Booklet for Hemato-Oncologists        

International BFM Study Group:
Early and Late Toxicity – Education Committee (ELTEC)



Treatment strategies to increase the curability of pediatric leukemias and lymphomas have led to the design of more intensive protocols. Despite improvements in supportive care, these have also increased the risk of serious adverse event. Within the I-BFM-SG (International BFM Study Group), a Committee dedicated to the study of early and late toxicities of antineoplastic therapy in childhood was set up in 1990. It meets annually during the I-BFM-SG meeting and in various as the work demands. The name of the group, ELTEC – Early and Late Toxicities and Education Committee, also includes Education, an important part of toxicity research. Our main purpose has been to learn as much as possible from serious or even fatal adversities encountered during antileukemic treatment; and from those data teach young doctors in particular how best to manage such situations.

The booklet includes:

  1. 315 multiple choice questions derived from 20 short case reports. These case reports refer to occurred “true” events: the reported events are not imaginary.
  2. 10 flow-charts in definition.

Please feel free and write a feed-back about these cases to, because we have realized during the review process that it is very hard to find always an evidence based correct answer.

The multiple-choice questions include:

  1. Short case reports
  2. 4 to 6 answers. One of this answers is the most appropriate.
  3. At the end of each group answers you could find what we consider the most appropriate answer followed by a comment of explanation and some references. However, we agree that there might remain controversy, in particular, since the value of diagnostic procedures is often unclear (in particular in the pediatric population) and since even therapeutic recommendations are often not based on randomized larger trials, but rather on experience and general agreement.

The ELTEC will provide also for:

  1. Two yearly update
  2. Two yearly modifications according to the new strategies.



Case # Description
1 Aphasia and headache in a 9-year old boy with T-ALL and hyperleukocytosis
2 Hyperleukocytosis resistant to steroid administration
3 Tachypnea and bilateral peri-hilar interstitial haziness during the induction phase, while in severe aplasia
4 Febrile neutropenia during induction therapy of AML
5 Abdominal pain with distension and stomatitis, no fever at the end of intensive treatment for HR-ALL
6 Chickenpox during aplasia in T-ALL
7 Severe hypotension and fever > 38°C during aplastic phase following intensive therapy
8 Mucous bleeding, PLT count <30,000 but normal coagulation profile in a 6-month old child with T-ALL and hyperleukocytosis successfully treated with leukopheresis
9 Seizures without other neurological signs in a 4-year old boy, without CNS involvement at diagnosis, during the second course of HD-MTX. No bleeding
10 Increase of serum AST and ALT during maintenance therapy with 6-MP and MTX
11 Tachycardia in a child with ALL and a central venous access device
12 Severe hypertension during the late intensification phase
13 Antibiotic resistant fever, not during aplasia, in a patient with HR-ALL with a Hickman catheter
14 Complete paralysis, loss of sensitivity, bilateral loss of tendon reflex during re-induction therapy for IR-ALL
15 Pain and swelling at the right shoulder during the induction phase including prednisone and L-ASP. Thrombus in the port-a-cath system.
16 Photophobia, and marked decrease of visus one month after the end of therapy in a boy who received prophylactic cranial irradiation
17 Erroneous introduction of 300 mg of MTX during triple intrathecal therapy
18 Acute leukemia presenting with hyperleukocytosis and thrombosis



We thank the whole ELTEC BFM group for their valuable assistance - Thomas Lehrnbecker, Tomas Kepak, Ricardo Haupt, Oussama Alba and Edit Bardi for the effort in reviewing all the material, Lillian Sung, Elio Castagnola and Andreas H. Groll for infectious cases and Ales Luks for editing this booklet to the Webside