The current treatment protocols from the North American Children’s Oncology Group, the European Working Group, others
There is no internationally accepted treatment protocol for JMML. Currently, 2 clinical treatment protocols most widely used to study JMML and improve treatment for these children are geographically-based:
- North America: The Children’s Oncology Group (COG) JMML Study
- Europe: The European Working Group for Myelodysplastic Syndromes (EWOG-MDS) JMML Study
- Other clinical trials open to patients with JMML may be searched for at the NIH Clinical Trials website.
The following procedures are used in one or both of the current clinical trials listed above:
The theory behind splenectomy is that in JMML, the spleen acts as a trap for leukemic cells, which leads to their enlarged size. The fear is that since radiation and chemotherapy attack active leukemia cells rather than dormant ones, if the spleen is not removed it may harbor JMML cells that can later lead to relapse. The impact of splenectomy for post-transplant relapse, though, is unknown.
The COG JMML Study includes splenectomy as a standard treatment for all clinically stable patients.
The EWOG-MDS JMML Study allows each child’s physician to determine whether or not a spleenectomy should be done, and large spleens are commonly removed prior to bone marrow transplant.
When a splenectomy is scheduled, JMML patients are advised to receive vaccines against Streptococcus pneumoneae and Haemophilus influenza at least 2 weeks prior to the procedure.
Following splenectomy, penicillin may be administered daily in order to protect the patient against bacterial infections that the spleen would otherwise have protected against; this daily preventative regimen will usually continue until the patient is an adult.
- Chemotherapy/Pharmacologic Treatment
The role of chemotherapy against JMML before bone marrow transplant has not been studied and is still unknown. Chemotherapy by itself has proven unable to bring about long-term survival in JMML.
Low-dose conventional chemotherapy:-
- Studies have shown no influence from low-dose conventional chemotherapy on JMML patients’ length of survival.
- Some combinations of 6-mercaptopurine with other chemotherapy drugs have produced results such as decrease in organ size and increase or normalization of platelet and leukocyte count.
- Complete remission from JMML has not been possible through use of intensive chemotherapy, but it is still used at times because it has improved the condition of a small but significant number of JMML patients who do not display an aggressive disease.
- The COG JMML Study administers 2 cycles of fludarabine and cytarabine for 5 consecutive days along with 13-cis retinoic acid during and afterwards.
- The EWOG-MDS JMML Study, however, does not recommend intensive chemotherapy before bone marrow transplant.
13-cis Retinoic acid (a.k.a. Accutane):-
- In the lab, 13-cis-retinoic acid has been proven to inhibit the growth of JMML cells.
- The COG JMML Study therefore includes 13-cis-retinoic acid in its treatment protocol, though its therapeutic value for JMML remains controversial.
Radiation to the spleen does not generally result in a decrease in spleen size or reduction of platelet transfusion requirement.
- Stem cell transplantation (a.k.a. bone marrow transplant)
The only treatment that has resulted in cures for JMML is a bone marrow transplant, with about a 50% survival rate.
The risk of relapsing after transplant is high, and has been recorded as high as 50%.
Generally, JMML clinical researchers recommend that a patient have a bone marrow transplant scheduled as soon as possible after diagnosis.
A younger age at bone marrow transplant appears to predict a better outcome.
- Transplants from a matched family donor (MFD), matched unrelated donor (MUD), and matched unrelated umbilical cord blood donors have all shown similar relapse rates, though transplant-related deaths are higher with MUDs and mostly due to infectious causes. Extra medicinal protection, therefore, is usually given to recipients of MUD transplants to protect the child from Graft Versus Host Disease (GVHD).
- JMML patients are justified for MUD transplants if no MFD is available due to the low rate of survival without a bone marrow transplant.
- The COG JMML Study involves 8 rounds of total-body irradiation (TBI) and doses of cyclophosphamide to prepare the JMML child’s body for bone marrow transplant. Use of TBI is controversial, though, because of the possibility of late side-effects such as slower growth, sterility, learning disabilities, and secondary cancers, and the fact that radiation can have devastating effects on very young children. It is used in this study, however, due to the concern that chemotherapy alone might not be enough to kill dormant JMML cells.
- The EWOG-MDS JMML Study includes busulfan in place of TBI due to its own research findings that appeared to show that busulfan was more effective against leukemia in JMML than TBI. The EWOG-MDS study also involves cyclophosphamide and melphalan in its conditioning regimen.
Graft versus leukemia:-
- Graft versus leukemia has been shown many times to play an important role in curing JMML, and it is usually evid
enced in a child after bone marrow transplant through some amount of acute or chronic Graft Versus Host Disease (GVHD). Evidence of either acute or chronic GVHD is linked to a lower relapse rate in JMML.
- Careful management of immunosuppressant drugs for control of GVHD is essential in JMML; importantly, children who receive less of this prophylaxis have a lower relapse rate.
- After bone marrow transplant, reducing ongoing immunosuppressive therapy has worked successfully to reverse the course of a bone marrow with a dropping donor percentage and to prevent a relapse. Donor lymphocyte infusion (DLI), on the other hand, does not frequently work to bring children with JMML back into remission.
For more information on Bone Marrow Transplants: http://www.umm.edu/blood/bonemarr.htm
After bone marrow transplant, the relapse rate for children with JMML may be as high as 50%.
Relapse often occurs within a few months after transplant and the risk of relapse drops considerably at the one-year point after transplant.
A significant number of JMML patients do achieve complete remission and long-term cure after a second bone marrow transplant, so this additional therapy should always be considered for children who relapse.
If you need help with some of the medical terms included in these pages, please use the NIH Medical Glossary
Page created: 12 May 2005 by Fred Dini
Last reviewed: Aug 2005 by Mignon Loh, MD