Howard Weinstein, MD

“These are excellent results, both overall and for patients randomly assigned to nelarabine with either high-dose methotrexate or escalated-dose methotrexate,” said Howard Weinstein, MD, Chief of Pediatric Hematology/Oncology at Massachusetts General Hospital, Boston, who was not involved in this study. “When you add a new drug to a backbone therapy, you need to be careful about toxicity. These investigators were careful about the integration of nelarabine into Children’s Oncology Group–augmented Berlin-Frankfurt-Münster (aBFM) chemotherapy, a regimen currently used at more than 200 pediatric oncology centers in the United States.”

“This is practice-changing for those who are using this regimen–aBFM– but you can’t necessarily extrapolate these results to other regimens,” Dr. Weinstein stated. “Based on this study, one would use nelarabine upfront if one were already using aBFM, but this doesn’t mean it would work as well with other protocols or without cranial radiation.”

The use of cranial radiation and high-dose methotrexate are both open questions, according to Dr. Weinstein. “Many centers are moving away from cranial radiation. Also, although this study showed that escalated methotrexate plus pegaspargase (Oncaspar) worked better than high-dose methotrexate, that is still open to question,” he stated. ■

DISCLOSURE: Dr. Weinstein reported no conflicts of interest.