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Optimizing ALL Treatment
Expert Guidance on Optimizing Treatment Strategies for Acute Lymphoblastic Leukemia

Released: April 16, 2020

Expiration: April 15, 2021

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In this module, Amir T. Fathi, MD, reviews patient cases and provides an overview of the latest treatment options for patients with acute lymphoblastic leukemia (ALL), including antibody–drug conjugate (ADC), bispecific T-cell engager (BiTE), and CAR T-cell therapy.

The key points discussed in this module are illustrated with thumbnails from the accompanying downloadable PowerPoint slideset; they can be found here or downloaded by clicking on any of the slide thumbnails in the module alongside the expert commentary.

Clinical Care Options plans to measure the educational impact of this activity. A few questions will be asked twice: once before the discussion that informs the best choice and then again after that specific discussion. Your responses will be aggregated for analysis, and your specific responses will not be shared.

Before continuing with this educational activity, please take a moment to answer the following questions. 

If you are a practicing clinician, how many patients with ALL do you provide care for in a typical month?

A 68-year-old man with a white blood cell (WBC) count of 45,000 cells/mm3, a hemoglobin concentration of 7.8 g/dL, and a platelet count of 45,000 cells/mm3 presents to the hospital. The differential showed a large proportion of large immature-appearing cells, consistent with blasts. A marrow biopsy with microscopic and flow cytometric analysis revealed marrow involvement with 60% B-lymphoid blasts, consistent with a pre­–B-cell ALL. Karyotypic analysis was normal, and no BCR-ABL fusion was detected; lymphoid blasts did not express CD20, but expressed CD19 and CD22.


There was no suitable donor for transplantation. The man received 1 cycle of induction chemotherapy per the CALGB 8811 protocol (daunorubicin, vincristine, prednisone, pegaspargase, and cyclophosphamide). Three weeks later, count recovery is achieved and morphologic remission is established by marrow assessment. Flow cytometry of the aspirate revealed a 0.2% residual population of lymphoid blasts. The patient received 2 additional cycles of chemotherapy, which he tolerated fairly well, but a repeat marrow biopsy revealed an increase to 6% lymphoid blasts. He was treated with blinatumomab for 2 cycles, but failed to respond with continued progression of leukemia in the marrow.

In your current clinical practice, what therapy would you recommend for this patient?

In a discussion with the newest members of your clinical team, which of the following management approaches would you indicate is NOT appropriate for a patient with B-cell ALL who is experiencing severe veno-occlusive disease (VOD)/sinusoidal obstruction syndrome (SOS) following an alloSCT?

A 55-year-old man was diagnosed with B-cell precursor ALL with 60% B-lymphoid blasts on bone marrow biopsy, normal karyotype, and no BCR-ABL fusion. He received 1 cycle of induction chemotherapy per the CALGB 8811 protocol (daunorubicin, vincristine, prednisone, pegaspargase, and cyclophosphamide) and achieved count recovery 3 weeks later.


Marrow assessment showed morphologic remission, but flow cytometry of aspirate revealed 0.2% residual lymphoid blasts. He received 2 more cycles of chemotherapy, which he tolerated well. Flow cytometry of repeat aspirate now shows MRD with 0.18% B-lymphoid blasts.

In your current clinical practice, what therapy would you recommend for this patient?
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