Acute Lymphoblastic Leukemia Treatment with BFM Regimen

Core Components and Treatment Phases

The BFM regimen is a cornerstone multiagent chemotherapy protocol for ALL that includes a 4-drug induction regimen with vincristine, an anthracycline (daunorubicin/doxorubicin), a corticosteroid (prednisone/dexamethasone), and L-asparaginase, followed by structured consolidation and maintenance phases, as recommended by the National Comprehensive Cancer Network 1, 2
The primary goal of the induction phase is to reduce tumor burden by clearing leukemic cells from bone marrow, with a standard 4-drug backbone that includes vincristine 3, anthracycline (daunorubicin or doxorubicin) 1, corticosteroid (prednisone or dexamethasone) 1, and L-asparaginase/pegaspargase [2, 3] [1]
For standard-risk pediatric patients, a 3-drug induction (without anthracyclines) may be used, according to the National Comprehensive Cancer Network guidelines 4
Antimetabolites (methotrexate, cytarabine, mercaptopurine) are often included for CNS prophylaxis, as part of the BFM regimen 1

Poor prognostic factors include elevated WBC count (≥30×10⁹/L for B-cell lineage; ≥100×10⁹/L for T-cell lineage), as identified by the National Comprehensive Cancer Network 5
Hypodiploidy is also a poor prognostic factor, according to the National Comprehensive Cancer Network guidelines 2
MLL/KMT2A rearrangements are associated with a poor prognosis, as reported by the National Comprehensive Cancer Network 1, 5

The BFM approach has been adapted for adolescent and young adult (AYA) patients, with modifications that include the addition of cyclophosphamide to the 4-drug induction regimen, as recommended by the National Comprehensive Cancer Network 1
Recent modifications include more rapid drug sequencing during induction, incorporation of MRD assessment to guide therapy intensity, and reduced use of anthracyclines and cranial radiation to minimize toxicity, according to the National Comprehensive Cancer Network guidelines 4

Dexamethasone versus prednisone: dexamethasone significantly reduces CNS relapse risk and improves event-free survival, but is associated with higher risks of induction mortality, neuropsychiatric events, and myopathy, as reported by the National Comprehensive Cancer Network 1
No conclusive advantage for overall survival has been demonstrated with dexamethasone versus prednisone, according to the National Comprehensive Cancer Network guidelines 2
Age-specific considerations: treatment intensity is typically reduced for patients ≥65 years or those with substantial comorbidities, as recommended by the National Comprehensive Cancer Network 1, 6
Chronologic age alone is a poor surrogate for determining fitness for therapy, according to the National Comprehensive Cancer Network guidelines 5