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NCCN Guidelines for Patients



Acute Lymphoblastic Leukemia, Version 1.2017


Treatment guide

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.

Treatment options

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

dexamethasone, with

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.