Long-Term Outcomes of Childhood Acute Lymphocytic Leukemia Treated with Adapted Berlin–Frankfurt–Münster (BFM) Protocols: A Multicentric Analysis from a Developing Country
Abstract
:Simple Summary
Abstract
1. Introduction
2. Methods
Statistical Analysis
3. Results
3.1. First Period (1997–2007)
3.2. Second Period (2008–2018)
3.3. Time-Dependent Variables
4. Discussion
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Data Availability Statement
Conflicts of Interest
References
- Wilson, C.L.; Chemaitilly, W.; Jones, K.E.; Kaste, S.C.; Srivastava, D.K.; Ojha, R.P.; Yasui, Y.; Pui, C.-H.; Robison, L.L.; Hudson, M.M.; et al. Modifiable Factors Associated with Aging Phenotypes among Adult Survivors of Childhood Acute Lymphoblastic Leukemia. J. Clin. Oncol. 2016, 34, 2509–2515. [Google Scholar] [CrossRef] [PubMed]
- Siegel, D.A.; King, J.; Tai, E.; Buchanan, N.; Ajani, U.A.; Li, J. Cancer Incidence Rates and Trends among Children and Adolescents in the United States, 2001–2009. Pediatrics 2014, 134, e945–e955. [Google Scholar] [CrossRef] [PubMed]
- Mejía-Aranguré, J.M.; Bonilla, M.; Lorenzana, R.; Juárez-Ocaña, S.; De Reyes, G.; Pérez-Saldivar, M.L.; González-Miranda, G.; Bernáldez-Ríos, R.; Ortiz-Fernández, A.; Ortega-Alvarez, M.; et al. Incidence of Leukemias in Children from El Salvador and Mexico City between 1996 and 2000: Population-Based Data. BMC Cancer 2005, 5, 33. [Google Scholar] [CrossRef] [PubMed]
- Ministério da Saúde. Registros de Câncer de Base Populacional. Available online: https://www.gov.br/inca/pt-br/assuntos/cancer/numeros/registros/base-populacional (accessed on 9 May 2024).
- Howard, S.C.; Metzger, M.L.; Wilimas, J.A.; Quintana, Y.; Pui, C.; Robison, L.L.; Ribeiro, R.C. Childhood Cancer Epidemiology in Low-income Countries. Cancer 2008, 112, 461–472. [Google Scholar] [CrossRef] [PubMed]
- Aguiar, T.F.; Da Conceição Barbosa, T.; Maciel, A.L.T.; Blunck, C.B.; Sellos-Laclette, J.; De Melo, A.C.; Mansur, M.B.; Emerenciano, M. Outcome of Adolescents and Young Adults with Acute Lymphoblastic Leukemia in a Single Center in Brazil. Hematol. Transfus. Cell Ther. 2023, 45, S108–S112. [Google Scholar] [CrossRef] [PubMed]
- Pinheiro Junior, E.D.; Pracchia, L.F.; Beitler De Mauriño, B.; Martinez, G.A.; Dorlhiac-Llacer, P.E.; Medina, A.B.; Velloso, E.D.R.P. Prognostic Factors in Adolescent and Adult Patients with Acute Lymphoblastic Leukemia with Two Protocols of Chemotherapy: A Cross-Sectional Study. Clin. Lymphoma Myeloma Leuk. 2015, 15, e7–e14. [Google Scholar] [CrossRef] [PubMed]
- Campbell, M.; Kiss, C.; Zimmermann, M.; Riccheri, C.; Kowalczyk, J.; Felice, M.S.; Kuzmanovic, M.; Kovacs, G.; Kosmidis, H.; Gonzalez, A.; et al. Childhood Acute Lymphoblastic Leukemia: Results of the Randomized Acute Lymphoblastic Leukemia Intercontinental-Berlin-Frankfurt-Münster 2009 Trial. J. Clin. Oncol. 2023, 41, 3499–3511. [Google Scholar] [CrossRef] [PubMed]
- Jaime-Pérez, J.C.; Santos, J.A.H.L.; Gómez-Almaguer, D. Childhood T-Cell Acute Lymphoblastic Leukemia in a Single Latin American Center: Impact of Improved Treatment Scheme and Support Therapy on Survival. Hematol. Transfus. Cell Ther. 2020, 42, 320–325. [Google Scholar] [CrossRef] [PubMed]
- Cézar, R.S.; Cerqueira, B.A.V.; Da Paz, S.D.S.; Barbosa, C.G.; De Moura Neto, J.P.; Barreto, J.H.D.S.; Goncalves, M.D.S. Outcome of B-Cell Acute Lymphoblastic Leukemia in Brazilian Children: Immunophenotypical, Hematological, and Clinical Evaluation. J. Pediatr. Hematol. Oncol. 2015, 37, 423–428. [Google Scholar] [CrossRef] [PubMed]
- Quiroz, E.; Aldoss, I.; Pullarkat, V.; Rego, E.; Marcucci, G.; Douer, D. The Emerging Story of Acute Lymphoblastic Leukemia among the Latin American Population—Biological and Clinical Implications. Blood Rev. 2019, 33, 98–105. [Google Scholar] [CrossRef] [PubMed]
- Abrahão, R.; Lichtensztajn, D.Y.; Ribeiro, R.C.; Marina, N.M.; Keogh, R.H.; Marcos-Gragera, R.; Glaser, S.L.; Keegan, T.H.M. Racial/Ethnic and Socioeconomic Disparities in Survival among Children with Acute Lymphoblastic Leukemia in California, 1988-2011: A Population-Based Observational Study: Survival Disparities in Childhood Leukemia by Race. Pediatr Blood Cancer 2015, 62, 1819–1825. [Google Scholar] [CrossRef] [PubMed]
- Desiderata Institute Unidos Pela Cura. Available online: https://desiderata.org.br/ (accessed on 1 May 2024).
- Bona, K.; Blonquist, T.M.; Neuberg, D.S.; Silverman, L.B.; Wolfe, J. Impact of Socioeconomic Status on Timing of Relapse and Overall Survival for Children Treated on Dana-Farber Cancer Institute ALL Consortium Protocols (2000–2010). Pediatr. Blood Cancer 2016, 63, 1012–1018. [Google Scholar] [CrossRef] [PubMed]
- Möricke, A.; Reiter, A.; Zimmermann, M.; Gadner, H.; Stanulla, M.; Dördelmann, M.; Löning, L.; Beier, R.; Ludwig, W.-D.; Ratei, R.; et al. Risk-Adjusted Therapy of Acute Lymphoblastic Leukemia Can Decrease Treatment Burden and Improve Survival: Treatment Results of 2169 Unselected Pediatric and Adolescent Patients Enrolled in the Trial ALL-BFM 95. Blood 2008, 111, 4477–4489. [Google Scholar] [CrossRef] [PubMed]
- Arcuri, L.J. Immortal Time Bias in Hematopoietic Cell Transplantation. Bone Marrow Transpl. 2023, 58, 946. [Google Scholar] [CrossRef] [PubMed]
Period | p Value | ||
---|---|---|---|
1997–2007 | 2008–2018 | ||
Total | 285 | 410 | |
Sex | 0.22 | ||
Female | 126 (44) | 162 (40) | |
Male | 159 (56) | 248 (60) | |
Age | 0.43 | ||
<1 or ≥10 y/o | 77 (27) | 122 (30) | |
1–9 y/o | 208 (73) | 288 (70) | |
Immunophenotyping | 0.19 | ||
B-ALL | 238 (84) | 326 (80) | |
T-ALL | 47 (16) | 84 (20) | |
ALL subtype | 0.75 | ||
None | 168 (89) | 319 (88) | |
t(1,19) | 6 (3) | 8 (2) | |
t(4,11) | 7 (4) | 16 (4) | |
t(9,22) | 8 (4) | 21 (6) | |
CNS | 0.03 | ||
CNS- | 249 (87) | 333 (81) | |
CNS+ | 36 (13) | 77 (19) | |
WBC (1 × 109/L) | 0.65 | ||
≤10 | 120 (45) | 171 (44) | |
>10 and ≤50 | 81 (31) | 108 (28) | |
>50 and ≤100 | 24 (9) | 35 (9) | |
>100 | 39 (15) | 71 (18) | |
BFM risk group | 0.8 | ||
Standard risk | 26 (9) | 32 (8) | |
Intermediate risk | 111 (40) | 166 (41) | |
High risk | 144 (51) | 208 (51) | |
NCI risk group | 0.07 | ||
B-ALL, standard risk | 111 (39) | 171 (42) | |
B-ALL, high risk | 127 (45) | 155 (38) | |
T-ALL, standard risk | 16 (6) | 16 (4) | |
T-ALL, high risk | 31 (11) | 68 (17) | |
Cytogenetic risk | <0.001 | ||
Good | 20 (11) | 87 (24) | |
Intermediate | 147 (78) | 230 (63) | |
Poor | 22 (12) | 47 (13) | |
Prednisone response | 0.03 | ||
Poor | 115 (42) | 136 (34) | |
Good | 159 (58) | 267 (66) | |
Cranial radiotherapy | 0.75 | ||
No | 148 (52) | 218 (53) | |
Yes | 137 (48) | 192 (47) |
Category | 1997–2007 Period | 2008–2018 Period | |||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|
HR | 95%CI | p (Wald) | 5y-OS | 95%CI | p (Logrank) | HR | 95%CI | p (Wald) | 5y-OS | 95%CI | p (Logrank) | ||
Sex | Female | 1.00 | 69% | 61–78 | 0.0054 | 1.00 | 73% | 66–81 | 0.22 | ||||
Male | 1.68 | 1.16–2.44 | 0.006 | 56% | 48–64 | 1.28 | 0.86–1.90 | 0.22 | 69% | 62–76 | |||
Age | 1–9 y/o | 1.00 | 68% | 61–74 | <0.001 | 1.00 | 77% | 71–83 | <0.001 | ||||
<1 or ≥10 y/o | 1.88 | 1.30–2.72 | <0.001 | 45% | 34–58 | 2.04 | 1.40–2.98 | <0.001 | 56% | 46–67 | |||
Immunophenotyping | B-ALL | 1.00 | 63% | 57–70 | 0.18 | 1.00 | 71% | 65–77 | 0.27 | ||||
T-ALL | 1.35 | 0.87–2.09 | 0.18 | 53% | 40–69 | 1.27 | 0.83–1.97 | 0.27 | 69% | 60–80 | |||
ALL subtype | None | 1.00 | 68% | 62–76 | <0.001 | 1.00 | 72% | 66–78 | 0.14 | ||||
t(1;19) | 1.83 | 0.67–5.03 | 0.24 | 50% | 22–100 | 1.88 | 0.69–5.13 | 0.22 | 47% | 21–100 | |||
t(4;11) | 1.86 | 0.68–5.10 | 0.23 | 43% | 18–100 | 2.16 | 1.00–4.68 | 0.051 | 52% | 30–88 | |||
t(9;22) | 4.09 | 1.94–8.60 | <0.001 | 12% | 2–78 | 0.90 | 0.36–2.21 | 0.81 | 69% | 49–97 | |||
CNS | CNS- | 1.00 | 63% | 57–69 | 0.27 | 1.00 | 71% | 66–77 | 0.72 | ||||
CNS+ | 1.32 | 0.81–2.15 | 0.27 | 51% | 36–71 | 1.09 | 0.68–1.75 | 0.72 | 66% | 55–79 | |||
WBC (1E9/L) | ≤10 | 1.00 | 68% | 59–77 | <0.001 | 1.00 | 79% | 72–87 | 0.019 | ||||
>10 and ≤50 | 0.81 | 0.50–1.31 | 0.39 | 71% | 62–82 | 1.62 | 0.99–2.66 | 0.055 | 68% | 59–78 | |||
>50 and ≤100 | 1.76 | 0.95–3.25 | 0.071 | 50% | 34–75 | 2.46 | 1.29–4.71 | 0.0064 | 50% | 32–77 | |||
>100 | 2.44 | 1.52–3.91 | <0.001 | 33% | 21–52 | 1.87 | 1.09–3.20 | 0.023 | 67% | 56–80 | |||
BFM risk group | Standard risk | 1.00 | 88% | 76–100 | <0.001 | 1.00 | 93% | 83–100 | <0.001 | ||||
Intermediate risk | 2.13 | 0.76–6.02 | 0.15 | 75% | 67–84 | 4.24 | 1.02–17.68 | 0.047 | 75% | 68–84 | |||
High risk | 5.61 | 2.06–15.3 | <0.001 | 48% | 40–57 | 7.64 | 1.87–31.18 | 0.0046 | 64% | 57–72 | |||
NCI_risk group | B-ALL, standard risk | 1.00 | 78% | 71–86 | <0.001 | 1.00 | 81% | 74–89 | 0.0027 | ||||
B-ALL, high risk | 2.21 | 1.46–3.36 | <0.001 | 51% | 42–60 | 2.30 | 1.46–3.62 | <0.001 | 60% | 51–69 | |||
T-ALL, standard risk | 1.53 | 0.67–3.45 | 0.31 | 62% | 43–91 | 1.81 | 0.70–4.70 | 0.22 | 73% | 54–100 | |||
T-ALL, high risk | 2.55 | 1.43–4.54 | 0.0014 | 48% | 33–69 | 2.10 | 1.20–3.67 | 0.0094 | 68% | 58–81 | |||
Cytogenetic risk | Good | 1.00 | 95% | 86–100 | <0.001 | 1.00 | 75% | 66–87 | 0.26 | ||||
Intermediate | 3.50 | 1.10–11.2 | 0.034 | 65% | 57–73 | 1.33 | 0.81–2.18 | 0.26 | 70% | 64–77 | |||
Poor | 7.30 | 2.12–25.1 | 0.0016 | 36% | 21–63 | 1.70 | 0.89–3.27 | 0.11 | 59% | 44–78 | |||
Prednisone response | Good | 1.00 | 74% | 67–81 | <0.001 | 1.00 | 78% | 72–84 | <0.001 | ||||
Poor | 2.62 | 1.82–3.78 | <0.001 | 45% | 37–55 | 2.80 | 1.71–3.67 | <0.001 | 58% | 49–67 | |||
Cranial radiotherapy | No | 1.00 | 60% | 52–69 | 0.89 | 1.00 | 68% | 61–75 | 0.094 | ||||
Yes | 0.98 | 0.69–1.38 | 0.89 | 64% | 56–72 | 0.73 | 0.50–1.06 | 0.096 | 74% | 67–81 |
Variable | Category | OS, 1997–2007 | EFS, 1997–2007 | OS, 2008–2018 | EFS, 2008–2018 | ||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|
HR | 95%CI | p | HR | 95%CI | p | HR | 95%CI | p | HR | 95%CI | p | ||
Age | 1–9 y/o | 1.00 | 1.00 | 1.00 | 1.00 | ||||||||
<1 or ≥10 y/o | 1.60 | 1.1–2.32 | 0.015 | 1.57 | 1.04–2.39 | 0.033 | 1.68 | 1.14–2.48 | 0.0088 | 1.63 | 1.14–2.33 | 0.007 | |
Sex | Female | 1.00 | 1.00 | - | 1.00 | ||||||||
Male | 1.56 | 1.07–2.27 | 0.021 | 1.79 | 1.14–2.80 | 0.012 | - | 1.28 | 0.89–1.84 | 0.18 | |||
BFM risk group | Standard risk | 1.00 | 1.00 | 1.00 | 1.00 | ||||||||
Intermediate | 1.98 | 0.70–5.59 | 0.20 | 2.71 | 0.83–8.83 | 0.098 | 3.78 | 0.9–15.8 | 0.068 | 2.46 | 0.88–6.86 | 0.086 | |
High risk | 4.77 | 1.74–13.1 | 0.0025 | 3.38 | 1.065–10.9 | 0.042 | 6.41 | 1.56–26.4 | 0.01 | 3.48 | 1.26–9.59 | 0.016 |
Category | 1997–2007 Period | 2008–2018 Period | |||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|
HR | 95%CI | p (Wald) | 5y-EFS | 95%CI | p (Logrank) | HR | 95%CI | p (Wald) | 5y-EFS | 95%CI | p (Logrank) | ||
Sex | Female | 1.00 | 63% | 55–72 | <0.001 | 1.00 | 67% | 59–76 | 0.082 | ||||
Male | 1.84 | 1.31–2.59 | <0.001 | 40% | 33–49 | 1.38 | 0.96–1.97 | 0.084 | 58% | 52–66 | |||
Age | 1–9 y/o | 1.00 | 55% | 48–62 | 0.001 | 1.00 | 67% | 61–73 | <0.001 | ||||
<1 or ≥10 y/o | 1.76 | 1.25–2.48 | 0.0012 | 37% | 28–50 | 1.90 | 1.35–2.69 | <0.001 | 50% | 42–61 | |||
Immunophenotyping | B-ALL | 1.00 | 52% | 46–59 | 0.14 | 1.00 | 63% | 57–69 | 0.16 | ||||
T-ALL | 1.36 | 0.9–2.03 | 0.14 | 38% | 27–55 | 1.33 | 0.89–1.97 | 0.16 | 58% | 47–71 | |||
ALL subtype | None | 1.00 | 57% | 50–65 | 0.0011 | 1.00 | 62% | 56–69 | 0.31 | ||||
t(1;19) | 1.5 | 0.55–4.11 | 0.43 | 50% | 22–100 | 1.60 | 0.59–4.36 | 0.35 | 50% | 25–100 | |||
t(4;11) | 1.61 | 0.59–4.39 | 0.36 | 43% | 18–100 | 1.72 | 0.8–3.69 | 0.17 | 52% | 31–88 | |||
t(9;22) | 4.01 | 1.9–8.46 | <0.001 | 0% | 1.46 | 0.74–2.89 | 0.27 | 45% | 25–81 | ||||
CNS | CNS- | 1.00 | 53% | 47–60 | 0.016 | 1.00 | 63% | 57–69 | 0.33 | ||||
CNS+ | 1.69 | 1.1–2.6 | 0.017 | 29% | 17–48 | 1.23 | 0.81–1.85 | 0.33 | 57% | 45–71 | |||
WBC (1 × 109/L) | ≤10 | 1.00 | 57% | 49–67 | <0.001 | 1.00 | 71% | 63–80 | 0.0052 | ||||
>10 and ≤50 | 0.98 | 0.65–1.5 | 0.94 | 57% | 47–70 | 1.49 | 0.95–2.33 | 0.08 | 60% | 51–72 | |||
>50 and ≤100 | 1.89 | 1.09–3.3 | 0.025 | 38% | 22–63 | 2.53 | 1.42–4.52 | 0.0017 | 46% | 31–69 | |||
>100 | 2.21 | 1.41–3.49 | <0.001 | 28% | 17–47 | 1.87 | 1.15–3.03 | 0.011 | 55% | 44–70 | |||
BFM risk group | Standard risk | 1.00 | 80% | 65–97 | <0.001 | 1.00 | 84% | 72–100 | 0.0019 | ||||
Intermediate risk | 1.76 | 0.75–4.15 | 0.2 | 67% | 58–76 | 2.75 | 0.99–7.64 | 0.053 | 63% | 55–73 | |||
High risk | 4.76 | 2.08–10.86 | <0.001 | 33% | 26–42 | 4.17 | 1.53–11.4 | 0.0053 | 57% | 50–65 | |||
NCI risk group | B-ALL, standard risk | 1.00 | 66% | 58–76 | < 0.001 | 1.00 | 74% | 66–82 | <0.001 | ||||
B-ALL, high risk | 2.28 | 1.56–3.33 | <0.001 | 40% | 32–50 | 2.33 | 1.54–3.51 | <0.001 | 51% | 43–61 | |||
T-ALL, standard risk | 1.76 | 0.86–3.64 | 0.12 | 44% | 25–76 | 1.80 | 0.76–4.28 | 0.18 | 63% | 41–97 | |||
T-ALL, high risk | 2.42 | 1.41–4.15 | 0.0013 | 35% | 22–57 | 2.19 | 1.33–3.62 | 0.0022 | 56% | 45–71 | |||
Cytogenetic risk | Good | 1.00 | 79% | 63–100 | 0.0062 | 1.00 | 67% | 56–79 | 0.15 | ||||
Intermediate | 2.37 | 0.96–5.88 | 0.062 | 53% | 46–62 | 1.27 | 0.81–1.99 | 0.29 | 60% | 53–68 | |||
Poor | 4.41 | 1.61–12.06 | 0.0039 | 32% | 17–59 | 1.78 | 0.99–3.19 | 0.053 | 50% | 36–70 | |||
Prednisone response | Good | 1.00 | 65% | 58–73 | <0.001 | 1.00 | 69% | 62–76 | <0.001 | ||||
Poor | 2.56 | 1.83–3.57 | <0.001 | 31% | 23–41 | 2.31 | 1.64–3.27 | <0.001 | 50% | 42–60 | |||
Cranial radiotherapy | No | 1.00 | 56% | 49–65 | 0.1 | 1.00 | 67% | 61–74 | 0.77 | ||||
Yes | 1.31 | 0.95–1.81 | 0.1 | 44% | 36–53 | 1.05 | 0.75–1.48 | 0.77 | 57% | 50–66 |
Outcome | N | First Period (%) | N | Second Period (%) | p |
---|---|---|---|---|---|
Death before CR (induction death) | 9 | 3.1 | 10 | 2.4 | 0.575 |
Abandonment | 12 | 4.0 | 5 | 1.2 | 0.017 |
Resistant disease | 4 | 1.4 | 5 | 1.2 | 0.818 |
Death in the first CR | 33 | 12.1 | 24 | 6.1 | 0.007 |
Death in first CR SRG | 1 | 3.8 | 1 | 3.1 | 0.885 |
Death in first CR IRG | 8 | 7.3 | 7 | 4.3 | 0.288 |
Death in first CR HRG | 24 | 17.6 | 16 | 8.0 | <0.001 |
Relapse | 103 | 37.9 | 94 | 23.9 | <0.001 |
Relapse SRG | 5 | 19.2 | 3 | 9.4 | 0.288 |
Relapse IRG | 32 | 29.1 | 36 | 22.1 | 0.192 |
Relapse HRG | 66 | 48.5 | 55 | 27.6 | <0.001 |
Isolated BM | 78 | 28.7 | 77 | 19.5 | 0.006 |
Isolated CNS | 7 | 2.4 | 4 | 1.0 | 0.154 |
Isolated Testes | 7 | 2.4 | 4 | 1.0 | 0.154 |
Combined CNS/BM | 5 | 1.7 | 6 | 1.5 | 0.839 |
Combine BM/Other | 11 | 3.8 | 9 | 2.2 | 0.223 |
Other relapse | 0 | 0 | 3 | 0.7 | 0.168 |
Secondary neoplasia | 1 | 0.3 | 0 | 0 | 0.277 |
BMT in refractory disease | 0 | 0 | |||
BMT in CR1 | 5 | 1.7 | 17 | 4.1 | 0.081 |
BMT after relapse | 28 | 9.8 | 27 | 6.5 | 0.120 |
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content. |
© 2024 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).
Share and Cite
Horn, P.R.C.B.; Ribeiro-Carvalho, M.d.M.; Azevedo, A.M.B.d.; Sousa, A.M.d.; Faria, S.; Wiggers, C.; Rouxinol, S.; Schramm, M.T.; Sanches, B.S.; Duarte, N.L.; et al. Long-Term Outcomes of Childhood Acute Lymphocytic Leukemia Treated with Adapted Berlin–Frankfurt–Münster (BFM) Protocols: A Multicentric Analysis from a Developing Country. Cancers 2024, 16, 2898. https://doi.org/10.3390/cancers16162898
Horn PRCB, Ribeiro-Carvalho MdM, Azevedo AMBd, Sousa AMd, Faria S, Wiggers C, Rouxinol S, Schramm MT, Sanches BS, Duarte NL, et al. Long-Term Outcomes of Childhood Acute Lymphocytic Leukemia Treated with Adapted Berlin–Frankfurt–Münster (BFM) Protocols: A Multicentric Analysis from a Developing Country. Cancers. 2024; 16(16):2898. https://doi.org/10.3390/cancers16162898
Chicago/Turabian StyleHorn, Patricia Regina Cavalcanti Barbosa, Marilza de Moura Ribeiro-Carvalho, Alice Maria Boulhosa de Azevedo, Adriana Martins de Sousa, Simone Faria, Cristina Wiggers, Soraia Rouxinol, Marcia Trindade Schramm, Bárbara Sarni Sanches, Nathalia Lopez Duarte, and et al. 2024. "Long-Term Outcomes of Childhood Acute Lymphocytic Leukemia Treated with Adapted Berlin–Frankfurt–Münster (BFM) Protocols: A Multicentric Analysis from a Developing Country" Cancers 16, no. 16: 2898. https://doi.org/10.3390/cancers16162898
APA StyleHorn, P. R. C. B., Ribeiro-Carvalho, M. d. M., Azevedo, A. M. B. d., Sousa, A. M. d., Faria, S., Wiggers, C., Rouxinol, S., Schramm, M. T., Sanches, B. S., Duarte, N. L., Seixas, T. d. S. F., Gomes, B. E., Oliveira, E. d., Arcuri, L. J., Costa, E. S. d., Land, M. G. P., & Souza, M. H. F. O. d. (2024). Long-Term Outcomes of Childhood Acute Lymphocytic Leukemia Treated with Adapted Berlin–Frankfurt–Münster (BFM) Protocols: A Multicentric Analysis from a Developing Country. Cancers, 16(16), 2898. https://doi.org/10.3390/cancers16162898