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Not all children who fail to respond to induction chemotherapy for acute lymphoblastic leukaemia (ALL) have a gloomy prognosis. Data from 14 cooperative study groups in Europe, North America, and Asia (New England Journal of Medicine 2012;366:1371–81; see also editorial, ibid: 1445–6) have shown that certain features indicate a better prognosis and probable response to chemotherapy without stem-cell transplantation. Of a total of 44017 children with ALL treated between 1985 and 2000, 1041 (2.4%) had induction failure. They often presented with high-risk features and after an average follow-up of 8.3 years the overall estimated 10-year survival rate was 32%. A poor prognosis was associated with age >10 years, T-cell leukaemia, 11q23 rearrangement, and 25% or more blasts in bone marrow at the end of induction therapy. Features associated with a better prognosis, however, included age 1–5 years and high hyperdiploidy (modal chromosome number >50) in children with precursor B-cell leukaemia. Among such children with no adverse genetic features the estimated 10-year survival was 72% with chemotherapy alone. About 25% of patients with cytogenetic data were in this group. Children with T-cell leukaemia and induction failure will probably continue to be treated with allogeneic stem-cell transplantation. Children with B-cell leukaemia and other favourable features may do better with chemotherapy alone.

Evidence including registry based cohort studies and meta-analyses has linked reproductive technologies such as in vitro …

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