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NCCN Guidelines for Patients



Acute Lymphoblastic Leukemia, Version 1.2017


Treatment guide

Relapsed or refractory Ph-negative ALL

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 have a different induction

regimen than you had before. ALL that relapses

more than three years after diagnosis is called a late

relapse. For AYAs with a late relapse, treatment with

the same induction regimen used before is an option

to consider.

Another option is to have chemotherapy for relapsed

or refractory ALL. There are many drugs and drug

combinations to choose from. Blinatumomab is the

preferred option for B-cell ALL. Blinatumomab is a

type of targeted therapy called a bispecific T-cell

engager. It uses the immune system to help kill

leukemia cells.

Combination regimens that include cytarabine or an

alkylating agent such as ifosfamide are also options.

An alkylating agent is a type of chemotherapy drug

that directly damages the DNA in leukemia cells.

Nelarabine is an option for patients with T-cell ALL.

Augmented hyper-CVAD is an intense chemotherapy

regimen that may be used for relapsed or refractory

ALL. It uses many drugs and gives some in

higher (intensified) doses. This regimen includes

cyclophosphamide, vincristine, doxorubicin,

dexamethasone, pegaspargase, methotrexate, and


VSLI is a form of the chemotherapy drug called

vincristine. VSLI has a special coating around it

called a liposome. The coating helps to limit the side

effects of vincristine. This allows doctors to give

higher doses of the drug without increasing side


Another option for patients with B-cell ALL is to have

a regimen that includes clofarabine. Clofarabine is

approved for patients aged 21 years or younger.

But, adults may also benefit from regimens with this

chemotherapy drug. The MOpAD regimen is another

option and includes methotrexate, vincristine,

pegaspargase, and dexamethasone, with rituximab

for CD20-positive disease.

If you did not previously receive an allogeneic SCT,

this is an important option to consider if you are able

to obtain a remission and a matched donor has been

found. In this case, your doctor will assess if you

are healthy enough to have an allogenic SCT. 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 an initial allogeneic SCT, a

second allogeneic SCT is an option. Or, your doctor

may consider a donor lymphocyte infusion. For this

treatment, you will be given white blood cells called

lymphocytes from the same donor used for the SCT.