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A robust and validated integrated prognostic index for defining risk groups in adult acute lymphoblastic leukemia: an EWALL collaborative study

Lookup NU author(s): Dr Amir EnshaeiORCiD, Melvin JoyORCiD, Ellie Butler, Professor Anthony MoormanORCiD



This work is licensed under a Creative Commons Attribution 4.0 International License (CC BY 4.0).


© 2024 by The American Society of Hematology.Risk stratification is crucial to the successful treatment of acute lymphoblastic leukemia (ALL). Although numerous risk factors have been identified, an optimal prognostic model for integrating variables has not been developed. We used individual patient data from 4 contemporary academic national clinical trials, UKALL14, NILG-ALL10/07, GIMEMALAL1913, and PETHEMA-ALL-HR2011, to generate and validate the European Working Group for Adult ALL prognostic index (EWALL-PI), which is based on white blood cell count, genetics, and end of induction minimal residual disease (MRD). Individual patient risk scores were calculated for 778 patients aged 15 to 67 years in complete remission using the validated UKALL-PI formula, applying minor modifications to reflect differences between pediatric and adult ALL. Per-trial analysis revealed that EWALL-PI correlated with relapse and death. Regression analysis revealed that each unit increase in EWALL-PI increased the risk of relapse or death by ~30% with no evidence of heterogeneity across trials or patient subgroups. EWALL-PI–defined risk models outperformed the stratification algorithms used by each trial. Threshold analysis revealed an EWALL-PI threshold that divided patients with B cell and T cell into standard (EWALL-PI <2.50) and high (EWALL-PI ≥2.50) risk groups, respectively. Per-trial analysis showed that patients at high risk had a significantly increased relapse rate and inferior survival compared with patients with standard risk (subdistribution hazard ratio for relapse, ranged from 1.85 to 3.28; hazard ratio for death, 1.73 to 3.03). Subgroup analysis confirmed the robustness of these risk groups by sex, age, white blood cell count, and lineage. In conclusion, we validated an integrated risk model across 4 independent adult ALL clinical trials, demonstrating its utility defining clinically relevant risk groups.

Publication metadata

Author(s): Enshaei A, Joy M, Butler E, Kirkwood AA, Messina M, Pavoni C, Morgades M, Harrison CJ, Foa R, Ribera J-M, Chiaretti S, Bassan R, Fielding AK, Moorman AV

Publication type: Article

Publication status: Published

Journal: Blood Advances

Year: 2024

Volume: 8

Issue: 5

Pages: 1155-1166

Print publication date: 12/03/2024

Online publication date: 19/12/2023

Acceptance date: 30/11/2023

Date deposited: 25/03/2024

ISSN (print): 2473-9529

ISSN (electronic): 2473-9537

Publisher: American Society of Hematology


DOI: 10.1182/bloodadvances.2023011661

PubMed id: 38113467


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Funder referenceFunder name
Blood Cancer UK
Cancer Research UK (CRCBPA-Jul21\100004, A21019 (C27995);