A low- versus standard-dose regimen as induction for pediatric AML: a multicenter, randomized noninferiority trial

Intensive chemotherapy is standard for AML but carries high risks of life-threatening complications, particularly in vulnerable patients. We aimed to compare the efficacy and safety of a low-dose chemotherapy (LDC) regimen for induction of AML. A randomized, multicenter, noninferiority trial was conducted in patients aged <18 years with AML. Patients received low-dose cytarabine, mitoxantrone or idarubicin, and G-CSF (LDC) or standard-dose induction chemotherapy (SDC) (cytarabine, daunomycin, and etoposide). All patients received post-remission consolidation with standard chemotherapy and/ or hematopoietic stem cell transplantation. The primary endpoint was to compare response rates between treatments. The secondary endpoints were to compare the outcomes, toxicity, and safety of the LDC and SDC regimens. The two treatment arms showed no significant differences in outcomes. Complete remission (CR/CRi) rates after induction were 95.1% and 95.3% in the LDC and SDC arms, respectively. Measurable residual disease < 0.1% after induction II was observed in 87.4% and 87.1% of patients in the LDC and SDC arms, respectively. Median time to neutrophil and platelet recovery was significantly shorter among patients receiving the LDC regimen. Patients in the LDC arm had a 4-year overall survival (OS) of 81.3% vs. 83.6% (P = .611) and a 4-year event-free survival (EFS) of 61.5% vs. 63.1% (P = .832). In conclusion, the LDC regimen was well tolerated and was associated with CR, EFS, and OS rates that were not inferior to those of patients treated with the SDC regimen. The trial was registered at Chinese Clinical Trial Registry (ChiCTR1800015883).