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NCCN Guidelines for Patients



Acute Lymphoblastic Leukemia, Version 1.2017


Treatment guide

Relapsed or refractory Ph-positive ALL

Relapsed or refractory Ph-positive ALL

Guide 16. Treatment for relapsed or refractory Ph-positive ALL

Tests Treatment options

Consider BCR-ABL

gene mutation testing

• Clinical trial

• TKI ± chemotherapy

• TKI ± corticosteroids

• Blinatumomab (If no response to 2 TKIs)

TKIs and chemotherapy for relapsed or refractory Ph-positive ALL:

• Dasatinib

• Imatinib

• Ponatinib

• Nilotinib

• Bosutinib

• Blinatumomab (If no response to 2 TKIs)

• Any TKI above + induction chemotherapy regimen not used before

• MOpAD regimen includes methotrexate, vincristine, pegaspargase,

and dexamethasone, with rituximab for CD20-positive disease and TKI

• If no response to TKIs, consider chemotherapy regimens for relapsed

or refractory Ph-negative ALL

Guide 16

shows the treatment options for relapsed

or refractory Ph-positive ALL. Ph-positive means the

leukemia cells have the Philadelphia chromosome.

A relapse is when leukemia cells come back after

a complete remission. Refractory means that the

leukemia cells didn’t respond to treatment. ALL that

isn’t in complete remission after induction therapy

is called refractory ALL. (See page 37 to read more

about treatment responses.) Similar treatments are

used for relapsed ALL and refractory ALL.


Before starting treatment,


gene mutation

testing should be done. This test checks for changes

(mutations) in the


fusion gene that affect

how well certain TKIs work. Each TKI drug works in

a slightly different way. One TKI drug may be able

to work against a mutation that another TKI can’t.

Knowing which mutations the


gene has will

help your doctor choose which TKI is best for you.