Treatment of infantile acute lymphoblastic leukemia, experience of a country with limited resources

Abstract: BACKGROUND: Infantile acute lymphoblastic leukemia (ALL) is associated with poor outcomes worldwide, particularly in low-resource settings. Despite advances in pediatric ALL therapy, survival rates for infants remain substantially lower than those observed in older children. Evaluating treatment outcomes over time may help identify factors associated with improved survival. OBJECTIVES: To assess treatment outcomes and survival trends of infants with ALL treated at a single tertiary center in Iraq over three distinct treatment periods. MATERIALS AND METHODS: This retrospective study included infants (<1 year old) diagnosed with ALL and treated at the Children’s Welfare Teaching Hospital in Baghdad between January 2000 and December 2016. Patients were treated using adapted UKALL-97, UKALL-2003, and UKALL-2011 protocols, with a small subset receiving an infant-specific protocol. Patients were grouped by treatment period (2000–2005, 2006–2011, and 2012–2016). Overall survival (OS) and event-free survival (EFS) were estimated using the Kaplan–Meier method and compared using the log-rank test. RESULTS: Among 59 infants diagnosed with ALL, 11 (19%) refused treatment. Of the remaining 48 treated patients, 24 (50%) achieved complete remission, 4 (8%) were resistant to therapy, and 17 (35%) died during induction. Complete remission rates improved across treatment periods from 36% to 45% and 71%, respectively. Among responders, 6 (25%) relapsed, 10 died during subsequent therapy, and 5 were lost to follow-up. The 36-month OS and EFS for treated patients were 30.2% and 17%, respectively, with a nonsignificant trend toward improved EFS in the 2012–2016 cohort. CONCLUSION: The outcomes of infantile ALL in this low-resource setting remain poor, characterized by high induction mortality and treatment abandonment. Although survival improved over time—particularly following the introduction of a steroid prephase and enhanced supportive care—overall prognosis remains unsatisfactory, underscoring the need for further therapeutic and supportive care improvements.