{
  "abstract": "Background: The treatment of pediatric acute lymphoblastic leukemia (ALL) is highly successful worldwide; however, treatment-related mortality remains unacceptably high in many low- and middle-income countries. Children treated on the previous Brazilian national ALL protocol (GBTLI), which used a Berlin-Frankfurt-Münster (BFM)-based backbone, experienced approximately 6% induction mortality. The primary objective of the GBTLI-2021 protocol was to reduce treatment-related mortality while maintaining excellent leukemia control. Methods: The GBTLI-2021 protocol is based on the St. Jude Total XV backbone, following its successful implementation in Recife, Brazil (ReLLA). Eligible patients were 1–21 years of age, and enrollment began on January 1, 2023. Initial risk stratification incorporated age, presenting white blood cell count, extramedullary disease, cytogenetic/molecular abnormalities, and ploidy. Risk assignment was refined using MRD measured on days 19 and 49. This protocol introduced several modifications designed to reduce induction toxicity, including administration of only two doses of daunorubicin during B-lineage ALL induction with postponement of the second dose in patients with profound neutropenia, risk-adapted use of pegaspargase, and continuous national case discussions and education involving participating centers. Patients were reviewed twice weekly through a centralized multidisciplinary discussion involving all participating institutions. Results: A total of 1497 children with ALL were enrolled from 41 centers across Brazil through May 31, 2026. B-lineage ALL accounted for 85% of cases, T-ALL for 13%, and Philadelphia chromosome-positive (Ph+) ALL for 2%. Induction mortality decreased from 6.2% with the previous GBTLI protocol to 3% with GBTLI-2021(p < 0,001). Mortality during complete remission also declined from 3.6% to 2.0%. The greatest improvement was observed in B-lineage ALL, where mortality decreased from 8.7% to 2.7%, whereas reductions were more modest in T-ALL (8.0% to 7.0%) and Ph+ ALL (11.0% to 8.0%). Importantly, the complete remission rate remained unchanged at 98%, indicating that reduced treatment intensity during induction did not compromise antileukemic efficacy. Conclusion: The implementation of the GBTLI-2021 protocol across a nationwide collaborative network reduced induction mortality by nearly one-half while maintaining a 98% remission rate. These findings suggest that judicious reduction of induction intensity, together with continuous education, centralized case discussions, and protocol adherence, can substantially improve outcomes in resource-constrained settings without compromising leukemia control.",
  "abstract_shown": true,
  "affiliations": [
    "Grupo de Apoio ao Adolescente e à Criança com Câncer (GRAAC), São Paulo, SP, Brazil",
    "Beneficência Portuguesa, São Paulo, SP, Brazil",
    "Instituto de Medicina Integral Professor Fernando Figueira (IMIP), Recife, PE, Brazil",
    "Hospital Infantil Albert Sabin, Fortaleza, CE, Brazil",
    "Hospital Pequeno Príncipe, Curitiba, PR, Brazil",
    "Hospital Araújo Jorge, Goiânia, GO, Brazil",
    "Hospital Oncológico Infantil Otavio Lobo, Belém, PA, Brazil",
    "Hospital Nossa Senhora da Glória, Vitória, ES, Brazil",
    "Hospital Beneficência Portuguesa, São Paulo, SP, Brazil",
    "St Jude Children's Hospital, United States"
  ],
  "article_type": null,
  "arxiv": null,
  "author_total": 13,
  "authors": [
    {
      "affs": [
        0
      ],
      "name": "Adriana SEBER"
    },
    {
      "affs": [
        1
      ],
      "name": "Maria Lucia De Martino LEE"
    },
    {
      "affs": [
        2
      ],
      "name": "Mecneide Mendes LINS"
    },
    {
      "affs": [
        2
      ],
      "name": "Maria do Céu Diniz BORBOREMA"
    },
    {
      "affs": [
        3
      ],
      "name": "Viviany VIANA"
    },
    {
      "affs": [
        4
      ],
      "name": "Alejandra Adriana Cardoso DE CASTRO"
    },
    {
      "affs": [
        5
      ],
      "name": "Vanusa Maria ROSA"
    },
    {
      "affs": [
        6
      ],
      "name": "Alayde Vieira WANDERLEY"
    },
    {
      "affs": [
        7
      ],
      "name": "Glaucia Perini Zouain FIGUEIREDO"
    },
    {
      "affs": [
        8
      ],
      "name": "Fabricio Tera ROMAGNOL"
    },
    {
      "affs": [
        0
      ],
      "name": "Ana Virginia LOPES"
    },
    {
      "affs": [
        2
      ],
      "name": "Maria Julia Gonçalves DE MELO"
    },
    {
      "affs": [
        9
      ],
      "name": "Raul RIBEIRO"
    }
  ],
  "bibtex": "https://research.draconitic.com/paper/cq31x090se0mg.bib",
  "cited_by": 0,
  "doi": "10.1016/j.htct.2026.108425",
  "fulltext_url": "http://www.sciencedirect.com/science/article/pii/S2531137926021723",
  "id": "cq31x090se0mg",
  "issns": [
    "2531-1379",
    "2531-1387"
  ],
  "landing_url": "https://doi.org/10.1016/j.htct.2026.108425",
  "language": "en",
  "licence": "CC-BY",
  "licence_label": "CC BY",
  "licence_source": "journal",
  "licence_url": "https://creativecommons.org/licenses/by/4.0/",
  "metadata_licence": null,
  "native_subjects": [
    [
      "lcc",
      "RC633-647.5"
    ],
    [
      "openalex",
      "2739|Acute Lymphoblastic Leukemia research"
    ]
  ],
  "openalex": "W7223550582",
  "pdf_url": null,
  "pmcid": null,
  "pmid": null,
  "published": "2026-10-23",
  "publisher": "Elsevier",
  "ris": "https://research.draconitic.com/paper/cq31x090se0mg.ris",
  "sources": [
    {
      "first_seen": "2026-10-30T13:43:25Z",
      "native_id": "3c0292790ef64db7b778440562a6b690",
      "source": "doaj",
      "url": "https://doi.org/10.1016/j.htct.2026.108425"
    }
  ],
  "subjects": [
    {
      "field": "medicine",
      "origin": "openalex:2739|Acute Lymphoblastic Leukemia research",
      "subfield": "epidemiology-public-health"
    }
  ],
  "title": "REDUCTION IN EARLY TREATMENT-RELATED MORTALITY IN THE NATIONAL BRAZILIAN CHILDHOOD ACUTE LYMPHOBLASTIC LEUKEMIA PROTOCOL (GBTLI-LLA 2021)",
  "title_text": "REDUCTION IN EARLY TREATMENT-RELATED MORTALITY IN THE NATIONAL BRAZILIAN CHILDHOOD ACUTE LYMPHOBLASTIC LEUKEMIA PROTOCOL (GBTLI-LLA 2021)",
  "type": "peer-reviewed",
  "updated_at": "2026-10-30T13:43:25Z",
  "url": "https://research.draconitic.com/paper/cq31x090se0mg",
  "venue": "Hematology, Transfusion and Cell Therapy",
  "versions": []
}