Standard-risk B-cell acute lymphoblastic leukaemia in children
Standard-risk acute lymphoblastic leukaemia is the commonest and most curable childhood cancer: a child aged one to nine with a modest white cell count and favourable genetics. Two to three years of chemotherapy cures about nine in ten, and adding the immune drug blinatumomab to the chemotherapy in the AALL1731 trial cut relapses further.
Overview
The National Cancer Institute criteria of 1996 put children aged one to nine with a presenting white count under 50 x 10^9/L into the standard-risk group, about two thirds of B-cell precursor ALL. Within it, the ETV6::RUNX1 fusion and high hyperdiploidy with trisomies of chromosomes 4 and 10 mark the most favourable disease, and measurable residual disease (MRD) by flow cytometry at the end of the four-week induction, below 0.01 percent, is the strongest single predictor of cure. Children with central nervous system disease, testicular involvement, hypodiploidy, iAMP21 or high end-induction MRD are moved to high-risk therapy whatever their age and count.
Treatment follows the Berlin-Frankfurt-Münster and Children's Oncology Group backbone worked out over five decades: a three-drug induction of vincristine, dexamethasone and pegylated asparaginase; consolidation with cyclophosphamide, cytarabine and mercaptopurine or, for the lowest risk, mercaptopurine and vincristine alone; interim maintenance with escalating methotrexate; a delayed intensification block; and maintenance with daily mercaptopurine, weekly methotrexate and pulses of vincristine and steroid to two years or more, with intrathecal methotrexate throughout in place of cranial irradiation. UKALL 2003, reported in 2013, showed that MRD-low children could safely receive one delayed intensification instead of two, with five-year event-free survival around 95 percent in both arms, while MRD-high children gained from augmented therapy. AALL1731, reported in the New England Journal of Medicine in 2025, randomised 1,440 children with standard-risk average or higher B-ALL to two cycles of blinatumomab added to chemotherapy: three-year disease-free survival 96.0 percent against 87.9 percent with chemotherapy alone, and the trial was stopped early for benefit. Blinatumomab was approved for consolidation of newly diagnosed CD19-positive B-ALL in children and adults in June 2024 on E1910 and this trial.
The cure rate leaves the research questions on the other side: how much therapy can be removed. Vincristine and steroid pulses in maintenance, the second delayed intensification and anthracycline exposure have each been trimmed in trials without loss; asparaginase allergy and silent inactivation, osteonecrosis in adolescents and the cognitive cost of intrathecal methotrexate are the toxicities that remain. Whether blinatumomab lets chemotherapy be shortened rather than merely added to, whether MRD by next-generation sequencing at day 8 or day 29 can select children for even less, and how to make a two-year outpatient regimen deliverable in low-income countries, where most children with ALL live and where cure rates are far lower, are the live questions.
State of the art
- About nine in ten children with standard-risk B-ALL are cured with chemotherapy alone, and blinatumomab consolidation raised three-year disease-free survival to 96 percent in AALL1731.
- End-induction flow cytometry MRD is the pivot of every protocol: it moves children up to intensified therapy and, in MRD-low children, permits less.
- Cranial irradiation has gone from standard-risk therapy altogether, replaced by intrathecal methotrexate.
Red cards
From the labels and guidelines behind the standard of care. Your team's thresholds win.- Emergency services nowBleeding or bruising
Bleeding that will not stop, black or bloody stools, or unexplained bruising when platelets are expected to be low.
- Emergency services nowBlood clot (lenalidomide, pomalidomide, thalidomide)
A swollen painful calf, or sudden breathlessness with chest pain; venous and arterial thromboembolism is a boxed warning and blood-thinning prophylaxis is recommended.
- Emergency services nowCytokine release syndrome
Fever of 38 C or higher, chills, low blood pressure, fast heartbeat or breathlessness, especially after a step-up dose. Boxed warning on teclistamab, epcoritamab, glofitamab, tarlatamab and blinatumomab.
- Emergency services nowCytokine release syndrome
Fever of 38 C or higher is grade 1 CRS; fever with low blood pressure, fast heartbeat, breathlessness or low oxygen is grade 2 or higher. The labels carry a boxed warning and say to report fever immediately.
- Emergency services nowSkin reaction
Blisters, peeling, or sores in the mouth or eyes with a rash. Enfortumab vedotin carries a boxed warning for Stevens-Johnson syndrome and toxic epidermal necrolysis, mostly in the first cycle.
- Check before combiningFood and drink: Doxorubicin
Cumulative dose: risk rises steeply above 400-550 mg/m² (see the anthracycline calculator).
See all on the product pages:BlinatumomabCyclophosphamideCytarabineDoxorubicinInotuzumab ozogamicinMethotrexateTisagenlecleucelVincristine·Printable cards in the navigator
Anatomy and lymph node drainage
- Bone marrow (leukaemia, MDS, MPN, myeloma)
- Lymph node germinal centre (lymphomas)
- Spleen
- Blood (leukaemic phase)
- Lytic bone lesions (myeloma)
- Skin and extranodal sites
- Nodes: cervical
- Nodes: axillary
- Nodes: mediastinal
- Nodes: para-aortic and mesenteric
- Nodes: inguinal
Leukaemias, myeloma and MDS live in the marrow and blood; lymphomas grow in lymph nodes and spleen. The node stations are the disease map, not a route of spread, and staging counts them.
- Bone marrow (leukaemia, MDS, MPN, myeloma)Standard-risk favourable B-ALL (ETV6::RUNX1 or double trisomy 4 and 10, end-induction MRD below 0.01 percent) · Standard-risk average B-ALL (neutral genetics, MRD-low) · Standard-risk high B-ALL (end-induction MRD 0.01 percent or higher, moved to intensified therapy) · Down syndrome-associated B-ALL (standard-risk criteria but higher toxicity, CRLF2 rearrangements common)
- Lymph node germinal centre (lymphomas)
- Spleen
- Blood (leukaemic phase)
- Lytic bone lesions (myeloma)
- Skin and extranodal sites
- cervical
- axillary
- mediastinal
- para-aortic and mesenteric
- inguinal
In lymphoma the node stations are the disease itself; staging (Ann Arbor / Lugano) counts how many regions and sides of the diaphragm are involved.
Same organ: Marginal zone lymphoma, Cutaneous T-cell lymphoma (mycosis fungoides and Sezary syndrome), Primary mediastinal (thymic) large B-cell lymphoma, Leukaemia (all types), Acute myeloid leukaemia, Acute lymphoblastic leukaemia, Chronic lymphocytic leukaemia, Chronic myeloid leukaemia (CML), Diffuse large B-cell lymphoma, Follicular lymphoma, Hodgkin lymphoma, Mantle cell lymphoma, Multiple myeloma, Non-Hodgkin lymphoma (all types), Myelodysplastic syndromes / neoplasms (MDS), Myeloproliferative neoplasms (PV, ET, myelofibrosis), Polycythaemia vera (PV), Essential thrombocythaemia (ET), Waldenström macroglobulinaemia, Hairy cell leukaemia, Peripheral T-cell lymphomas (including cutaneous T-cell lymphoma), Blastic plasmacytoid dendritic cell neoplasm (BPDCN), Burkitt lymphoma, HIV-associated (AIDS-related) lymphomas, Chronic myelomonocytic leukaemia and MDS/MPN overlap neoplasms, Systemic mastocytosis, Erdheim-Chester disease, Rosai-Dorfman disease and other histiocytic neoplasms, Langerhans cell histiocytosis (LCH), Post-transplant lymphoproliferative disorder (PTLD), FLT3-mutated acute myeloid leukaemia, IDH1- and IDH2-mutated acute myeloid leukaemia, NPM1-mutated and KMT2A-rearranged acute myeloid leukaemia, Secondary and therapy-related acute myeloid leukaemia, Acute promyelocytic leukaemia, Acute myeloid leukaemia in older or unfit patients, Smouldering multiple myeloma, Newly diagnosed multiple myeloma, transplant-eligible, Newly diagnosed multiple myeloma, transplant-ineligible, Relapsed or refractory multiple myeloma, Plasma cell leukaemia, Lower-risk myelodysplastic syndromes, Higher-risk myelodysplastic syndromes, Chronic lymphocytic leukaemia, first treatment, Relapsed or refractory chronic lymphocytic leukaemia, Richter transformation of chronic lymphocytic leukaemia, Chronic myeloid leukaemia, chronic phase, Chronic myeloid leukaemia, accelerated and blast phase, Primary myelofibrosis, High-risk acute lymphoblastic leukaemia in children (high-risk B-ALL and T-ALL), Philadelphia chromosome-positive acute lymphoblastic leukaemia in children (Ph-positive ALL), Philadelphia chromosome-like acute lymphoblastic leukaemia (Ph-like or BCR::ABL1-like ALL), Infant acute lymphoblastic leukaemia (KMT2A-rearranged, under one year), Relapsed and refractory acute lymphoblastic leukaemia in children, Acute myeloid leukaemia in children
Acute lymphoblastic leukaemia is the commonest childhood cancer, and roughly two thirds of children with the B-cell form fall into the standard-risk group at diagnosis: aged one to nine with a white cell count below 50 x 10^9/L.
Cases by country
No country-level case numbers. This cancer is not mapped to a GLOBOCAN site.
One section per setting: the options named, what each is for, the trials behind them, the recorded trade-offs and the questions to ask.
Vincristine, dexamethasone and pegylated asparaginase with intrathecal methotrexate; flow cytometry MRD at day 29 decides the post-induction arm.
Cyclophosphamide, cytarabine and mercaptopurine, then escalating methotrexate; two cycles of blinatumomab added for standard-risk average and high disease (AALL1731).
One delayed intensification block with vincristine, dexamethasone, doxorubicin, asparaginase, cyclophosphamide, cytarabine and thioguanine; then daily mercaptopurine, weekly methotrexate and vincristine-steroid pulses to two years or more.
Reinduction chemotherapy with blinatumomab for high- and intermediate-risk relapse; tisagenlecleucel or inotuzumab ozogamicin for later relapse (see the relapsed ALL page).
Subtypes & biomarkers
top- Standard-risk favourable B-ALL (ETV6::RUNX1 or double trisomy 4 and 10, end-induction MRD below 0.01 percent)
- Standard-risk average B-ALL (neutral genetics, MRD-low)
- Standard-risk high B-ALL (end-induction MRD 0.01 percent or higher, moved to intensified therapy)
- Down syndrome-associated B-ALL (standard-risk criteria but higher toxicity, CRLF2 rearrangements common)
- Age and presenting white cell count (NCI criteria)
- ETV6 ::RUNX1 fusion
- High hyperdiploidy with trisomies 4 and 10
- Flow cytometry MRD at day 8 and day 29
- CNS status at diagnosis
- TPMT and NUDT15 genotype for mercaptopurine dosing
How often this target appears
- 1948Farber produces temporary remissions in childhood leukaemia with aminopterin, the first antifolate
- 1962St Jude Total Therapy: combination chemotherapy with central nervous system-directed treatment begins to cure children
- 1996National Cancer Institute risk criteria by age and white count adopted
- 2013UKALL 2003: MRD-directed reduction of therapy is safe for low-risk children
- 2024Blinatumomab approved for consolidation of newly diagnosed CD19-positive B-ALL
- 2025AALL1731: blinatumomab added to chemotherapy lifts three-year disease-free survival to 96 percent
Dated changes read from the records linked to this cancer: approvals, regulatory steps, reported trials, guideline versions and milestones. Newest first; no date is inferred.
All 9 changes by month →- 2026-09-17This recordStandard-risk B-cell acute lymphoblastic leukaemia in childrenFacts on this page last checked
When this page itself was last checked or edited.
- 2025MilestoneCOG AALL1731AALL1731: blinatumomab added to chemotherapy lifts three-year disease-free survival to 96 percent
A milestone in how this cancer is treated.
- 2024Trial resultCOG AALL1731COG AALL1731 reported
3-year DFS 96.
- 2024Trial resultECOG-ACRIN E1910ECOG-ACRIN E1910 reported
3-year OS 85% vs 68%; HR 0.
- 2024MilestoneBlinatumomabBlinatumomab approved for consolidation of newly diagnosed CD19-positive B-ALL
A milestone in how this cancer is treated.
- 2013MilestoneMultiparameter flow cytometry MRDUKALL 2003: MRD-directed reduction of therapy is safe for low-risk children
A milestone in how this cancer is treated.
What is in development for Standard-risk B-cell acute lymphoblastic leukaemia in children, drawn from the whole corpus: 3 items. Drugs are grouped by the most advanced trial phase they have reached anywhere; approved treatments sit under standard of care. Technologies are the methods being tested for this cancer, trials are the studies recorded here, and ideas are proposals not yet in a trial.
Trials reported · 1
- COG AALL1731 · phase 3 · 2024 · positive
Combinations being explored · 1
Ideas not yet in a trial · 1
Open problems and what is being done
Whether blinatumomab allows chemotherapy to be shortened rather than only added to.
Asparaginase hypersensitivity and silent inactivation, and osteonecrosis in older children.
Delivering a two-year outpatient regimen in low- and middle-income countries, where most children with ALL live.
and how the field plans to fix it →What is being done about thisCost and accessAvailable nowIn trialsNothing recorded yet.
Ideas and roadmapsNothing recorded yet.
Also on OnCo: Financial help · Coverage by country · HTA decisions.
Trials
topTrials recruiting now
Country and place are remembered in this browser only. A postcode is sent to OpenStreetMap's Nominatim service to find coordinates when you press the button; nothing else leaves your device.
Landmark trials
Expert centres
topExpert centres
Monrovia, CA · consortium | United States | none recorded | 1 | 20 | 186 | none recorded | - |
Philadelphia, PA · consortium | United States | none recorded | 1 | 15 | 142 | - | |
Bethesda, MD · government | United States | none recorded | 0 | 2,905 | 47,715 | - | |
St. Louis, MO · cancer center | United States | 0 | 1,950 | 25,697 | - | ||
Miami, FL · cancer center | United States | 0 | 1,607 | 15,145 | - | ||
Madrid · hospital | Spain | none recorded | 0 | 764 | 13,767 | - | |
Pamplona · cancer center | Spain | none recorded | 0 | 751 | 10,993 | - | |
Philadelphia, PA · hospital | United States | none recorded | 0 | 695 | 9,931 | - | |
Memphis, TN · cancer center | United States | 0 | 636 | 8,887 | - | ||
| Spain | none recorded | 0 | 377 | 3,050 | - | ||
Toulouse · cancer center | France | none recorded | 0 | 232 | 3,172 | - | |
| Lebanon | none recorded | 0 | 162 | 1,048 | none recorded | - | |
Sydney · hospital | Australia | none recorded | 0 | 98 | 893 | - | |
Rotterdam · consortium | Netherlands | none recorded | 0 | 8 | 207 | - | |
Washington, DC · consortium | United States | none recorded | 0 | 4 | 22 | - |
These are the things we can measure; they are not a ranking of quality. Each column is a field on the institution record or a count over what OnCo has linked; a centre that treats many patients with Standard-risk B-cell acute lymphoblastic leukaemia in children but is thinly recorded here will look small.
Not known: OnCo holds no case-volume or outcome figures for centres, so none are shown. Where a national audit or registry publishes them, the centre's page links to it. Default order: Newsweek rank, then trials for this cancer, then research output.
Questions to ask
topQuestions to ask your oncologist about Standard-risk B-cell acute lymphoblastic leukaemia in children
Newly diagnosed
- What is my exact diagnosis, stage, and grade, and which tests established them?Why: Everything else follows from an accurate stage and subtype.
- Which biomarkers have been tested on my tumour (for example Age and presenting white cell count, ETV6::RUNX1 fusion, High hyperdiploidy with trisomies 4 and 10, Flow cytometry MRD at day 8 and day 29, CNS status at diagnosis), and what were the results?Why: These results decide eligibility for targeted therapy, immunotherapy, and trials.
- Which subtype is my cancer, and does that change the recommended treatment?Why: Recognised subtypes for this cancer include Standard-risk favourable B-ALL, Standard-risk average B-ALL, Standard-risk high B-ALL.
- Is germline (inherited) genetic testing recommended for me or my family?Why: Inherited variants can change treatment and matter for relatives.
Induction (four weeks)
- For my situation (induction (four weeks)), which of the standard options do you recommend and why?Why: Guideline options include: Vincristine, dexamethasone and pegylated asparaginase with intrathecal methotrexate; flow cytometry MRD at day 29 decides the post-induction arm.
- Am I a candidate for Vincristine, Dexamethasone, Asparaginase (pegaspargase, calaspargase pegol, Erwinia asparaginase) or related drugs, and what side effects should I expect?Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
Consolidation and interim maintenance
- For my situation (consolidation and interim maintenance), which of the standard options do you recommend and why?Why: Guideline options include: Cyclophosphamide, cytarabine and mercaptopurine, then escalating methotrexate; two cycles of blinatumomab added for standard-risk average and high disease (AALL1731).
- Am I a candidate for Cyclophosphamide, Cytarabine, Mercaptopurine or related drugs, and what side effects should I expect?Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of COG AALL1731 apply to someone like me?Why: Trial populations differ from individual patients; ask how closely you match.
Delayed intensification and maintenance
- For my situation (delayed intensification and maintenance), which of the standard options do you recommend and why?Why: Guideline options include: One delayed intensification block with vincristine, dexamethasone, doxorubicin, asparaginase, cyclophosphamide, cytarabine and thioguanine; then daily mercaptopurine, weekly methotrexate and vincristine-steroid pulses to two years or more.
- Am I a candidate for Vincristine, Dexamethasone, Doxorubicin or related drugs, and what side effects should I expect?Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
Relapse
- For my situation (relapse), which of the standard options do you recommend and why?Why: Guideline options include: Reinduction chemotherapy with blinatumomab for high- and intermediate-risk relapse; tisagenlecleucel or inotuzumab ozogamicin for later relapse (see the relapsed ALL page).
- Am I a candidate for Blinatumomab, Tisagenlecleucel, Inotuzumab ozogamicin, and what side effects should I expect?Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
Any stage
- Are there clinical trials I could join, for example of Blinatumomab, COG AALL1731, NGS-based MRD (clonoSEQ and molecular MRD), Blinatumomab added to frontline chemotherapy?Why: Trials are how the next standard of care is set; asking early keeps options open.
- Would a second opinion at a high-volume centre change anything, and can you help arrange it?Why: Rare or high-stakes decisions benefit from a centre that treats many similar patients.
- What supportive care (symptom control, nutrition, exercise, mental health, financial help) is available from the start?Why: Supportive care improves quality of life and helps patients complete treatment.
- I read that “Whether blinatumomab allows chemotherapy to be shortened rather than only added to”. How does that affect my plan?Why: Open problems are where trials and second opinions matter most.
- I read that “Asparaginase hypersensitivity and silent inactivation, and osteonecrosis in older children”. How does that affect my plan?Why: Open problems are where trials and second opinions matter most.
Newly diagnosed? Read the first 60 days with Standard-risk B-cell acute lymphoblastic leukaemia in children, then print the one-page appointment sheet with room for the answers.
Print this page for your appointment (your browser's print command). These prompts are for discussion; your clinical team knows your case.
Direct links plus the targets, companies, and technologies of this cancer's products.
technologies
9targets
3drugs
12companies
5institutions
2terms
2trials
2pairings
1ideas
1key papers
1Latest papers
topQuery for this cancer: (TITLE:"Standard-risk B-cell acute lymphoblastic leukaemia in children" OR ABSTRACT:"Standard-risk B-cell acute lymphoblastic leukaemia in children" OR TITLE:"NCI standard-risk B-ALL" OR ABSTRACT:"NCI standard-risk B-ALL" OR TITLE:"Average-risk childhood ALL" OR ABSTRACT:"Average-risk childhood ALL" OR TITLE:"Low-risk childhood ALL" OR ABSTRACT:"Low-risk childhood ALL") AND (treatment OR therapy OR trial OR survival OR diagnosis). Results are unfiltered search hits about Standard-risk B-cell acute lymphoblastic leukaemia in children, not a curated reading list.
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