NCCN Guidelines for Patients
Acute Lymphoblastic Leukemia, Version 1.2017
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
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
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.