NCCN Guidelines for Patients
Acute Lymphoblastic Leukemia, Version 1.2017
Relapsed or refractory Ph-positive ALL
Along with the mutation testing results, your doctor
will look at other factors to help plan treatment. Some
factors include your age, general health, symptoms,
and side effects. This helps your doctor to know if
you are healthy enough to receive strong treatments.
There are several treatment options to choose
from. But, any treatment given should include
CNS preventive treatment. The options for treating
relapsed and refractory ALL are described next.
Treatment within a clinical trial is preferred if one is
open and is the right fit for you. A clinical trial is a
type of research that studies how safe and helpful a
treatment is. If you aren’t able to join a clinical trial,
there are a few other choices.
A second option is to receive a different TKI than
you had during induction therapy. Many patients with
Ph-positive ALL receive imatinib during induction
therapy. TKI options for relapsed or refractory ALL
are dasatinib, ponatinib, imatinib, nilotinib, and
bosutinib. Blinatumomab may be an option if the
cancer is not responding to 2 other TKI treatments.
The TKI may be given alone. Or, it may be
combined with multiagent chemotherapy or with a
corticosteroid. Prednisone and dexamethasone are
the main steroids that may be used. If combined
with chemotherapy, an induction regimen other than
the one you had before can be used. The MOpAD
regimen is another option and includes methotrexate,
vincristine, pegaspargase, and
rituximab for CD20-positive disease.
Some older adults may not be able to tolerate
multiagent chemotherapy. Steroids can be easier
to take than chemotherapy. Thus, treatment with a
TKI and steroids may be the best choice for some
If ALL doesn’t respond to treatment with TKIs, then
the regimens for relapsed or refractory Ph-negative
ALL may be tried.
See Guide 17.
An allogeneic SCT is also an option if you are
healthy enough and a well-matched donor has been
found. Some patients may not be able to tolerate this
intensive treatment. This is especially true for older
adults who may have other health problems.
If ALL relapses after the first allogeneic SCT, a
second allogeneic SCT is an option. Or your doctor
may consider a donor lymphocyte infusion. For this
treatment, you are given white blood cells called
lymphocytes from the same donor used for the SCT.