Aim of the study is to determine the clinical outcome of 158 cases of childhood acute lymphoblastic leukemia (ALL) treated with a risk-directed protocol in Shanghai, China. One hundred fifty eight consecutive newly diagnosed patients were enrolled in the ALL-XH-99 protocol. The Kaplan - Meier method was used to estimate survival rates and comparisons were made by using the 2-sided log-rank test. Of all the 158 patients evaluated, 153 (96.8%) achieved complete remission (CR) in a median time of 33 days. The 5-year event-free survival (EFS) rate was 66.9% +/- 13.1%. Relapse occurred in 15 patients with isolated hematologic relapse in 13 and isolated central nervous system relapse in 2. Seven patients died of treatment-related complications. The medical cost for each patient does not exceed 25,000 USD. Contemporary risk-directed therapy can cure approximately two thirds of patients with ALL at relatively low cost. The challenge is to extend curative treatment to less privileged patients having fewer financial resources.