adverse presenting
features, excluding patients at very high or very low risk of relapse from
the analysis, and considering levels of peripheral blood lymphoblasts at d
ay 7 and day 10 of induction therapy. The incidence of relapse among patien
ts with MRD at the end of the induction phase was 68% +/- 16% (SE) ii they
remained with MRD through week 14 of continuation therapy, compared with 7%
+/- 7% ii MRD became undetectable (P = .035), The persistence of MRD until
week 32 was highly predictive of relapse (all 4 MRD+ patients relapsed vs
2 of the 8 who converted to undetectable MRD status; P = .021), Sequential
monitoring of MRD by the method described here provides highly significant,
independent prognostic information in children with ALL. Recent improvemen
ts in this flow cytometric assay have made it applicable to more than 90% o
f all new patients. (C) 2000 by The American Society of Hematology.