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9 slides generated from the cancer page, with a quiz from the open benchmark and speaker notes that cite the sources. Arrow keys move between slides; Print gives one slide per page.
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.
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.
| Setting | Approach | Guideline |
|---|---|---|
| Induction (four weeks) | Vincristine, dexamethasone and pegylated asparaginase with intrathecal methotrexate; flow cytometry MRD at day 29 decides the post-induction arm. | not mapped |
| Consolidation and interim maintenance | Cyclophosphamide, cytarabine and mercaptopurine, then escalating methotrexate; two cycles of blinatumomab added for standard-risk average and high disease (AALL1731). | not mapped |
| Delayed intensification and maintenance | 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. | not mapped |
| Relapse | Reinduction chemotherapy with blinatumomab for high- and intermediate-risk relapse; tisagenlecleucel or inotuzumab ozogamicin for later relapse (see the relapsed ALL page). | not mapped |