NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®)

Acute Lymphoblastic
Leukemia
Version 2.2020 — October 23, 2020

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*Patrick A. Brown, MD/Chair € Daniel J. DeAngelo, MD, PhD † ‡ Lori J Maness, MD ‡

The Sidney Kimmel Comprehensive Dana-Farber/Brigham and Women’s Fred & Pamela Buffett Cancer Center
Cancer Center at Johns Hopkins Cancer Center Stephanie Massaro, MD, MPH € ‡
*Bijal Shah, MD/Vice-Chair † Shira Dinner, MD † ‡ Yale Cancer Center/Smilow Cancer Hospital
Moffitt Cancer Center Robert H. Lurie Comprehensive Cancer Ryan J. Mattison, MD † ‡ Þ
Anjali Advani, MD † ‡ Center of Northwestern University University of Wisconsin Carbone Cancer Center
Case Comprehensive Cancer Center/University Amir T. Fathi, MD † ‡ Þ Olalekan Oluwole, MD ‡
Hospitals Seidman Cancer Center and Massachusetts General Hospital Vanderbilt-Ingram Cancer Center
Cleveland Clinic Taussig Cancer Institute Cancer Center
Jae Park, MD †
Patricia Aoun, MD, MPH ≠ Nitin Jain, MD † ‡ Memorial Sloan Kettering Cancer Center
City of Hope National Medical Center The University of Texas
MD Anderson Cancer Center Jeffrey E. Rubnitz, MD, PhD €
Bhavana Bhatnagar, DO ‡ † Þ St. Jude Children’s Research Hospital/The
The Ohio State University Comprehensive Suzanne Kirby, MD ‡ University of Tennessee Health Science Center
Cancer Center - James Cancer Hospital Duke Cancer Institute
and Solove Research Institute Geoffrey L. Uy, MD ‡ † ξ
Michaela Liedtke, MD ‡ Siteman Cancer Center at Barnes-
Michael W. Boyer, MD ‡ ξ € Stanford Cancer Institute Jewish Hospital and Washington
Huntsman Cancer Institute Mark Litzow, MD ‡ University School of Medicine
at the University of Utah Mayo Clinic Cancer Center Matthew Wieduwilt, MD, PhD ‡ ξ
Patrick W. Burke, MD † ‡ Aaron Logan, MD, PhD ‡ UC San Diego Moores Cancer Center
University of Michigan Rogel Cancer Center UCSF Helen Diller Family NCCN
Ryan D. Cassaday, MD † ‡ Þ Comprehensive Cancer Center Ndiya Ogba, PhD
Fred Hutchinson Cancer Research Center/ Selina Luger, MD †
Seattle Cancer Care Alliance Abramson Cancer Center
at the University of Pennsylvania

ξ Bone marrow ≠ Pathology

transplantation € Pediatric oncology
‡ Hematology/Hematology § Radiotherapy/Radiation
NCCN Guidelines Panel Disclosures Continue oncology oncology
Þ Internal medicine * Discussion Section
† Medical oncology Writing Committee

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Acute Lymphoblastic Leukemia Discussion

NCCN Acute Lymphoblastic Leukemia Panel Members Clinical Trials: NCCN believes that
Summary of the Guidelines Updates the best management for any patient
with cancer is in a clinical trial.
Participation in clinical trials is
Diagnosis (ALL-1) especially encouraged.
Workup and Risk Stratification (ALL-2) To find clinical trials online at NCCN
Ph+ ALL (AYA) Treatment Induction and Consolidation Therapy (ALL-3) Member Institutions, click here:
Ph+ ALL (Adult) Treatment Induction and Consolidation Therapy (ALL-4) nccn.org/clinical_trials/member_
institutions.aspx.
Ph- ALL (AYA) Treatment Induction and Consolidation Therapy (ALL-5)
NCCN Categories of Evidence and
Ph- ALL (Adult) Treatment Induction and Consolidation Therapy (ALL-6) Consensus: All recommendations
Surveillance (ALL-7) are category 2A unless otherwise
Relapsed/Refractory Disease, Treatment (ALL-8) indicated.
See NCCN Categories of Evidence
and Consensus.
Cytogenetic Risk Groups for B-ALL (ALL-A)
NCCN Categories of Preference:
Evaluation and Treatment of Extramedullary Involvement (ALL-B) All recommendations are considered
Supportive Care (ALL-C) appropriate.
Principles of Systemic Therapy (ALL-D) See NCCN Categories of Preference.
Response Assessment (ALL-E)
Minimal/Measurable Residual Disease Assessment (ALL-F)

The NCCN Guidelines® are a statement of evidence and consensus of the authors regarding their views of currently accepted approaches to
treatment. Any clinician seeking to apply or consult the NCCN Guidelines is expected to use independent medical judgment in the context of individual
clinical circumstances to determine any patient’s care or treatment. The National Comprehensive Cancer Network® (NCCN®) makes no representations
or warranties of any kind regarding their content, use or application and disclaims any responsibility for their application or use in any way. The NCCN
Guidelines are copyrighted by National Comprehensive Cancer Network®. All rights reserved. The NCCN Guidelines and the illustrations herein may
not be reproduced in any form without the express written permission of NCCN. 2020.
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Acute Lymphoblastic Leukemia Discussion

Updates in Version 2.2020 of the NCCN Guidelines for Acute Lymphoblastic Leukemia from Version 1.2020 include:
Minimal/Measureable Residual Disease Assessment (ALL-F)
• 6th bullet, 1st sub-bullet was revised, "For flow cytometric analysis of MRD, notify lab performing the MRD assessment if immunotherapy (such
as rituximab, blinatumomab, inotuzumab ozogamicin, or tisagenlecleucel) has been used.
MS-1
• The Discussion section has been updated to reflect the changes in the algorithm.

Updates in Version 1.2020 of the NCCN Guidelines for Acute Lymphoblastic Leukemia from Version 2.2019 include:
ALL-1
• Diagnosis, 3rd bullet was updated: " Baseline minimal/measurable residual disease (MRD) flow cytometric and/or molecular characterization
of leukemic clone to facilitate subsequent minimal/measurable residual disease (MRD) analysis"
• Footnote f: "(typically lacking expression of CD5, CD8, and CD1a and expression of one or more myeloid/stem cell markers)" was added.
ALL-8
• "B-ALL" was added to blinatumomab, inotuzumab ozogamicin, and tisagenlecleucel. Also for ALL-D, 4 of 8.

Cytogenetic Risk Groups for B-ALL (ALL-A)

• Footnote a is new: "The translocation t(12;21)(p13;q22) is typically cryptic by karyotyping and requires FISH or PCR to identify"
• Footnote b is new: "There are other results that are not less than 44 chromosomes that may be equivalent to hypodiploidy and have
the same implications. It is important to distinguish true hypodiploidy from masked hypodiploidy, which results from the doubling of
hypodiploid clones. Carroll AJ, Shago M, Mikhail FM, et al. Masked hypodiploidy: Hypodiploid acute lymphoblastic leukemia (ALL) mimicking
hyperdiploid ALL in children: A report from the Children's Oncology Group. Cancer Genet. 2019;238:62-68."

Supportive Care
ALL-C (1 of 4)
• Best Supportive Care
First sub-bullet is new: "For infection risk, monitoring, and prophylaxis recommendations for immune-targeted therapies, see INF-A in the
NCCN Guidelines for Prevention and Treatment of Cancer-Related Infections"
5th bullet, first sub bullet is new: "Trimethoprim/Sulfamethoxazole may be held when high-dose methotrexate is administered and re-
started when methotrexate clearance is achieved per protocol or institutional guidelines."
ALL-C (2 of 4)
• Blinatumomab, 2nd bullet: "Consider tocilizumab for patients with refractory CRS" was added.

Principles of Systemic Therapy (ALL-D)

• The NCCN Categories of Preference have been applied to the suggested treatment regimens.
• Footnote a is new: "For infection risk, monitoring, and prophylaxis recommendations for immune targeted therapies, see INF-A in the NCCN
Guidelines for Prevention and Treatment of Cancer-Related Infections."
• Footnote c is new: "The use of rituximab should be considered in addition to chemotherapy for CD20-positive patients (especially in patients
<60 years)."
• Footnote d is new: "TKI options include (in alphabetical order): bosutinib, dasatinib, imatinib, nilotinib, or ponatinib. Dasatinib and imatinib
are the preferred TKIs for induction therapy; ponatinib is also preferred for the hyper-CVAD regimen. Not all TKIs have been directly studied
within the context of each specific regimen and the panel notes that there is limited data for bosutinib in Ph+ ALL. Use of a specific TKI
should account for anticipated/prior TKI intolerance and disease-related features."
• References were updated. Continued

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Updates in Version 1.2020 of the NCCN Guidelines for Acute Lymphoblastic Leukemia from Version 2.2019 include:
Principles of Systemic Therapy (continued)
ALL-D (1 of 8)
• The following regimen was added for AYA and Adult Patients with appropriate reference: "CALGB 10701 regimen: TKI + multiagent
chemotherapy (dexamethasone, vincristine, daunorubicin, methotrexate, etoposide, and cytarabine)" Also for ALL-D (7 of 8)
• AYA Patients: "(cyclophosphamide, vincristine, daunorubicin, dexamethasone, cytarabine, methotrexate, pegaspargase, and prednisone)"
was added to EsPhALL regimen bullet.
• "(<65 y)" was added to "Adult Patients" heading. Also for ALL-D (2 of 8).
• "For treatment of older adult patients ≥65 y with ALL see Treatment of Older Patients (≥65 y) with ALL (ALL-D, 7 of 8)" was added below the
"Adult Patients" table.
ALL-D (2 of 8)
• Adult patients: "± rituximab" was added to the Linker 4-drug regimen with appropriate reference.
ALL-D (3 of 8)
• The "Treatment Options Based on BCR-ABL1 Mutation Profile" table was updated to include Contraindicated mutations.
• Footnote n is new: "Mutations contraindicated for imatinib are too numerous to include. There are compound mutations that can cause
resistance to ponatinib, but those are uncommon following treatment with bosutinib, dasatinib or nilotinib."
• Footnote o is new: "Bosutinib has minimal activity against F317L mutation. Nilotinib may be preferred over bosutinib in patients with F317L
mutation."
• Footnote p is new: "Ponatinib is a treatment option for patients with a T315I mutation and/or for patients for whom no other TKI is indicated.
ALL-D (4 of 8)
• The following regimen was added with appropriate reference: "Inotuzumab ozogamicin + mini-hyperCVD for B-ALL (cyclophosphamide,
dexamethasone, vincristine, methotrexate, cytarabine)"
ALL-D (7 of 8)
• Second bullet, second sub-bullet was updated: "For tools to aid optimal assessment and management of older adults with cancer, see the
NCCN Guidelines for Older Adult Oncology. Discussion of ALL in the elderly can be found on OAO-C page 2 of 7."
• Induction Regimens for Ph-Negative ALL, the following regimen was added under Moderate Intensity with appropriate reference:
"Inotuzumab ozogamicin + mini-hyperCVD (cyclophosphamide, dexamethasone, vincristine, methotrexate, cytarabine)"

Minimal/Measureable Residual Disease Assessment (ALL-F)

• Last bullet
First sub-bullet is new: "Notify lab if immunotherapy (such as rituximab, blinatumomab, or tisagenlecleucel) has been used."
Last sub-sub-bullet is new: "For some techniques, a baseline sample may be needed or helpful for the MRD assessment to be valid."

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DIAGNOSIS
Patients should undergo evaluation and treatment at specialized centers

The diagnosis of ALL generally requires demonstration of ≥20% bone marrow lymphoblastsd,e upon
hematopathology review of bone marrow aspirate and biopsy materials, which includes:
• Morphologic assessment of Wright-Giemsa–stained bone marrow aspirate smears, and H&E–stained core
biopsy and clot sections
• Comprehensive flow cytometric immunophenotypingf
• Baseline flow cytometric and/or molecular characterization of leukemic clone to facilitate subsequent
minimal/measurable residual disease (MRD) analysis (see AML-F)
• Karyotyping of G-banded metaphase chromosomes
Acute MOLECULAR CHARACTERIZATION See Workup
lymphoblastic Optimal risk stratification and treatment planning requires testing marrow or peripheral blood lymphoblasts and Risk
leukemia for specific recurrent genetic abnormalities using: Stratification
(ALL)a,b,c • Interphase fluorescence in situ hybridization (FISH) testing, including probes capable of detecting the (ALL-2)
major recurrent genetic abnormalitiesa
• Reverse transcriptase-polymerase chain reaction (RT-PCR) testing BCR-ABL1 in B-ALL (quantitative or
qualitative) including determination of transcript size (ie, p190 vs. p210)
• Testing is encouraged for gene fusions and pathogenic mutations, particulary if known to be BCR-ABL1
negativeg
Additional optional tests include:
• Assessment (array cGH) in cases of aneuploidy or failed karyotype
CLASSIFICATION
Together, these studies allow determination of the World Health Organization (WHO) ALL subtypes and
cytogenetic risk grouph

See footnotes on ALL-1A

Note: All recommendations are category 2A unless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any patient with cancer is in a clinical trial. Participation in clinical trials is especially encouraged.

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ALL-1
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FOOTNOTES
a Subtypes: B-cell lymphoblastic leukemia/lymphoma with recurrent genetic abnormalities includes hyperdiploidy, hypodiploidy, and commonly occurring translocations:
t(9;22)(q34.1;q11.2)[BCR-ABL1]; t(v;11q23.3)[KMT2A rearranged]; t(12;21)(p13.2;q22.1)[ETV6-RUNX1]; t(1;19)(q23;p13.3)[TCF3-PBX1]; t(5;14)(q31.1;q32.3)[IL3-
IGH]; Ph–like; B-lymphoblastic leukemia/lymphoma with iAMP21; early T-cell precursor lymphoblastic leukemia.
b Criteria for classification of mixed phenotype acute leukemia (MPAL) should be based on the WHO 2016 criteria. Note that in ALL, myeloid-associated antigens such
as CD13 and CD33 may be expressed, and the presence of these myeloid markers does not exclude the diagnosis of ALL, nor is it associated with adverse prognosis.
c Burkitt leukemia/lymphoma, see the NCCN Guidelines for B-Cell Lymphomas.
d While these guidelines pertain primarily to patients with leukemia, patients with lymphoblastic lymphoma (LL) (B- or T-cell) also benefit from ALL-like regimens versus
traditional lymphoma therapy. Such patients should be treated in a center that has experience with LL. See Discussion.
e If there are sufficient numbers of circulating lymphoblasts (at least 1,000 per microliter as a general guideline) and clinical situation precludes bone marrow aspirate
and biopsy, then peripheral blood can be substituted for bone marrow.
f The following immunophenotypic findings are particularly notable: CD10 negativity correlates with KMT2A rearrangement; ETP T-ALL (typically lacking expression
of CD5, CD8, and CD1a and expression of one or more myeloid/stem cell markers); CD20 positivity: definition not clear, most studies have used >20% of blasts
expressing CD20. See Discussion.
g The Ph-like phenotype is associated with recurrent gene fusions and mutations that activate tyrosine kinase pathways and includes gene fusions involving ABL1,
ABL2, CRLF2, CSF1R, EPOR, JAK2, or PDGFRB and mutations involving FLT3, IL7R, SH2B3, JAK1, JAK3, and JAK2 (in combination with CRLF2 gene fusions).
Testing for these abnormalities at diagnosis may aid in risk stratification. The safety and efficacy of targeted agents in this population is an area of active research. For
more information regarding Ph-like ALL, please see the Discussion.
h See Cytogenetic Risk Groups for B-ALL (ALL-A).

Note: All recommendations are category 2A unless otherwise indicated.

Clinical Trials: NCCN believes that the best management of any patient with cancer is in a clinical trial. Participation in clinical trials is especially encouraged.

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WORKUPi RISK STRATIFICATION

• History and physical (H&P)

• Complete blood count (CBC), platelets, differential, chemistry profile, liver function tests
(LFTs)
• Disseminated intravascular coagulation (DIC) panel: d-dimer, fibrinogen, prothrombin time
(PT), partial thromboplastin time (PTT)
• Tumor lysis syndrome (TLS) panel: Lactate dehydrogenase (LDH), uric acid, potassium, See Treatment
Ph+ ALL (AYA)l
calcium, phosphorus (See Tumor Lysis Syndrome in the NCCN Guidelines for B-Cell (ALL-3)
Lymphomas.)
• Urinalysis
• Hepatitis B/C, HIV, CMV Ab testing
• Pregnancy testing, fertility counseling, and preservation See Treatment
Ph+ ALL (Adult)
• CT/MRI of head with contrast, if neurologic symptomsi (ALL-4)
• Lumbar puncture (LP)j,k with intrathecal (IT) chemotherapy
See Evaluation and Treatment of Extramedullary Involvement (ALL-B)
• CT of neck/chest/abdomen/pelvis with IV contrast, as indicated for symptoms See Treatment
Consider PET/CT if lymphomatous involvement is suspected Ph- ALL (AYA)l
(ALL-5)
• Testicular exam, including scrotal ultrasound as indicated
• Infection evaluation:
Screen for opportunistic infections, as appropriate (See NCCN Guidelines for Prevention
and Treatment of Cancer-Related Infections) See Treatment
• Echocardiogram or cardiac nuclear medicine scan should be considered in all patients, Ph- ALL (Adult)
(ALL-6)
since anthracyclines are important components of ALL therapy, but especially in
patients with prior cardiac history and prior anthracycline exposure or clinical symptoms
suggestive of cardiac dysfunction.
• Central venous access device of choice
• Strongly consider human leukocyte antigen (HLA) typing and early evaluation and search
for family or an alternative donor

i The following list represents minimal recommendations; other testing may be warranted according to clinical symptoms and discretion of the clinician.
j For patients with major neurologic signs or symptoms at diagnosis, appropriate imaging studies should be performed to detect meningeal disease, chloromas,
or
central nervous system (CNS) bleeding. See Evaluation and Treatment of Extramedullary Involvement (ALL-B).
k The panel recommends first LP be performed at time of initial scheduled IT therapy unless directed by symptoms to perform earlier.
l The ALL Panel considers AYA to be within the age range of 15–39 years. However, this age is not a firm reference point because some of the recommended regimens
have not been comprehensively tested across all ages.

Note: All recommendations are category 2A unless otherwise indicated.

Clinical Trials: NCCN believes that the best management of any patient with cancer is in a clinical trial. Participation in clinical trials is especially encouraged.

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RISK TREATMENT INDUCTIONp,q CONSOLIDATION THERAPY

STRATIFICATION

Allogeneic hematopoietic Consider See

cell transplantation post-HCT Surveillance
(HCT), in appropriate TKIw,x,y (ALL-7)
Clinical trial Complete Monitoring
candidatest,u,v
or response (CR) for MRDs,t
or Maintenance See
Chemotherapy + Continue multiagent
Ph+ ALL tyrosine kinase therapyq + Surveillance
chemotherapy + TKIr TKIw,x,y
(AYA)m,n,o inhibitor (TKI)r Response (ALL-7)
or Assessment
TKI + (ALL-E)
corticosteroidr
See Relapsed/Refractory
Less than CR
Disease (ALL-8)

u Data suggest that for younger patients (aged ≤21 y), allogeneic HCT may not
offer an advantage over chemotherapy + TKI. Schultz KR, et al. Improved
early event-free survival with imatinib in Philadelphia chromosome-positive
acute lymphoblastic leukemia: a children's oncology group study. J Clin Oncol
m Chronological
 age is a poor surrogate for fitness for therapy. Patients should be 2009;27:5175-5181; Schultz KR, et al. Long-term follow-up of imatinib in pediatric
evaluated on an individual basis, including for the following factors: end-organ Philadelphia chromosome-positive acute lymphoblastic leukemia: Children's
reserve, end-organ dysfunction, and performance status. Oncology Group study AALL0031. Leukemia 2014;28:1467-1471.
n For additional considerations in the management of AYA patients with ALL, see v Many variables determine eligibility for allogeneic HCT including donor availability,
the NCCN Guidelines for Adolescent and Young Adult (AYA) Oncology. depth of remission, comorbidities, and social support.
o It is reasonable to approach the initial treatment of blast phase CML with similar w See Discussion for use of different TKIs in this setting.
strategies to Ph+ ALL, with a goal of proceeding to HCT. x The recommended duration of TKI after HCT is at least one year. The
p All ALL treatment regimens include CNS prophylaxis. recommended duration of TKI during maintenance chemotherapy is at least
q See Principles of Supportive Care (ALL-C). until completion of maintenance chemotherapy. The optimal duration of TKI is
r See Principles of Systemic Therapy (ALL-D). unknown in both settings.
s See Minimal/Measurable Residual Disease Assessment (ALL-F). y Consider periodic MRD monitoring (no more than every 3 months) for patients
t Optimal timing of HCT is not clear. For fit patients, additional therapy may be with complete molecular remission (undetectable levels). Increased frequency
considered to eliminate MRD prior to transplant. may be indicated for detectable levels.

Note: All recommendations are category 2A unless otherwise indicated.

Clinical Trials: NCCN believes that the best management of any patient with cancer is in a clinical trial. Participation in clinical trials is especially encouraged.

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ALL-3
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RISK TREATMENT INDUCTIONp,q CONSOLIDATION THERAPY

STRATIFICATION
Allogeneic HCT Consider See
in appropriate post-HCT Surveillance
Clinical trial Monitoring candidatest,v TKIw,x,y (ALL-7)
Patients or CR
for MRDs,t or Maintenance See
<65 years of TKI + Continue multiagent
agem without chemotherapyr Response therapyq + Surveillance
chemotherapy + TKIr TKIw,x,y (ALL-7)
substantial or Assessment
comorbidities TKI + (ALL-E)
corticosteroidr
Less See Relapsed/Refractory
than CR Disease (ALL-8)
Ph+ ALL Continue TKI ±
(Adult)o corticosteroidr
or
Continue TKI ± Maintenance See
Clinical trial Monitoring
CR chemotherapyr therapyq + Surveillance
Patients or for MRDs,t
or TKIw,x,y (ALL-7)
≥65 years of TKI + Response Allogeneic HCT
agem,z or with corticosteroidr Assessment in appropriate
substantial or (ALL-E) candidatest,v
comorbidities TKI +
chemotherapyr,aa Less See Relapsed/Refractory
than CR Disease (ALL-8)
m Chronological age is a poor surrogate for fitness for therapy. Patients should be w See Discussion for use of different TKIs in this setting.
evaluated on an individual basis, including for the following factors: end-organ x The recommended duration of TKI after HCT is at least one year. The
reserve, end-organ dysfunction, and performance status. recommended duration of TKI during maintenance chemotherapy is at least
o It is reasonable to approach the initial treatment of blast phase CML with similar until completion of maintenance chemotherapy. The optimal duration of TKI is
strategies to Ph+ ALL, with a goal of proceeding to HCT. unknown in both settings.
p All ALL treatment regimens include CNS prophylaxis. y Consider periodic MRD monitoring (no more than every 3 months) for patients
q See Principles of Supportive Care (ALL-C). with complete molecular remission (undetectable levels). Increased frequency
r See Principles of Systemic Therapy (ALL-D). may be indicated for detectable levels.
s See Minimal/Measurable Residual Disease Assessment (ALL-F). z For additional considerations in the management of older adult patients with ALL,
t Optimal timing of HCT is not clear. For fit patients, additional therapy may be see the NCCN Guidelines for Older Adult Oncology.
considered to eliminate MRD prior to transplant. aa Consider dose modifications appropriate for patient age and performance status.
v Many variables determine eligibility for allogeneic HCT including donor availability, See Principles of Systemic Therapy - Treatment of Older Adults with ALL (ALL-D
depth of remission, comorbidities, and social support. 7 of 8).

Note: All recommendations are category 2A unless otherwise indicated.

Clinical Trials: NCCN believes that the best management of any patient with cancer is in a clinical trial. Participation in clinical trials is especially encouraged.

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RISK TREATMENT INDUCTIONp,q CONSOLIDATION THERAPY

STRATIFICATION
Blinatumomab (B-ALL)cc Allogeneic
MRD+bb or HCTdd
Consider allogeneic HCTt,v

Continue multiagent Maintenance

chemotherapyr therapyr See
Monitoring
CR MRD- or Surveillance
for MRDs
Consider allogeneic HCTt,v (ALL-7)
Clinical trial (especially if high-risk features)h,ee
or
Pediatric-inspired Allogeneic HCTv
Ph- ALL regimens Response (especially if high-risk features)h,ee
(AYA)m,n (preferred) Assessment MRD or
or (ALL-E) unavailableff Consider continuing
Multiagent multiagent Maintenance
chemotherapyr chemotherapy r therapyr

See Relapsed/Refractory
Less than CR
Disease (ALL-8)
bb The
prognostic significance of MRD positivity may be regimen-, ALL subtype-,
h See Cytogenetic Risk Groups for B-ALL (ALL-A). and/or ALL risk-dependent. MRD timepoints and levels prompting allogeneic
m Chronological age is a poor surrogate for fitness for therapy. Patients should be HCT should be guided by the specific treatment protocol being used. In general,
evaluated on an individual basis, including for the following factors: end-organ MRD positivity at the end of induction predicts high relapse rates and should
reserve, end-organ dysfunction, and performance status. prompt evalution for allogeneic HCT. Therapy aimed at eliminating MRD prior to
n For additional considerations in the management of AYA patients with ALL, see allogeneic HCT is preferred when possible. (See Discussion)
the NCCN Guidelines for Adolescent and Young Adult (AYA) Oncology. cc See Supportive Care: Toxicity Management (ALL-C 2 of 4).
p All ALL treatment regimens include CNS prophylaxis. dd Although long-term remission after blinatumomab treatment is possible,
q See Principles of Supportive Care (ALL-C). allogeneic HCT should be considered as consolidative therapy.
r See Principles of Systemic Therapy (ALL-D). ee High WBC count (≥30 x 109/L for B lineage or ≥100 x 109/L for T lineage) is
s See Minimal/Measurable Residual Disease Assessment (ALL-F). considered a high-risk factor based on some studies in ALL. Data demonstrating
t Optimal timing of HCT is not clear. For fit patients, additional therapy may be the effect of WBC counts on prognosis are less firmly established for adults than
considered to eliminate MRD prior to transplant. for the pediatric population and likely superseded by MRD quantification after
v Many variables determine eligibility for allogeneic HCT including donor availabiltiy, treatment.
depth of remission, comorbidities, and social support. ff Consider retesting for MRD at first available opportunity.

Note: All recommendations are category 2A unless otherwise indicated.

Clinical Trials: NCCN believes that the best management of any patient with cancer is in a clinical trial. Participation in clinical trials is especially encouraged.

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RISK TREATMENT INDUCTIONp,q CONSOLIDATION THERAPY

STRATIFICATION Allogeneic
Blinatumomab (B-ALL)cc
MRD+bb or HCTdd
Consider allogeneic HCTt,v

Patients
Clinical trial Continue multiagent Maintenance
<65 years of
or chemotherapyr therapyr
agem without Monitoring See
Multiagent CR MRD- or Surveillance
substantial for MRDs
chemotherapyr Consider allogeneic HCTt,v (ALL-7)
comorbidities
(especially if high-risk features)h,ee
Ph- ALL Response Allogeneic HCTv
(Adult) Assessment (especially if high-risk features)h,ee
(ALL-E) MRD
Clinical trial or
unavailableff
Patients or Consider continuing Maintenance
≥65 years of Multiagent multiagent chemotherapyr therapyr
agem,z or with chemotherapyr,aa See Relapsed/Refractory
substantial or Less than CR
Disease (ALL-8)
comorbidities Palliative
corticosteroid
h See Cytogenetic Risk Groups for B-ALL (ALL-A).
m Chronological
 age is a poor surrogate for fitness for therapy. Patients should be
evaluated on an individual basis, including for the following factors: end-organ bb The prognostic significance of MRD positivity may be regimen-, ALL subtype-,
reserve, end-organ dysfunction, and performance status. and/or ALL risk-dependent. MRD timepoints and levels prompting allogeneic
p All ALL treatment regimens include CNS prophylaxis. HCT should be guided by the specific treatment protocol being used. In general,
q See Principles of Supportive Care (ALL-C). MRD positivity at the end of induction predicts high relapse rates and should
r See Principles of Systemic Therapy (ALL-D). prompt evalution for allogeneic HCT. Therapy aimed at eliminating MRD prior to
s See Minimal/Measurable Residual Disease Assessment (ALL-F). allogeneic HCT is preferred when possible. (See Discussion)
t Optimal timing of HCT is not clear. For fit patients, additional therapy may be cc See Supportive Care: Toxicity Management (ALL-C 2 of 4).
considered to eliminate MRD prior to transplant. dd Although long-term remission after blinatumomab treatment is possible,
v Many variables determine eligibility for allogeneic HCT including donor availabiltiy, allogeneic HCT should be considered as consolidative therapy.
depth of remission, comorbidities, and social support. ee High WBC count (≥30 x 109/L for B lineage or ≥100 x 109/L for T lineage) is
z For additional considerations in the management of older adult patients with ALL, considered a high-risk factor based on some studies in ALL. Data demonstrating
see the NCCN Guidelines for Older Adult Oncology. the effect of WBC counts on prognosis are less firmly established for adults than
aa Consider dose modifications appropriate for patient age and performance status. for the pediatric population and likely superseded by MRD quantification after
See Principles of Systemic Therapy - Treatment of Older Adults with ALL (ALL-D treatment.
7 of 8). ff Consider retesting for MRD at first available opportunity.

Note: All recommendations are category 2A unless otherwise indicated.

Clinical Trials: NCCN believes that the best management of any patient with cancer is in a clinical trial. Participation in clinical trials is especially encouraged.

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SURVEILLANCEgg

• Year 1 (every 1–2 months):

Physical exam
CBC with differential
LFTs until normal
• Year 2 (every 3–6 months):
Physical exam
CBC with differential
• Year 3+ (every 6–12 months or as indicated):
Physical exam
CBC with differential See Relapsed/Refractory
Disease (ALL-8)
Other General Measures
• Bone marrow aspirate as clinically indicated every 3–6 months for at least 5 yearshh
If bone marrow aspirate is done: Flow cytometry with additional studies that
may include comprehensive cytogenetics, FISH, molecular testing, and MRD
assessment
• Periodic BCR-ABL1 transcript-specific quantification (Ph+ ALL)
• Refer to Survivorship recommendations in the NCCN Guidelines for Survivorship
• Refer to the ALL Long-term Follow-up Guidelines from the Children’s Oncology
Group (COG): http://www.survivorshipguidelines.org/

gg Surveillance recommendations apply after completion of chemotherapy, including maintenance.

hh While there is insufficient evidence to guide MRD monitoring for Ph-negative patients following completion of maintenance therapy, the approval of blinatumomab, and
potentially future therapies for the MRD-positive relapse, may warrant testing in this regard. Alternatively, for patients showing evidence of symptomatic relapse, the
diagnostic workup should be repeated as per ALL-1.

Note: All recommendations are category 2A unless otherwise indicated.

Clinical Trials: NCCN believes that the best management of any patient with cancer is in a clinical trial. Participation in clinical trials is especially encouraged.

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RELAPSED/REFRACTORY DISEASE TREATMENTll,mm

Clinical trial
or
TKI ± chemotherapynn or TKI ± corticosteroidnn
ABL1 kinase or
Ph+ ALL Blinatumomabcc (TKI intolerant/refractory, B-ALL)
domain
(AYA & or Consider
mutation
Adult) Inotuzumab ozogamicincc (TKI intolerant/refractory, HCTkk,ll,mm
testingkk
B-ALL)
or
Tisagenlecleucelcc (patients <26 y and with refractory
B-ALL disease or ≥2 relapses and failure of 2 TKIs)oo
Relapsed/
refractoryii,jj
Clinical trial
or
Molecular Blinatumomabcc (B-ALL) (category 1)
characterization or
Ph- ALL
and MRD Inotuzumab ozogamicincc (B-ALL) (category 1) Consider
(AYA &
assessment, if not or HCTkk,ll,mm
Adult)
previously done Tisagenlecleucelcc (patients <26 y and with refractory
(see ALL-1) B-ALL disease or ≥2 relapses)oo
or
Chemotherapynn,pp

cc See Supportive Care: Toxicity Management (ALL-C 2 of 4).

ii Isolated extramedullary relapse (both CNS and testicular) requires systemic therapy to prevent relapse in marrow.
jj See NCCN Guidelines for Palliative Care.
kk See Treatment Options Based on BCR-ABL1 Mutation Profile (ALL-D 3 of 8).
ll See Principles of Systemic Therapy (ALL-D 3 of 8 and ALL-D 4 of 8).
mm If second remission is achieved prior to transplant and patient has not had a prior HCT, consolidative HCT is recommended.
nn For patients with relapsed disease after allogeneic HCT, a second allogeneic HCT and/or donor lymphocyte infusion (DLI) can be considered.
oo The role of allogeneic HCT following tisagenlecleucel is unclear. Persistence of tisagenlecleucel in peripheral blood and persistent B-cell aplasia
has been associated
with durable clinical responses without subsequent HCT. In the global registration trial, relapse-free survival was 59% at 12 months, with only 9% of patients
proceeding to HCT.
pp For patients in late relapse (>3 years from initial diagnosis), consider treatment with the same induction regimen (See ALL-D 2 of 8).

Note: All recommendations are category 2A unless otherwise indicated.

Clinical Trials: NCCN believes that the best management of any patient with cancer is in a clinical trial. Participation in clinical trials is especially encouraged.

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CYTOGENETIC RISK GROUPS FOR B-ALL

RISK GROUPS CYTOGENETICS

• Hyperdiploidy (51–65 chromosomes)

Cases with trisomy of chromosomes 4, 10, and 17 appear to have the
Good risk
most favorable outcome
• t(12;21)(p13;q22): ETV6-RUNX1a

• Hypodiploidyb (<44 chromosomes)

• KMT2A rearranged (t[4;11] or others)
• t(v;14q32)/IgH
Poor risk
• t(9;22)(q34;q11.2): BCR-ABL1 (defined as high risk in the pre-TKI era)
• Complex karyotype (5 or more chromosomal abnormalities)
• Ph-like ALL; intrachromosomal amplification of chromosome 21 (iAMP21)

a The translocation t(12;21)(p13;q22) is typically cryptic by karyotyping and requires FISH or PCR to identify.
b There are other results that are not less than 44 chromosomes that may be equivalent to hypodiploidy and have the same implications. It is important to distinguish
true hypodiploidy from masked hypodiploidy, which results from the doubling of hypodiploid clones. Carroll AJ, Shago M, Mikhail FM, et al. Masked hypodiploidy:
Hypodiploid acute lymphoblastic leukemia (ALL) mimicking hyperdiploid ALL in children: A report from the Children's Oncology Group. Cancer Genet 2019;238:62-68.

Note: All recommendations are category 2A unless otherwise indicated.

Clinical Trials: NCCN believes that the best management of any patient with cancer is in a clinical trial. Participation in clinical trials is especially encouraged.

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EVALUATION AND TREATMENT OF EXTRAMEDULLARY INVOLVEMENT

• The aim of CNS prophylaxis and/or treatment is to clear leukemic cells within sites that cannot be readily accessed by systemic
chemotherapy due to the blood-brain barrier, with the overall goal of preventing CNS disease or relapse.
• Factors associated with increased risks for CNS leukemia in adults include mature B-cell immunophenotype, T-cell immunophenotype, high
presenting WBC counts, and elevated serum LDH levels.1
• CNS involvement should be evaluated (by LP) at the appropriate timing:
Timing of LP should be consistent with the chosen treatment regimen.
Pediatric-inspired regimens typically include LP at the time of diagnostic workup.
The panel recommends that LP be done concurrently with initial IT therapy.
• Classification of CNS status:
CNS-1: No lymphoblasts in cerebrospinal fluid (CSF) regardless of white blood cell (WBC) count.
CNS-2: WBC <5/mcL in CSF with presence of lymphoblasts.
CNS-3: WBC ≥5/mcL in CSF with presence of lymphoblasts.
If the patient has leukemic cells in the peripheral blood and the LP is traumatic and WBC ≥5/mcL in CSF with blasts, then compare the
CSF WBC/red blood cell (RBC) ratio to the blood WBC/RBC ratio. If the CSF ratio is at least two-fold greater than the blood ratio, then the
classification is CNS-3; if not, then it is CNS-2.
• All patients with ALL should receive CNS prophylaxis. Although the presence of CNS involvement at the time of diagnosis is uncommon
(about 3%–7%), a substantial proportion of patients (>50%) will eventually develop CNS leukemia in the absence of CNS-directed therapy.
• CNS-directed therapy may include cranial irradiation, IT chemotherapy (eg, methotrexate, cytarabine, corticosteroid), and/or systemic
chemotherapy (eg, high-dose methotrexate, intermediate or high-dose cytarabine, pegaspargase). Generally, IT therapy should start during
the induction phase.
• CNS leukemia (CNS-3 and/or cranial nerve involvement) at diagnosis, or persisting after induction, may warrant treatment with cranial
irradiation of ≥18 Gy in 1.8 to 2.0 Gy/fraction. The recommended dose of radiation, where given, is highly dependent on the intensity of
systemic chemotherapy; thus, it is critical to adhere to a given treatment protocol in its entirety. The entire brain and posterior half of the
globe should be included. The inferior border should include C2.
• Note that areas of the brain targeted by the radiation field in the management of ALL are different from areas targeted for brain metastases of
solid tumors.
• With the incorporation of adequate systemic chemotherapy (eg, high-dose methotrexate, intermediate or high-dose cytarabine) and IT
chemotherapy regimens (eg, methotrexate alone or with cytarabine and a corticosteroid, which constitutes the triple IT regimen), it may be
possible to avoid the use of upfront prophylactic cranial irradiation except in cases of overt CNS leukemia at diagnosis, and to reserve the
use of irradiation for relapsed/refractory therapy settings.
• Adequate systemic therapy should be given in the management of isolated CNS relapse.
• Patients with clinical evidence of testicular disease at diagnosis that is not fully resolved by the end of the induction therapy should
be considered for radiation to the testes in the scrotal sac, which is typically done concurrently with the first cycle of maintenance
chemotherapy. Testicular total dose should be 24 Gy in 2.0 Gy/fraction.
1 Lazarus HM, Richards SM, Chopra R, et al. Central nervous system involvement in adult acute lymphoblastic leukemia at diagnosis: results from the international ALL
trial MRC UKALL XII/ECOG E2993. Blood 2006;108:465-472.

Note: All recommendations are category 2A unless otherwise indicated.

Clinical Trials: NCCN believes that the best management of any patient with cancer is in a clinical trial. Participation in clinical trials is especially encouraged.

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SUPPORTIVE CARE
Best Supportive Care ––Use of a histamine-2 antagonist or proton pump inhibitor (PPI)
• Infection control (See NCCN Guidelines for Prevention and should be considered during steroid therapy.
Treatment of Cancer-Related Infections) ––There may be important drug interactions between PPIs and
For infection risk, monitoring, and prophylaxis recommendations methotrexate that need to be considered prior to initiation of
for immune-targeted therapies, see INF-A in the NCCN Guidelines methotrexate-based therapy.
for Prevention and Treatment of Cancer-Related Infections ––There are significant interactions between PPIs and TKIs
• Acute TLS (See Tumor Lysis Syndrome on NHODG-B in the NCCN regarding the bioavailability of certain BCR-ABL1 TKIs with
Guidelines for B-Cell Lymphomas) gastric acid suppression that should be considered.
• Toxicity Management for Inotuzumab ozogamicin, Blinatumomab, Long-term side effects of corticosteroids
and Tisagenlecleucel (ALL-C 2 of 4) ◊◊Osteonecrosis/avascular necrosis (also see Discussion)
• Pegaspargase Toxicity Management (ALL-C 3 of 4 and ALL-C 4 of 4) ––Obtain vitamin D and calcium status and replete as needed.
• Methotrexate and Glucarpidase ––Consider radiographic evaluation with plain films or MRI or
Trimethoprim/Sulfamethoxazole may be held when high-dose bone density study.
methotrexate is administered and re-started when methotrexate ––Consider withholding steroid in patients with severe avascular
clearance is achieved per protocol or institutional guidelines. necrosis.
Consider use of glucarpidase in patients with significant renal • Transfusions
dysfunction and toxic plasma methotrexate concentrations Products should be leukoreduced/irradiated.
with delayed methotrexate clearance (plasma methotrexate • Use of granulocyte colony-stimulating factor (G-CSF)
concentrations >2 standard deviations of the mean methotrexate Recommended for myelosuppressive blocks of therapy or as
excretion curve specific for the dose of methotrexate directed by treatment protocol
administered). Leucovorin remains a component in the treatment • Hyperleukocytosis
of methotrexate toxicity and should be continued for at least 2 Although uncommon in patients with ALL, symptomatic
days following glucarpidase administration. However, be aware hyperleukocytosis may require emergent treatment (See
that leucovorin is a substrate for glucarpidase, and therefore Symptomatic Leukocytosis in the NCCN Guidelines for Acute
should not be administered within two hours prior to or following Myeloid Leukemia).
glucarpidase. • Antiemetics (See NCCN Guidelines for Antiemesis)
• Consider defibrotide for patients who develop veno-occlusive Given as needed prior to chemotherapy and post chemotherapy
disease (VOD) related to inotuzumab ozogamicin toxicity. Routine use of corticosteroids as antiemetics are avoided
• Steroid management • Gastroenterology
Acute side effects Consider starting a bowel regimen to avoid constipation if
◊◊Steroid-induced diabetes mellitus receiving vincristine.
––Tight glucose control using insulin to decrease infection • Nutritional support
complications Consider enteral or parenteral support for >10% weight loss.
◊◊Steroid-induced psychosis and mood alteration • Palliative treatment for pain (See NCCN Guidelines for Adult Cancer
––Consider anti-psychotics. If no response, consider dose Pain)
reduction.
Continued
Note: All recommendations are category 2A unless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any patient with cancer is in a clinical trial. Participation in clinical trials is especially encouraged.
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SUPPORTIVE CARE
Toxicity Management for Inotuzumab, Blinatumomab, and Tisagenlecleucel
Inotuzumab Ozogamicin:
• Cytoreduction should be considered for those with WBC >10,000 cells per microliter. On clinical trial, hydroxyurea or a combination of
steroids and vincristine was used.
• Myelosuppression is common, and prophylactic antimicrobial strategies in accordance with institutional practice should be employed.
• Liver enzymes, and particularly bilirubin, should be closely monitored, as sinusoidal obstruction syndrome (SOS) (or VOD) may occur,
particularly among patients at higher risk (including those who are status-post allogeneic stem cell transplantation [SCT]), those whose
treatment extends beyond two cycles, and/or those who previously received or will receive double alkylator conditioning prior to allogeneic
SCT. For those patients receiving inotuzumab as a bridge to allogeneic transplant, double alkylator conditioning is strongly discouraged.
Ursodiol may be considered for VOD prophylaxis.

Blinatumomab:
• Cytoreduction should be considered for those with WBC >15,000 cells per microliter, as high tumor burden may increase the risks of toxicity.
On clinical trial, steroids were most commonly used.
• Patients should be monitored for cytokine release syndrome (CRS), a systemic inflammatory condition characterized by fever or
hypothermia, that may progress to hypotension, hypoxia, and/or end organ damage. Infusion should be held with consideration for steroids
and/or vasopressors for those with severe symptoms in accordance with manufacturer guidelines and prescriber information. Consider
tocilizumab for patients with refractory CRS.
• Because concurrent severe infection may mimic CRS, an evaluation for underlying infection and consideration of empiric antimicrobial
therapy in accordance with institutional practice should be performed.
• Patients should be monitored for neurologic toxicity, which may include confusion, word-finding difficulty, somnolence, ataxia, tremor,
seizure, or syncope. Infusion should be held with consideration of steroids for those with severe symptoms in accordance with
manufacturer guidelines and prescribing information, and re-started (once symptoms have sufficiently improved) with dosing adjustments
as per manufacturer guidelines and prescribing information.

Tisagenlecleucel:
• Severe CRS and/or neurologic toxicity may accompany therapy, and should be managed in accordance with the manufacturer Risk
Evaluation and Mitigation Strategies (REMS) program, to include tocilizumab (preferred for CRS) and steroids (preferred for tocilizumab-
refractory CRS and/or neurologic toxicity).
• Prophylaxis with anti-seizure medication may be considered during the first month after tisagenlecleucel infusion.
• Severe neutropenia, T-cell depletion, and B-cell aplasia can occur, for which growth factor, prophylactic antimicrobial therapy, and
intravenous immunoglobulin administration should be considered, in accordance with institutional practice.
• See NCCN Guidelines for Management of Immunotherapy-Related Toxicities.

Continued
Note: All recommendations are category 2A unless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any patient with cancer is in a clinical trial. Participation in clinical trials is especially encouraged.
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SUPPORTIVE CARE
Asparaginase Toxicity Management
• Asparaginase should only be used in specialized centers and patients should be closely monitored in the period during and after infusion for
allergic response.
• There are three formulations of asparaginase in clinical use: 1) pegaspargase (PEG), 2) Calaspargase pegol-mknl (Cal-PEG), and
3) asparaginase Erwinia chrysanthemi (Erwinia). PEG is a common component of therapy for children, adolescents, and young adults with
ALL. The preferred route for administration for both PEG and Cal-PEG is intravenous (IV). The toxicity profile of these asparaginase products
presents significant challenges in clinical management. The following guidelines are intended to help providers address these challenges.
• For more detailed information, refer to Stock W, Douer D, DeAngelo DJ, et al. Prevention and management of asparaginase/pegasparaginase-
associated toxicities in adults and older adolescents: recommendations of an expert panel. Leuk Lymphoma 2011:52:2237-2253. All toxicity
grades refer to CTCAE v4.03. National Cancer Institute; National Institutes of Health. Common Terminology Criteria for Adverse Events
(CTCAE) version 4.03 2010. Available at: https://evs.nci.nih.gov/ftp1/CTCAE/CTCAE_4.03/CTCAE_4.03_2010-06-14_QuickReference_8.5x11.pdf.

Hypersensitivity, Allergy, and Anaphylaxis

• There is a significant incidence of hypersensitivity reactions with asparaginase products in some regimens. Of particular concern are Grade
2 or higher systemic allergic reactions, urticaria, or anaphylaxis, because these episodes can be (but are not necessarily) associated with
neutralizing antibodies and lack of efficacy.
• Erwinia is commonly used as a second-line agent in patients who have developed a systemic allergic reaction or anaphylaxis due to PEG
hypersensitivity.
• Anaphylaxis or other allergic reactions of Grade 3–4 severity (CTCAE 4.0) merit permanent discontinuation of the type of asparaginase that
caused the reaction.
• For Grade 1 reactions and Grade 2 reactions (rash, flushing, urticaria, and drug fever ≥38°C) without bronchospasm, hypotension, edema,
or need for parenteral intervention, the asparaginase that caused the reaction may be continued, with consideration for anti-allergy
premedication (such as hydrocortisone, diphenhydramine, and acetaminophen).
• If anti-allergy premedication is used prior to PEG or Erwinia administration, consideration should be given to therapeutic drug monitoring
(TDM) using commercially available asparaginase activity assays, since premedication may “mask” the systemic allergic reactions that can
indicate the development of neutralizing antibodies.1

1 Bleyer A, Asselin
BL, Koontz SE, Hunger S. Clinical application of asparaginase activity levels following treatment with pegaspargase. Pediatr Blood Cancer
2015;62:1102-1105.
Continued
Note: All recommendations are category 2A unless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any patient with cancer is in a clinical trial. Participation in clinical trials is especially encouraged.
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SUPPORTIVE CARE
Asparaginase Toxicity Managment (continued)
Pancreatitis
• Permanently discontinue asparaginase in the presence of Grade 3 or 4 pancreatitis. In the case of Grade 2 pancreatitis (enzyme elevation or
radiologic findings only), asparaginase should be held until these findings normalize and then resume.

Non-CNS Hemorrhage
• For Grade 2 or greater hemorrhage, hold asparaginase until Grade 1, then resume. Consider coagulation factor replacement. Do not hold for
asymptomatic abnormal laboratory findings.

Non-CNS Thromboembolism
• For Grade 2 or greater thromboembolic event, hold asparaginase until resolved and treat with appropriate antithrombotic therapy. Upon
resolution of symptoms and antithrombotic therapy stable or completed, consider resuming asparaginase.
• Consider checking ATIII levels if administering heparin.

Intracranial Hemorrhage
• Discontinue asparaginase. Consider coagulation factor replacement. For Grade 3 or less, if symptoms/signs fully resolve, consider resuming
asparaginase at lower doses and/or longer intervals between doses. For Grade 4, permanently discontinue asparaginase.
• Magnetic resonance angiography (MRA)/magnetic resonance venography (MRV) to rule out bleeding associated with sinus venous
thrombosis.

Cerebral Thrombosis, Ischemia, or Stroke

• Discontinue asparaginase. Consider antithrombotic therapy. For Grade 3 or less, if symptoms/signs fully resolve, consider resuming
asparaginase at lower doses and/or longer intervals between doses. For Grade 4, permanently discontinue asparaginase.

Hyperglycemia
• Treat hyperglycemia with insulin as indicated. For Grade 3 or higher, hold asparaginase and steroids until blood glucose has been regulated
with insulin, then resume.

Hypertriglyceridemia
• Treat hypertriglyceridemia as indicated. For Grade 4, hold asparaginase until normalized, then resume.

Hepatotoxicity (elevation in bilirubin, AST, ALT)

• For direct bilirubin ≤3.0 mg/dL, continue asparaginase. For direct bilirubin 3.1–5.0 mg/dL, hold asparaginase until <2.0 mg/dL, then resume.
For direct bilirubin >5.0, either discontinue asparaginase or hold asparaginase until <2.0 mg/dL, then resume with very close monitoring.
• For Grade 3 AST or ALT elevation, hold until Grade 1, then resume. For Grade 4 AST or ALT elevation, hold until Grade 1. If resolution to
Grade 1 takes 1 week or less, then resume. Otherwise, either discontinue or resume with very close monitoring.

Note: All recommendations are category 2A unless otherwise indicated.

Clinical Trials: NCCN believes that the best management of any patient with cancer is in a clinical trial. Participation in clinical trials is especially encouraged.
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PRINCIPLES OF SYSTEMIC THERAPYa

INDUCTION REGIMENS FOR Ph-POSITIVE ALLb,c
Protocols for AYA Patients:
Other Recommended Regimens
• EsPhALL regimen: TKId + backbone of the Berlin-Frankfurt-Münster regimen (cyclophosphamide, vincristine, daunorubicin,
dexamethasone, cytarabine, methotrexate, pegaspargase, and prednisone)1-3
• TKId + hyper-CVAD (hyperfractionated cyclophosphamide, vincristine, doxorubicin, and dexamethasone), alternating with high-dose
methotrexate, and cytarabine4–8
• TKId + multiagent chemotherapy (daunorubicin, vincristine, prednisone, and cyclophosphamide)9-13
• TKId,14,15 + corticosteroide
• TKId + vincristine + dexamethasone16,e
• CALGB 10701 regimen: TKId + multiagent chemotherapy (dexamethasone, vincristine, daunorubicin, methotrexate, etoposide, and cytarabine)17
Adult Patients (<65 y):
Other Recommended Regimens
• TKId + hyper-CVAD (hyperfractionated cyclophosphamide, vincristine, doxorubicin, and dexamethasone), alternating with high-dose
methotrexate, and cytarabine4–8
• TKId + multiagent chemotherapy (daunorubicin, vincristine, prednisone, and cyclophosphamide)9-13
• TKId,14,15 + corticosteroide
• TKId + vincristine + dexamethasone16,18,e
• CALGB 10701 regimen: TKId + multiagent chemotherapy (dexamethasone, vincristine, daunorubicin, methotrexate, etoposide, and cytarabine)17
For treatment of older adult patients ≥65 y with ALL, see Treatment of Older Patients (≥65 y) with ALL (ALL-D, 7 of 8)
Maintenance Regimens:
• Add TKId to maintenance regimen; optimal duration is unknown.
• Monthly vincristine/prednisone pulses (for 2–3 years). May include weekly methotrexate + daily 6-mercaptopurine (6-MP) as tolerated.f,g
d TKI options include (in alphabetical order): bosutinib, dasatinib, imatinib, nilotinib,
or ponatinib. Dasatinib and imatinib are the preferred TKIs for induction therapy;
ponatinib is also preferred for the hyper-CVAD regimen. Not all TKIs have been
Induction Regimens for Ph-Negative ALL directly studied within the context of each specific regimen and the panel notes
a For infection risk, monitoring, and prophylaxis recommendations for immune that there is limited data for bosutinib in Ph+ ALL. Use of a specific TKI should
targeted therapies, see INF-A in the NCCN Guidelines for Prevention and account for anticipated/prior TKI intolerance and disease-related features.
Treatment of Cancer-Related Infections. e These regimens are used for induction therapy and additional therapy is needed.
b All regimens include CNS prophylaxis with systemic therapy (eg, methotrexate, f For patients receiving 6-MP, consider testing for TPMT gene polymorphisms,
cytarabine) and/or IT therapy (eg, IT methotrexate, IT cytarabine; triple IT therapy particularly in patients who develop severe neutropenia after starting 6-MP.
with methotrexate, cytarabine, corticosteroid). g Dose modifications for antimetabolites in maintenance should be consistent with
c The use of rituximab should be considered in addition to chemotherapy for CD20- the chosen treatment regimen. It may be necessary to reduce dose/eliminate
positive patients (especially in patients <60 years). antimetabolite in the setting of myelosuppression and/or hepatotoxicity.

Note: All recommendations are category 2A unless otherwise indicated.

References
Clinical Trials: NCCN believes that the best management of any patient with cancer is in a clinical trial. Participation in clinical trials is especially encouraged.
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Acute Lymphoblastic Leukemia Discussion

PRINCIPLES OF SYSTEMIC THERAPYa

INDUCTION REGIMENS FOR Ph-NEGATIVE ALLb,h
AYA Patients: Adult Patients (<65 y):
Preferred Regimens Other Recommended Regimens
• CALGB 10403 regimen: daunorubicin, vincristine, prednisone, and • CALGB 8811 Larson regimen: daunorubicin, vincristine,
pegaspargasei (ongoing study in patients aged <40 years)19,h,j prednisone, pegaspargase, and cyclophosphamide; for
• COG AALL0232 regimen: daunorubicin, vincristine, prednisone, patients aged ≥60 years, reduced doses for cyclophosphamide,
and pegaspargasei (patients aged ≤21 years)20,h,j daunorubicin, and prednisone28,29,h
• COG AALL0434 regimen with nelarabine (for T-ALL): daunorubicin, • GRAALL-2005 regimen: daunorubicin, vincristine, prednisone,
vincristine, prednisone, and pegaspargase;i nelarabine added to pegaspargase, and cyclophosphamide (patients aged <60 years)
consolidation regimen21,j with rituximab for CD20-positive disease23,h
• DFCI ALL regimen based on DFCI Protocol 00-01: doxorubicin, • Hyper-CVAD ± rituximab: hyperfractionated cyclophosphamide,
vincristine, prednisone, high-dose methotrexate, and vincristine, doxorubicin, and dexamethasone, alternating with
pegaspargasei (ongoing study in patients aged <50 years)22,h,j high-dose methotrexate and cytarabine; with or without rituximab
Other Recommended Regimens for CD20-positive disease25,30,h
• Linker 4-drug regimen ± rituximab: daunorubicin, vincristine,
• GRAALL-2005 regimen: daunorubicin, vincristine, prednisone, prednisone, and pegaspargase (patients aged <60 years)27,31,h
pegaspargase,i and cyclophosphamide (patients aged <60 years), • MRC UKALLXII/ECOG2993 regimen: daunorubicin, vincristine,
with rituximab for CD20-positive disease23,h,j prednisone, and pegaspargase (induction phase I); and
• PETHEMA ALL-96 regimen: daunorubicin, vincristine, prednisone, cyclophosphamide, cytarabine, and 6-MPf (induction phase II)32,h
pegaspargase,i and cyclophosphamide (patients aged <30
years)24,h,j For treatment of older adult patients ≥65 y with ALL, see Treatment of
• Hyper-CVAD ± rituximab: hyperfractionated cyclophosphamide, Older Patients (≥65 y) with ALL (7 of 8)
vincristine, doxorubicin, and dexamethasone, alternating with
high-dose methotrexate and cytarabine; with or without rituximab Maintenance Regimen:
for CD20-positive disease25,h • Weekly methotrexate + daily 6-MPf,g + monthly vincristine/
• USC ALL regimen based on CCG-1882 regimen: daunorubicin, prednisone pulses (duration based on regimen)
vincristine, prednisone, and methotrexate with augmented Induction Regimens for Ph-Positive ALL
pegaspargase (patients aged 18–57 years)26,h,j g Dose
• Linker 4-drug regimen: daunorubicin, vincristine, prednisone, and modifications for antimetabolites in maintenance should be consistent with
the chosen treatment regimen. It may be necessary to reduce dose/eliminate
pegaspargase27,h antimetabolite in the setting of myelosuppression and/or hepatotoxicity.
a For infection risk, monitoring, and prophylaxis recommendations for immune h There are data to support the benefit of rituximab in addition to chemotherapy
targeted therapies, see INF-A in the NCCN Guidelines for Prevention and for CD20-positive patients (especially in patients <60 years). Refer to the
Treatment of Cancer-Related Infections. GRAALL-2005 study for timing and frequency of administration.
b All regimens include CNS prophylaxis with systemic therapy (eg, methotrexate, i Pegaspargase may be substituted with calaspargase pegol-mknl, an asparagine-
cytarabine) and/or IT therapy (eg, IT methotrexate, IT cytarabine; triple IT therapy specific enzyme, in patients ≤21 years for more sustained asparaginase activity.
with methotrexate, cytarabine, corticosteroid). Silverman LB, et al. Blood 2016;128:175; Angiolillo AL, et al. J Clin Oncol
f For patients receiving 6-MP, consider testing for TPMT gene polymorphisms, 2014;32:3874-3882.
particularly in patients who develop severe neutropenia after starting 6-MP. j Pediatric-inspired regimen.
References
Note: All recommendations are category 2A unless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any patient with cancer is in a clinical trial. Participation in clinical trials is especially encouraged.
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Acute Lymphoblastic Leukemia Discussion

PRINCIPLES OF SYSTEMIC THERAPYa

REGIMENS FOR RELAPSED OR REFRACTORY Ph-POSITIVE ALLb,k
Other Recommended Regimens
• TKI (dasatinib,33,34 imatinib,35 ponatinib,36,l nilotinib,37 or bosutinib38)
The TKIs noted above may also be used in combination with any of the induction regimens noted on ALL-D 1 of 8 that were not previously
given.
• Blinatumomab (for B-ALL) (TKI intolerant/refractory)39,m
• Inotuzumab ozogamicin (for B-ALL) (TKI intolerant/refractory)40,m
• Tisagenlecleucel (for B-ALL) (patients <26 y and with refractory disease or ≥2 relapses and failure of 2 TKIs)41,m
• MOpAD regimen (category 2B): methotrexate, vincristine, pegaspargase, dexamethasone; with rituximab for CD20-positive disease and TKI.42
• The regimens listed on ALL-D 4 of 8 for Ph-negative ALL may be considered for Ph-positive ALL refractory to TKIs.

TREATMENT OPTIONS BASED ON BCR-ABL1 MUTATION PROFILE

Therapy Contraindicated Mutationsn
Bosutinib T315I, V299L, G250E, or F317Lo
Dasatinib T315I/A, F317L/V/I/C, or V299L
Nilotinib T315I, Y253H, E255K/V, or F359V/C/I or G250E
Ponatinib p None

Regimens for Relapsed/Refractory Ph-Negative ALL

a For infection risk, monitoring, and prophylaxis recommendations for immune targeted therapies, see INF-A in the NCCN Guidelines for Prevention and Treatment of
Cancer-Related Infections.
b All regimens include CNS prophylaxis with systemic therapy (eg, methotrexate, cytarabine) and/or IT therapy (eg, IT methotrexate, IT cytarabine; triple IT therapy with
methotrexate, cytarabine, corticosteroid).
k The safety of relapsed/refractory regimens in older adults (≥65 years) has not been established. Please see ALL-D 7 of 8 for additional information.
l Ponatinib has activity against T315I mutations and is effective in treating patients with resistant or progressive disease on multiple TKIs. However, it is associated with
a high frequency of serious vascular events (eg, strokes, heart attacks, tissue ischemia). The FDA indications are for the treatment of adult patients with T315I­-positive,
Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) and for the treatment of adult patients with Ph+ ALL for whom no other TKI therapy is
indicated. For details, see http://www.accessdata.fda.gov/drugsatfda_docs/label/2013/203469s007s008lbl.pdf.
m See Supportive Care: Toxicity Management (ALL-C 2 of 4).
n Mutations contraindicated for imatinib are too numerous to include. There are compound mutations that can cause resistance to ponatinib, but those are uncommon
following treatment with bosutinib, dasatinib, or nilotinib.
o Bosutinib has minimal activity against F317L mutation. Nilotinib may be preferred over bosutinib in patients with F317L mutation.
p Ponatinib is a treatment option for patients with a T315I mutation and/or for patients for whom no other TKI is indicated.
References
Note: All recommendations are category 2A unless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any patient with cancer is in a clinical trial. Participation in clinical trials is especially encouraged.
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Acute Lymphoblastic Leukemia Discussion

PRINCIPLES OF SYSTEMIC THERAPYa

REGIMENS FOR RELAPSED OR REFRACTORY Ph-NEGATIVE ALLb,k,q
Preferred Regimens
• Blinatumomab (for B-ALL) (category 1)43,m
• Inotuzumab ozogamicin (for B-ALL) (category 1)40,m
• Tisagenlecleucel (for B-ALL) (patients <26 y and with refractory disease or ≥2 relapses)41,m
Other Recommended Regimens
• Inotuzumab ozogamicinm + mini-hyperCVD for B-ALL (cyclophosphamide, dexamethasone, vincristine, methotrexate, cytarabine)44
• Nelarabine alone45,46 or in combination (eg, nelarabine, etoposide, cyclophosphamide) for T-ALL47,48
• Augmented hyper-CVAD: hyperfractionated cyclophosphamide, intensified vincristine, doxorubicin, intensified dexamethasone, and
pegaspargase; alternating with high-dose methotrexate and cytarabine49
• Vincristine sulfate liposome injection (VSLI)50,51
• Clofarabine alone52,53 or in combination (eg, clofarabine, cyclophosphamide, etoposide54)
• MOpAD regimen: methotrexate, vincristine, pegaspargase, dexamethasone; with rituximab for CD20-positive disease42
• Fludarabine-based regimens
FLAG-IDA: fludarabine, cytarabine, granulocyte colony-stimulating factor, ± idarubicin55
FLAM: fludarabine, cytarabine, and mitoxantrone56
• Cytarabine-containing regimens: eg, high-dose cytarabine, idarubicin, IT methotrexate57
• Alkylator combination regimens: eg, etoposide, ifosfamide, mitoxantrone58

Regimens for Relapsed/Refractory Ph-Positive ALL

a For infection risk, monitoring, and prophylaxis recommendations for immune targeted therapies, see INF-A in the NCCN Guidelines for Prevention and Treatment of
Cancer-Related Infections.
b All regimens include CNS prophylaxis with systemic therapy (eg, methotrexate, cytarabine) and/or IT therapy (eg, IT methotrexate, IT cytarabine; triple IT therapy with
methotrexate, cytarabine, corticosteroid).
k The safety of relapsed/refractory regimens in older adults (≥65 years) has not been established. Please see ALL-D 7 of 8 for additional information.
m See Supportive Care: Toxicity Management (ALL-C 2 of 4).
q For patients in late relapse (>3 years from initial diagnosis), consider treatment with the same induction regimen (See ALL-D 2 of 8).
References
Note: All recommendations are category 2A unless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any patient with cancer is in a clinical trial. Participation in clinical trials is especially encouraged.
ALL-D
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PRINCIPLES OF SYSTEMIC THERAPY - REFERENCES

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Note: All recommendations are category 2A unless otherwise indicated.

Clinical Trials: NCCN believes that the best management of any patient with cancer is in a clinical trial. Participation in clinical trials is especially encouraged.
ALL-D
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44 Jabbour E, Ravandi F, Kebriaei P, et al. Salvage chemoimmunotherapy with inotuzumab 58 Schiller G, Lee M, Territo M, Gajewski J, Nimer S. Phase II study of etoposide, ifosfamide, and
ozogamicin combined with mini-Hyper-CVD for patients with relapsed or refractory Philadelphia mitoxantrone for the treatment of resistant adult acute lymphoblastic leukemia. Am J Hematol
chromosome-negative acute lymphoblastic leukemia: A phase 2 clinical trial. JAMA Oncol 1993;43:195-199.
2018;4:230-234.

Note: All recommendations are category 2A unless otherwise indicated.

Clinical Trials: NCCN believes that the best management of any patient with cancer is in a clinical trial. Participation in clinical trials is especially encouraged.
ALL-D
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Acute Lymphoblastic Leukemia Discussion

PRINCIPLES OF SYSTEMIC THERAPYa

Treatment of Older Adults with ALL
• Older adults (defined as those aged 65 years and older) benefit from therapy, in spite of higher treatment-related morbidity and mortality.
• Careful assessment of comorbid conditions, performance status, and ability to attend to activities of daily living (ADLs) and instrumental
ADLs (IADLs) is important when deciding treatment intensity.
For tools to aid optimal assessment and management of older adults with cancer, see the NCCN Guidelines for Older Adult Oncology.
• Dose reduction of pegylated asparaginase (1000 IU/m2), anthracycline (50% dose), and/or other myelosuppressive agents may be warranted.
• The categorization of regimens as low, moderate, or high intensity is based on two factors: 1) the presence or absence of myelosuppressive
cytotoxic agents, and 2) the relative dose intensity of the included agents.
• All regimens should include CNS prophylaxis, antimicrobial prophylaxis, and growth factor support.
• For appropriate fit individuals achieving remission, consideration of autologous or reduced-intensity allogeneic SCT may be appropriate.

INDUCTION REGIMENS for Ph-negative ALL – Adults Aged ≥65 y INDUCTION REGIMENS for Ph-positive ALL – Adults Aged ≥65 y
• Low intensity • Low intensity
Vincristine + prednisone1 TKId ± corticosteroid10-13,14
Prednisone, vincristine, methotrexate, and 6-mercaptopurine TKId + vincristine + dexamethasone15-17
(POMP)2 • Moderate intensity
• Moderate intensity EWALL: TKId with multiagent chemotherapy (vincristine,
GMALL: idarubicin + dexamethasone + vincristine + dexamethasone, methotrexate, cytarabine, asparaginase)18
cyclophosphamide + cytarabine ± rituximab3 CALGB 10701: TKId + multiagent chemotherapy (dexamethasone,
PETHEMA-based regimen4 vincristine, daunorubicin, methotrexate, etoposide, cytarabine)19
◊◊ALLOLD07 regimen: vincristine, dexamethasone, idarubicin, • High intensity20,21
cyclophosphamide, cytarabine, methotrexate, and TKId + HyperCVAD with dose-reduced cytarabine to 1 g/m2
L-asparaginase
GRAALL: doxorubicin + vincristine + dexamethasone + cytarabine
+ cyclophosphamide5
Modified DFCI 91-01 protocol: dexamethasone, doxorubicin,
vincristine, methotrexate, cytarabine, L-asparaginase, and IT
chemotherapy6
a For infection risk, monitoring, and prophylaxis recommendations for immune
Inotuzumab ozogamicin + mini-hyperCVD for B-ALL
(cyclophosphamide, dexamethasone, vincristine, methotrexate, targeted therapies, see INF-A in the NCCN Guidelines for Prevention and
cytarabine)7 Treatment of Cancer-Related Infections.
d TKI options include (in alphabetical order): bosutinib, dasatinib, imatinib, nilotinib,
• High intensity
or ponatinib. Dasatinib and imatinib are the preferred TKIs for induction therapy;
Hyper-CVAD8 with dose-reduced cytarabine to 1 g/m2 ponatinib is also preferred for the hyper-CVAD regimen. Not all TKIs have been
CALGB 91119 (cyclophosphamide, daunorubicin, vincristine, directly studied within the context of each specific regimen and the panel notes
prednisone, and pegaspargase) that there is limited data for bosutinib in Ph+ ALL. Use of a specific TKI should
account for anticipated/prior TKI intolerance and disease-related features.

Note: All recommendations are category 2A unless otherwise indicated. References

Clinical Trials: NCCN believes that the best management of any patient with cancer is in a clinical trial. Participation in clinical trials is especially encouraged.
ALL-D
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Acute Lymphoblastic Leukemia Discussion

PRINCIPLES OF SYSTEMIC THERAPY - Treatment of Older Adults with ALL

References
1 Hardisty RM, McElwain TJ, and Darby CW. Vincristine and prednisone for the 13 Papayannidis C, Fazi P, Piciocchi A, et al. Treating Ph+ acute lymphoblastic
induction of remissions in acute childhood leukaemia. Br Med J 1969;2:662-665. leukemia (ALL) in the elderly: the sequence of two tyrosine kinase inhibitors
2 Berry DH, Pullen J, George S, et al. Comparison of prednisolone, vincristine, (TKI) (nilotinib and imatinib) does not prevent mutations and relapse. Blood
mehtotrexate, and 6-mercaptopurine vs. vincristine and prednisone induction 2012;120:Abstract 2601.
therapy in childhood acute leukemia. Cancer 1975;36:98-102. 14 Martinelli G, Piciocchi A, Papayannidis C, et al. First report of the GIMEMA LAL
3 Gokbuget N, Beck J, Bruggemann M et al. Moderate intensive chemotherapy 1811 prospective study of the combination of steroids with ponatinib as frontline
including CNS prophylaxis with liposomal cytarabine is feasible and effective in therapy of elderly or unfit patients with Philadelphia chromosome-positive acute
older patients with Ph-negative acute lymphoblastic leukemia (ALL): results of a lymphoblastic leukemia. Blood 2017;139:99.
prospective trial from the German multicenter study group for adult ALL (GMALL). 15 Rousselot P, Coude MM, Gokbuget N et al. Dasatinib and low-intensity
Blood 2012;120:1493. chemotherapy in elderly patients with Philadelphia chromosome-positive ALL.
4 Ribera JM, Garcia O, Oriol A et al. PETHEMA group: Feasibility and results Blood 2016;128:774-82.
of subtype-oriented protocols in older adults and fit patients with acute 16 Rousselot P, Coude MM, Huguet F, et al. Dasatinib and low intensity
lymphoblastic leukemia: results of three prospective parallel trials from the chemotherapy for first-line treatment in patients with de novo Philadelphia
PETHEMA group. Leuk Res 2016;41:12-20. Positive ALL aged 55 and over: final results of the EWALL-Ph-01 study
5 Hunault-Berger M, Leguay T, Thomas X, et al. A randomized study of pegylated [abstract]. Blood 2012;120:Abstract 666.
liposomal doxorubicin versus continuous-infusion doxorubicin in elderly patients 17 Rea D, Legros L, Raffoux E, et al. High-dose imatinib mesylate combined with
with acute lymphoblastic leukemia: the GRAALL-SA1 study. Haematologica vincristine and dexamethasone (DIV regimen) as induction therapy in patients
2011;96(2):245-252. with resistant Philadelphia-positive acute lymphoblastic leukemia and lymphoid
6 Martell MP, Atenafu EG, Minden MD, et al. Treatment of elderly patients with blast crisis of chronic myeloid leukemia. Leukemia 2006;20:400-403.
acute lymphoblastic leukaemia using a paediatric-based protocol. Br J Haematol 18 Ottmann OG, Pfeifer H, Cayuela JM, et al. Nilotinib (Tasigna®) and low intensity
2013;163:458-464. chemotherapy for first-line treatment of elderly patients with BCR-ABL1-positive
7 Kantarjian H, Ravandi F, Short NJ, et al. Inotuzumab ozogamicin in combination acute lymphoblastic leukemia: Final results of a prospective multicenter trial
with low-intensity chemotherapy for older patients with Philadelphia chromosome- (EWALL-PH02). Blood 2018;132:Abstract 31.
negative acute lymphoblastic leukaemia: a single-arm, phase 2 study. Lancet 19 Wieduwilt MJ, Jones BA, Schiller GJ, et al. A phase II study of pegylated
Oncol 2018;19:240-248. asparaginase, cyclophosphamide, rituximab, and dasatinib added to
8 O’Brien S, Thomas DA, Ravand F et al. Results of the hyperfractionated the UCSF 8707 (linker 4-drug) regimen with liposomal cytarabine CNS
cyclophosphamide, vincristine, doxorubicin and dexamethasone in elderly prophylaxis for adults with newly diagnosed acute lymphoblastic leukemia
patients with acute lymphocytic leukemia. Cancer 2008;113:2097-2101. (ALL) or lymphoblastic lymphoma (LBL): University of California Hematologic
9 Larson RA, Dodge RK, Linker CA et al. A randomized control trial of filgrastim Malignancies Consortium Study (UCHMC) 1401. Blood 2018:132:4018.
during remission induction and consolidation chemotherapy for adults with acute 20 Ravandi F, O'Brien S, Thomas D, et al. First report of phase 2 study of
lymphoblastic leukemia: CALGB 9111. Blood 1998;92:1556-1564. dasatinib with hyper-CVAD for the frontline treatment of patients with
10 Ottmann OG, Wassmann B, Pfeiffer H et al. Imatinib compared with Philadelphia chromosome-positive (Ph+) acute lymphoblastic leukemia. Blood
chemotherapy as front-line treatment of elderly patients with Ph-chromosome 2010;116:2070-2077.
positive acute lymphoblastic leukemia. Cancer 2007;109:2068-2076. 21 Jabbour E, Kantarjian H, Ravandi F, et al. Combination of hyper-CVAD with
11 Foa
 R, Vitale A, Vignetti M, et al Dasatinib as first-line treatment for adult ponatinib as first-line therapy for patients with Philadelphia chromosome-positive
patients with Philadelphia chromosome positive acute lymphoblastic leukemia. acute lymphoblastic leukaemia: a single-centre, phase 2 study. Lancet Oncol
Blood 2011;118:6521-6528. 2015;16:1547-1555.
12 Vignetti M, Fazi P, Cimino G et al. Imatinib plus steroids induces complete
remissions and prolonged survival in elderly Philadelphia chromosome positive
patients with acute lymphoblastic leukemia without additional chemotherapy:
results of the Gruppo Italiano Malattie Ematologiche dell Adulto (GIMEMA)
LAL0201-B protocol. Blood 2007;109:3676-3678.

Note: All recommendations are category 2A unless otherwise indicated.

Clinical Trials: NCCN believes that the best management of any patient with cancer is in a clinical trial. Participation in clinical trials is especially encouraged.
ALL-D
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Acute Lymphoblastic Leukemia Discussion

RESPONSE ASSESSMENT
Response Criteria for Blood and Bone Marrow: Response Criteria for Lymphomatous Extramedullary Disease:
• CR • CT of neck/chest/abdomen/pelvis with IV contrast and PET/
No circulating lymphoblasts or extramedullary disease CT should be performed to assess response for extramedullary
◊◊No lymphadenopathy, splenomegaly, skin/gum infiltration/ disease.
testicular mass/CNS involvement • CR: Complete resolution of lymphomatous enlargement by CT.
Trilineage hematopoiesis (TLH) and <5% blasts For patients with a previous positive PET scan, a post-treatment
Absolute neutrophil count (ANC) >1000/microL residual mass of any size is considered a CR as long as it is PET
Platelets >100,000/microL negative.
No recurrence for 4 weeks • PR: >50% decrease in the sum of the product of the greatest
• CR with incomplete blood count recovery (CRi) perpendicular diameters (SPD) of the mediastinal enlargement. For
Meets all criteria for CR except platelet count or ANC patients with a previous positive PET scan, post-treatment PET must
• Overall response rate (ORR = CR + CRi) be positive in at least one previously involved site.
• NOTE: MRD assessment is not included in morphologic assessment • PD: >25% increase in the SPD of the mediastinal enlargement. For
and should be obtained (see ALL-F) patients with a previous positive PET scan, post-treatment PET must
be positive in at least one previously involved site.
• Refractory disease • No Response (NR): Failure to qualify for PR or PD.
Failure to achieve CR at the end of induction • Relapse: Recurrence of mediastinal enlargement after achieving CR.
• Progressive disease (PD) For patients with a previous positive PET scan, post-treatment PET
Increase of at least 25% in the absolute number of circulating or must be positive in at least one previously involved site.
bone marrow blasts or development of extramedullary disease
• Relapsed disease
Reappearance of blasts in the blood or bone marrow (>5%) or in
any extramedullary site after a CR

Response Criteria for CNS Disease:

• CNS remission: Achievement of CNS-1 status (see ALL-B) in a
patient with CNS-2 or CNS-3 status at diagnosis.
• CNS relapse: New development of CNS-3 status or clinical signs of
CNS leukemia such as facial nerve palsy, brain/eye involvement, or
hypothalamic syndrome without another explanation.

Note: All recommendations are category 2A unless otherwise indicated.

Clinical Trials: NCCN believes that the best management of any patient with cancer is in a clinical trial. Participation in clinical trials is especially encouraged.

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MINIMAL/MEASURABLE RESIDUAL DISEASE ASSESSMENT

• The optimal sample for MRD assessment is the first pull or early pull of the bone marrow aspirate.
• MRD in ALL refers to the presence of leukemic cells below the threshold of detection by conventional morphologic methods. Patients who
achieved a CR by morphologic assessment alone can potentially harbor a large number of leukemic cells in the bone marrow.
• MRD is an essential component of patient evaluation over the course of sequential therapy. If patient is not treated in an academic center,
there are commercially available tests available that should be used for MRD assessment.
• Studies in both children and adults with ALL have demonstrated the strong correlation between MRD and risks for relapse, as well as the
prognostic significance of MRD measurements during and after initial induction therapy.1
• The most frequently employed methods for MRD assessment include at least 6-color flow cytometry assays2,3 specifically designed to detect
abnormal MRD immunophenotypes, real-time quantitative polymerase chain reaction (RQ-PCR) assays to detect fusion genes (eg, BCR-
ABL1), and next-generation sequencing (NGS)-based assays, to detect clonal rearrangements in immunoglobulin (Ig) heavy chain genes
and/or T-cell receptor (TCR) genes.
• Current 6-color flow cytometry can detect leukemic cells at a sensitivity threshold of <1 × 10-4 (<0.01%) bone marrow mononuclear cells
(MNCs).2,3 PCR/NGS methods can detect leukemic cells at a sensitivity threshold of <1 x 10-6 (<0.0001%) bone MNCs.4,5 The concordance
rate for detecting MRD between these methods is generally high.
For flow cytometric analysis of MRD, notify lab performing the MRD assessment if immunotherapy (such as rituximab, blinatumomab,
inotuzumab ozogamicin, or tisagenlecleucel) has been used.
Timing of MRD assessment:
◊◊Upon completion of initial induction.
◊◊Additional time points should be guided by the regimen used.
◊◊Serial monitoring frequency may be increased in patients with molecular relapse or persistent low-level disease burden.
◊◊For some techniques, a baseline sample may be needed or helpful for the MRD assessment to be valid.

1 Berry DA, Zhou S, Higley H, et al. Association of minimal residual disease with clinical outcome in pediatric and adult lymphoblastic leukemia. JAMA Oncol
2017;3:e170580.
2 Gaipa G, Cazzaniga G, Valsecchi MG, et al. Time point-dependent concordance of flow cytometry and real-time quantitative polymerase chain reaction for minimal
residual disease detection in childhood acute lymphoblastic leukemia. Haematologica 2012;97(10):1582-1593.
3 Denys B, van der Sluijs-Gelling AJ, Homburg C, et al. Improved flow cytometric detection of minimal residual disease in childhood acute lymphoblastic leukemia.
Leukemia 2013;27:635-641.
4 Bruggemann M, Schrauder A, Raff T, et al. Standardized MRD quantification in European ALL trials: proceedings of the Second International Symposium on MRD
assessment in Kiel, Germany, 18-20 September 2008. Leukemia 2010;24:521-535.
5 Campana D. Minimal residual disease in acute lymphoblastic leukemia. Hematology Am Soc Hematol Educ Program 2010;2010:7-12.

Note: All recommendations are category 2A unless otherwise indicated.

Clinical Trials: NCCN believes that the best management of any patient with cancer is in a clinical trial. Participation in clinical trials is especially encouraged.

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NCCN Categories of Evidence and Consensus

Category 1 Based upon high-level evidence, there is uniform NCCN consensus that the intervention is appropriate.
Category 2A Based upon lower-level evidence, there is uniform NCCN consensus that the intervention is appropriate.
Category 2B Based upon lower-level evidence, there is NCCN consensus that the intervention is appropriate.
Category 3 Based upon any level of evidence, there is major NCCN disagreement that the intervention is appropriate.
All recommendations are category 2A unless otherwise indicated.

NCCN Categories of Preference

Interventions that are based on superior efficacy, safety, and evidence; and, when appropriate,
Preferred intervention affordability.
Other recommended Other interventions that may be somewhat less efficacious, more toxic, or based on less mature data;
intervention or significantly less affordable for similar outcomes.
Useful in certain
Other interventions that may be used for selected patient populations (defined with recommendation).
circumstances
All recommendations are considered appropriate.

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Discussion This discussion corresponds to the NCCN Guidelines for Initial Treatment in Adults with Ph-Positive ALL ......................... MS-17
Acute Lymphoblastic Leukemia. Last updated: October 22, Treatment of Relapsed Ph-Positive ALL .................................... MS-21
2020
NCCN Recommendations for Ph-Positive ALL ........................... MS-25
Table of Contents Management of Ph-Negative ALL ................................................. MS-27

Overview ......................................................................................... MS-2 Initial Treatment in AYA Patients with Ph-Negative ALL ............. MS-27

Literature Search Criteria and Guidelines Update Methodology........ MS-3 Initial Treatment in Adults with Ph-Negative ALL ........................ MS-34

Diagnosis ........................................................................................ MS-3 Treatment of Relapsed Ph-Negative ALL ................................... MS-38

Clinical Presentation and Diagnosis ............................................. MS-3 NCCN Recommendations for Ph-Negative ALL ......................... MS-43

Immunophenotyping..................................................................... MS-4 Management of Lymphoblastic Lymphoma ................................... MS-45

Cytogenetic and Molecular Subtypes............................................ MS-5 Evaluation and Treatment of Extramedullary Disease.................... MS-45

Table 1: Common Chromosomal and Molecular Abnormalities in ALL CNS Involvement in ALL ........................................................... MS-45
.................................................................................................... MS-6 NCCN Recommendations for Evaluation and Treatment of
Workup ........................................................................................... MS-7 Extramedullary Involvement ...................................................... MS-46

Prognostic Factors and Risk Stratification ........................................ MS-8 Response Assessment and Surveillance ....................................... MS-47

Prognostic Factors in AYA Patients with ALL ................................ MS-8 Response Criteria ..................................................................... MS-47

Prognostic Factors in Adults with ALL .......................................... MS-9 Surveillance .............................................................................. MS-48

NCCN Recommendations for Risk Assessment in ALL ............... MS-11 Role of MRD Evaluation................................................................ MS-48

Overview of Treatment Phases in ALL Management ...................... MS-11 MRD Assessment in Childhood ALL .......................................... MS-49

Induction .................................................................................... MS-12 MRD Assessment in Adult ALL .................................................. MS-52

CNS Prophylaxis and Treatment ................................................ MS-12 NCCN Recommendations for MRD Assessment ........................ MS-54

Consolidation ............................................................................. MS-12 Supportive Care for Patients with ALL ........................................... MS-54

Hematopoietic Stem Cell Transplantation ................................... MS-13 NCCN Recommendations for Supportive Care .......................... MS-55

Maintenance .............................................................................. MS-13 References ................................................................................... MS-59

Targeted Agents ........................................................................ MS-14

Management of Ph-Positive ALL .................................................... MS-14
Initial Treatment in AYA Patients with Ph-Positive ALL ............... MS-14

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Klinefelter syndrome,10-12 Fanconi anemia,13,14 Shwachman-Diamond

Overview
syndrome,15,16 Bloom syndrome,17 and ataxia telangiectasia.18
The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®)
for Acute Lymphoblastic Leukemia (ALL) were developed as a result of The cure rates and survival outcomes for patients with ALL have improved
meetings convened by a multidisciplinary panel of ALL experts, with the dramatically over the past several decades, primarily among children.19
goal of providing recommendations on standard treatment approaches Improvements are largely owed to advances in the understanding of the
based on current evidence. The NCCN Guidelines focus on the molecular genetics and pathogenesis of the disease, the incorporation of
classification of ALL subtypes based on immunophenotype and risk-adapted therapy, the advent of new targeted agents, and the use of
cytogenetic/molecular markers; risk assessment and stratification for risk- allogeneic hematopoietic cell transplantation (HCT).
adapted therapy; treatment strategies for Philadelphia chromosome (Ph)–
positive and Ph-negative ALL for both adolescent and young adult (AYA) Analyses from the SEER database have shown improvements in survival
and adult patients; and supportive care considerations. Given the for children and AYA patients with 5-year overall survival (OS) rates of
complexity of ALL treatment regimens and the required supportive care 89% and 61%, respectively.19,20 However, survival rates for adult patients
measures, the NCCN ALL Panel recommends that patients be treated at a remains low at approximately 20% to 40%.21-23 Survival rates are
specialized cancer center with expertise in the management of ALL. especially poor in older adult patients at approximately 20%.22,24,25
Although the exact OS percentage can vary based on how the age range
ALL is a heterogeneous hematologic disease characterized by the is defined for pediatric, AYA, and adult patients, the trend is nonetheless
proliferation of immature lymphoid cells in the bone marrow, peripheral clear that OS decreases substantially with increased age.22 The exception
blood, and other organs.1 The age-adjusted incidence rate of ALL in the is infants younger than age 1, which is an age group that has not seen any
United States is 1.38 per 100,000 individuals per year,2 with approximately improvement in survival over the last 30 years. The 5-year OS in this
6,150 new cases and 1,520 deaths estimated in 2020.3 The median age at population is 55.8%19 (see Cytogenetic and Molecular Subtypes). Cure
diagnosis for ALL is 15 years4 with 55.4% of patients diagnosed at rates for AYAs with ALL remain suboptimal compared with those for
younger than 20 years of age.5 In contrast, 28% of cases are diagnosed at children, although substantial improvements have been seen with the
45 years or older and only approximately 12.3% of patients are diagnosed adoption of pediatric treatment regimens.26 AYA patients represent a
at 65 years or older.5 ALL represents 75% to 80% of acute leukemias unique population, because they may receive treatment based on either a
among children, making it the most common form of childhood leukemia; pediatric or an adult protocol, depending on local referral patterns and
by contrast, ALL represents approximately 20% of all leukemias among institutional practices. Favorable cytogenetic subtypes, such as ETV6-
adults.1,6 RUNX1 ALL and hyperploidy, occur less frequently among AYA patients
compared with children, whereas the incidence of ALL with BCR-ABL (Ph-
Risk factors for developing ALL include older age (>70 years), exposure to positive ALL) is higher in AYA patients.
chemotherapy or radiation therapy, and genetic disorders, particularly
Down syndrome.7,8 Although rare, other genetic conditions have been
categorized as a risk factor for ALL and include neurofibromatosis,9

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Acute Lymphoblastic Leukemia

Literature Search Criteria and Guidelines Update gastrointestinal involvement, or chin numbness resulting from cranial
Methodology nerve involvement, are more suggestive of mature B-cell ALL (B-ALL).1,28
Prior to the update of this version of the NCCN Guidelines for Acute
The diagnosis of ALL generally requires demonstration of 20% or greater
Lymphoblastic Leukemia, an electronic search of the PubMed database
bone marrow lymphoblasts on hematopathology review of bone marrow
was performed to obtain key literature published in the field since the
aspirate and biopsy materials. Peripheral blood may be substituted for
previous Guidelines update, using the following search term: acute
bone marrow provided there is a significant amount of circulating
lymphoblastic leukemia. The PubMed database was chosen as it remains
disease,29,30 with the NCCN ALL Panel suggesting a general guide of
the most widely used resource for medical literature and indexes peer-
≥1,000 circulating lymphoblasts per microliter. The 2008 WHO
reviewed biomedical literature.27
classification lists ALL and lymphoblastic lymphoma as the same entity,
The search results were narrowed by selecting studies in humans distinguished only by the primary location of the disease.31,32 When the
published in English. Results were confined to the following article types: disease is restricted to a mass lesion primarily involving nodal or
Clinical Trial, II; Clinical Trial, III; Clinical Trial, IV; Guideline; Meta- extranodal sites with no or minimal involvement in blood or bone marrow
Analysis; Randomized Controlled Trial; Systematic Reviews; and (generally defined as <20% lymphoblasts in the marrow), the case would
Validation Studies. The data from key PubMed articles as well as articles be consistent with a diagnosis of lymphoblastic lymphoma.31,32
from additional sources deemed as relevant to these Guidelines and Lymphoblastic lymphoma was previously categorized with non-Hodgkin
discussed by the panel during the Guidelines update have been included lymphoma and is associated with exposure to radiation or pesticide and
in this version of the Discussion section. Recommendations for which congenital or acquired immunosuppression. However, based on
high-level evidence is lacking are based on the panel’s review of lower- morphologic, genetic, and immunophenotypic features, lymphoblastic
level evidence and expert opinion. The complete details of the lymphoma is indistinguishable from ALL. Patients with lymphoblastic
Development and Update of the NCCN Guidelines are available at lymphoma generally benefit from treatment with ALL-like regimens versus
www.NCCN.org. traditional lymphoma therapy and should be treated in a center that has
experience with lymphoblastic lymphoma (see Management of
Diagnosis Lymphoblastic Lymphoma).
Clinical Presentation and Diagnosis
Hematopathology evaluations should include morphologic examination of
The clinical presentation of ALL is typically nonspecific, and may include malignant lymphocytes using Wright-Giemsa–stained slides and
fatigue or lethargy, constitutional symptoms (eg, fevers, night sweats, hematoxylin and eosin–stained core biopsy and clot sections;
weight loss), dyspnea, dizziness, infections, and easy bruising or comprehensive immunophenotyping with flow cytometry (see
bleeding.1,28 Among children, pain in the extremities or joints may be the Immunophenotyping); and baseline flow cytometric and/or molecular
only presenting symptom.1 The presence of lymphadenopathy, characterization of leukemic clone(s) to facilitate subsequent analysis of
splenomegaly, and/or hepatomegaly on physical examination may be minimal/measurable residual disease (MRD).
found in approximately 20% of patients. Abdominal masses from

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Identification of specific recurrent genetic abnormalities is critical for Immunophenotyping

disease evaluation, optimal risk stratification, and treatment planning (see Immunophenotypic classification of ALL involves flow cytometry to
Cytogenetic and Molecular Subtypes). Subtypes of B-ALL with recurrent determine the presence of cell surface antigens on lymphocytes. ALL can
genetic abnormalities include the following: hyperdiploidy (51–65 be broadly classified into three groups based on immunophenotype, which
chromosomes); hypodiploidy (<44 chromosomes); t(9;22)(q34;q11.2), include precursor B-ALL, mature B-ALL, and T-ALL.1,38 Among children, B-
BCR-ABL1; t(4;11) and other KMT2A rearranged, t(v;11q23); cell lineage ALL constitutes approximately 88% of cases;39 in adult
t(12;21)(p13;q22), ETV6-RUNX1; t(1;19)(q23;p13.3), TCF3-PBX1; and patients, subtypes of B-cell lineage ALL represent approximately 75% of
t(5;14)(q31;q32), IL3-IGH.33 During the 2016 WHO classification update, cases (including mature B-ALL that constitutes 5% of adult ALL), whereas
two new provisional entities were added to the B-ALL classification: B- the remaining 25% comprise T-cell lineage ALL.39,40 Within the B-cell
lymphoblastic leukemia/lymphoma with translocations involving tyrosine lineage, the profile of cell surface markers differs according to the stage of
kinases or cytokine receptors (BCR-ABL1–like ALL or Ph-like ALL)34-36 and B-cell maturation, which includes early precursor B-cell (early pre-B-cell),
B-lymphoblastic leukemia/lymphoma with intrachromosomal amplification pre-B-cell, and mature B-ALL. Early pre-B-ALL is characterized by the
of chromosome 21 (iAMP21).34,37 Two new provisional entities were also presence of terminal deoxynucleotidyl transferase (TdT), the expression of
added to T-cell ALL (T-ALL): early T-cell precursor (ETP) lymphoblastic CD19/CD22/CD79a, and the absence of CD10 (formerly termed common
leukemia and natural killer (NK) cell lymphoblastic leukemia/lymphoma.34 ALL antigen) or surface immunoglobulins. CD10 negativity correlates with
The Ph-like ALL, B-ALL with iAMP21 and ETP T-ALL subtypes are no KMT2A rearrangement and poor prognosis.41,42 Pre-B-ALL is
characterized by the presence of cytoplasmic immunoglobulins and
longer considered provisional entities.
CD10/CD19/CD22/CD79a expression1,28,31,40 and was previously termed
Presence of recurrent genetic abnormalities should be evaluated using common B-ALL due to the expression of CD10 at diagnosis. Mature B-ALL
karyotyping of G-banded metaphase chromosomes (conventional shows positivity for surface immunoglobulins and clonal lambda or kappa
cytogenetics), and interphase fluorescence in situ hybridization (FISH) light chains, and is negative for TdT.1 The definition of CD20 positivity is
assays that include probes capable of detecting the genetic abnormalities unclear, though most studies use 20% or greater of blasts expressing
and/or reverse transcriptase-polymerase chain reaction (RT-PCR) testing, CD20.43 CD20 may be expressed in approximately 50% of B-cell lineage
ALL in adults, with a higher frequency (>80%) observed in cases of
using qualitative or quantitative methods, to measure transcript sizes (ie,
mature B-ALL.43,44
p190 vs. p210) of BCR-ABL1 in B-ALL. If samples are BCR-ABL1–
negative, testing for other gene fusions and mutations associated with Ph-
T-cell lineage ALL is typically associated with the presence of cytoplasmic
like ALL is essential. In cases of aneuploidy or failed karyotype, additional
CD3 (T-cell lineage blasts) or cell surface CD3 (mature T cells) in addition
assessment may include array comparative genomic hybridization
to variable expression of CD1a/CD2/CD5/CD7 and expression of
(aCGH). The translocation t(12;21)(p13;q22) is typically cryptic by TdT.1,28,32 CD52 may be expressed in 30% to 50% of T-cell lineage ALL in
karyotyping and requires FISH or PCR to be identified. adults.1 Combined data from the German Multicenter Study Group to Adult
ALL (GMALL) 06/99 study and the GMALL 07/03 study revealed a
distribution of T-cell lineage ALL among three subgroups: cortical/thymic

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NCCN Guidelines Version 2.2020

Acute Lymphoblastic Leukemia

(56%), medullary/mature (21%), and early (23%) T-ALL.38 The latter is remission may be an alternative. This regimen had previously
further divided between ETP ALL and early immature T-ALL. Early demonstrated superior results for patients with T-ALL and poor early
immature T-ALL includes both pro-T-ALL and pre-T-ALL responses.47
immunophenotypes.
Hematologic malignancies related to ALL include acute leukemias with
ETP ALL represents a distinct biologic subtype of T-cell lineage ALL that ambiguous lineage, such as the mixed phenotype acute leukemias
accounts for 12% of pediatric T-ALLs (and about 2% of ALL), and is (MPALs). MPALs include bilineage leukemias, in which two distinct
associated with poor clinical outcomes even with contemporary treatment populations of lymphoblasts are identified, with one meeting the criteria for
regimens. This subtype is characterized by the absence of CD1a/CD8, acute myeloid leukemia. Biphenotypic MPAL is defined as a single
weak expression of CD5 (<75% positive lymphoblasts), and the presence population of lymphoblasts that expresses markers consistent with B-cell
of 1 or more myeloid or stem cell markers (CD117, CD34, HLA-DR, CD13, or T-ALL, in addition to expressing myeloid or monocytic markers. Notably,
CD33, CD11b, or CD65) on at least 25% of lymphoblasts.45 In a study of myeloid-associated markers such as CD13 and CD33 may be expressed
239 patients with T-ALL, gene expression profiling, flow cytometry, and in ALL, and the presence of these markers does not exclude this
single nucleotide polymorphism array analysis were employed to identify diagnosis, nor is it associated with adverse prognosis.31,32 The
patients with ETP-ALL.45 ETP-ALL was associated with a 10-year OS of identification of mixed lineage leukemias should follow the criteria
19% (95% CI, 0%–92%) compared with 84% (95% CI, 72%–96%) in the presented in the 2008 WHO classification of neoplasms, which did not
non–ETP-ALL patients. The 10-year event-free survival (EFS) was change with the 2016 update.34 The initial immunophenotyping panel
similarly poor in patients with ETP-ALL (22%; 95% CI, 5%–49%) should be sufficiently comprehensive to establish a leukemia-associated
compared with non–ETP-ALL patients (69%; 95% CI, 53%–84%). phenotype that may include expression of nonlineage antigens; these are
Remission failure and hematologic relapse were significantly higher for useful in classification, particularly for MPAL.
patients with ETP-ALL (P < .0001).45
Cytogenetic and Molecular Subtypes
A pivotal study from Zhang et al46 identified a high frequency of activating Recurrent chromosomal and molecular abnormalities characterize ALL
mutations in the cytokine receptor and RAS signaling pathways that subtypes in both adults and children (Table 1), and often provide
included NRAS, KRAS, FLT3, IL7R, JAK3, JAK1, SH2B3, and BRAF. prognostic information that may weigh into risk stratification and treatment
Furthermore, inactivating mutations of genes that encode hematopoietic decisions. The frequency of certain subtypes differs between adult and
developmental transcription factors, including GATA3, ETV6, RUNX1, childhood ALL, which partially explains the difference in clinical outcomes
IKZF1, and EP300, were observed. These mutations are more frequent in between patient populations. Among children with ALL, the most common
myeloid neoplasms than in other subtypes of ALL, suggesting that chromosomal abnormality is hyperdiploidy (>50 chromosomes; 25% of
myeloid-derived therapies and targeted therapy may be better treatment cases) seen in B-cell lineage ALL compared to 7% in the adult ALL patient
options for select ALL subtypes. The data indicate a need for alternative population.39,48 The ETV6-RUNX1 subtype (also within the B-cell lineage)
treatments to standard intensive chemotherapy in this subpopulation. Due
resulting from chromosomal translocation t(12;21) is among the most
to the nature of ETP-ALL, myeloablative therapy followed by HCT in first

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Acute Lymphoblastic Leukemia

commonly occurring subtypes in childhood ALL (22%) compared to adults with favorable outcomes in ALL.48-50 Ph-positive ALL, associated with poor
(2%).39 Both hyperdiploidy and ETV6-RUNX1 subtypes are associated prognosis, is relatively uncommon among childhood ALL (3%), whereas
this abnormality is the most common subtype among adults (25%).39 The
Table 1: Common Chromosomal and Molecular Abnormalities in
ALL frequency of Ph-positive ALL increases with age (10%, patients 15–39
years; 25%, patients 40–49 years; 20%–40%, patients >50 years).49,51-53
Cytogenetics Gene Frequency Frequency
Moreover, younger children (1–9 years) with Ph-positive ALL have a better
in Adults in Children
Hyperdiploidy -- 7% 25% prognosis than adolescents with this subtype.54
(>50 chromosomes)
Hypodiploidy -- 2% 1% BCR-ABL1–like or Ph–like ALL is a subgroup of B-cell lineage ALL
(<44 chromosomes) associated with unfavorable prognosis.35,36 A study using gene expression
t(9;22)(q34;q11): BCR-ABL1 25% 2%–4% signatures to classify pediatric patients with ALL into subtypes estimated
Philadelphia chromosome (Ph) the 5-year disease-free survival (DFS) in the BCR-ABL1–like ALL group to
t(12;21)(p13;q22) ETV6-RUNX1 2% 22% be 60%.35 In adult patients with BCR-ABL1–like ALL, the 5-year EFS is
(TEL-AML1) significantly lower (22.5%; 95% CI, 14.9%–29.3%) compared to patients
t(v;11q23) [eg, t(4;11) and KMT2A 10% 8% with non-BCR-ABL1–like ALL (49.3%; 95% CI, 42.8%–56.2%).36 Although
others], t(11;19) rearranged
this subgroup is Ph-negative, there is an otherwise similar genetic profile
t(1;19)(q23;p13) TCF3-PBX1 3% 6%
to the Ph-positive ALL subgroup including mutation of the IKZF1 gene.55
(E2A-PBX1)
Genomically, this subtype is typically associated with gene fusions and
t(5;14)(q31;q32) IL3-IGH <1% <1%
mutations that activate tyrosine kinase pathways as the common
t(8;14), t(2;8), t(8;22) c-MYC 4% 2%
t(1;14)(p32;q11) TAL-1a 12% 7% mechanism of transformation. These gene fusions and mutations include
t(10;14)(q24;q11) HOX11 8% 1% ABL1, ABL2, CRLF2, CSF1R, EPOR, JAK1, JAK2, JAK3, PDGFRβ,
(TLX1)a EBF1, FLT3, IL7R, NTRK3, and SH2B3 genes.35,55-57 A genomic profiling
t(5;14)(q35;q32) HOX11L2a 1% 3% study found kinase-activating alternations in 91% of Ph-like ALL cases,56
t(11;14)(q11) [eg, (p13;q11), TCRα and 20%–25% 10%–20% suggesting potential for ABL-class tyrosine kinase inhibitors (TKIs) or
(p15;q11)] TCRδ other targeted therapies to significantly improve patient outcomes in this
BCR-ABL1–like/Ph–like variousb 10%–30% 15% subgroup.58
B-ALL with iAMP21 RUNX1 -- 2%
ETP variousb 2% 2% B-ALL with iAMP21 is characterized by amplification of a portion of
Ikaros IKZF1 25%–35% 12%–17% chromosome 21, detected by FISH with a probe for the RUNX1 gene.59,60
aAbnormalities observed exclusively in T-cell lineage ALL; all others occur
Occurring in approximately 2% of children with ALL, B-ALL with iAMP21 is
exclusively or predominantly in B-cell lineage ALL. bSee text for more details.
associated with adverse prognosis.59,60 Children with iAMP21 are typically

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Acute Lymphoblastic Leukemia

older, with a median age of 9 years, and have low platelet counts and low
Workup
white blood cell (WBC) counts.61
The initial workup for patients with ALL should include a thorough medical
Other cytogenetic and molecular subtypes are associated with ALL and history and physical examination, along with laboratory and imaging
prognosis. Although not as common, translocations in the KMT2A gene [in studies (where applicable). Laboratory studies include a complete blood
particular, cases with t(4;11) translocation] are known to have poor count (CBC) with platelets and differential, a blood chemistry profile, liver
prognosis.26,44 Hypodiploidy is associated with poor prognosis and is function tests, a disseminated intravascular coagulation panel (including
observed in 1% to 2% of patients.26,62 Low hypodiploidy (30–39 measurements for D-dimer, fibrinogen, prothrombin time, and partial
chromosomes)/near triploidy (60–68 chromosomes) and complex thromboplastin time), and a tumor lysis syndrome (TLS) panel (including
karyotype (≥5 chromosome abnormalities) are also associated with poor measurements for serum lactate dehydrogenase [LDH], uric acid,
prognosis, and occur more frequently with increasing age (1%–3%, potassium, phosphates, and calcium). Other recommended tests include a
patients 15–29 years; 3%–6%, patients 30–59 years; 5%–11%, patients urinalysis and hepatitis B/C, HIV, and cytomegalovirus (CMV) antibody
>60 years).49 Of note, low hypodiploidy is associated with a high frequency evaluations. Female patients should undergo pregnancy testing and all
of TP53 alterations.63,64 In addition, masked hypodiploidy, which results male patients should be evaluated for testicular involvement of disease,
from a doubling of hypodiploid clones, needs to be distinguished from true including a scrotal ultrasound as indicated; testicular involvement is
hyperdiploidy to allow appropriate treatment selection.65 especially common in cases of T-ALL. Fertility counseling and
preservation options should be presented to all patients. CT scans of the
In B-ALL, mutations in the Ikaros gene (IKZF1) are associated with a poor neck, chest, abdomen, and pelvis with IV contrast are recommended as
prognosis and a greater incidence of relapse.66 IKZF1 mutations are seen indicated by symptoms, and if any extramedullary involvement is
in approximately 15% to 20% of pediatric B-ALL67,68 and at a higher suspected, a PET/CT may be considered for diagnosis and follow-up.
frequency of greater than 75% in patients who are also BCR-ABL
positive.55,68 Incidence in adults is about 25% to 35% in B-ALL69-72 and All patients should be evaluated for opportunistic infections as appropriate
about 65% in patients who are BCR-ABL positive.73,74 A study evaluating (see NCCN Guidelines for Prevention and Treatment of Cancer-Related
the relationship between BCR-ABL1–like and IKZF1 in children with B-cell Infections). In addition, an echocardiogram or cardiac scan should be
precursor ALL showed that 40% of cases had co-occurrence of these considered for all patients due to the use of anthracyclines as the
mutations.75 The presence of either mutation was indicative of poor backbone of nearly all treatment regimens. Assessment of cardiac function
prognosis and was independent of conventional risk factors. Both is particularly important for patients with prior cardiac history, prior
mutations are considered strong independent risk factors for B-ALL and anthracycline exposure, or clinical symptoms suggestive of cardiac
are applicable across a broad range of stratified ALL including patients dysfunction, and for elderly patients. Human leukocyte antigen (HLA)
with intermediate MRD. typing should be performed at workup, and an early evaluation and search
for family or an alternative donor should be strongly considered.

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Acute Lymphoblastic Leukemia

Appropriate imaging studies (eg, CT/MRI scan of the head with contrast) than 50 × 109 cells/L, whereas all other patients with ALL, including T-ALL
should be performed to detect meningeal disease, chloromas, or central (regardless of age or WBC count), were considered high risk.62 It should
nervous system (CNS) bleeding for patients with major neurologic signs or be noted that despite exclusion from this report, patients younger than age
symptoms at diagnosis. CNS involvement should be evaluated through 1 should also be considered very high risk.77,78 The POG and CCG have
lumbar puncture at timing that is consistent with the treatment protocol. since merged to form the Children’s Oncology Group (COG) and
Pediatric-inspired regimens typically include lumbar puncture at diagnostic subsequent risk assessment has produced additional risk factors,
workup; the NCCN ALL Panel recommends that the first lumbar puncture particularly in precursor B-ALL, to further refine therapy. Specifically, in B-
be performed at the time of initial scheduled intrathecal therapy unless ALL, a group identified as very high risk, was defined as patients with any
directed by symptoms to perform earlier (see NCCN Recommendations of the following characteristics: t(9;22) chromosomal translocation (ie, Ph-
for Evaluation and Treatment of Extramedullary Involvement). positive ALL) and/or presence of BCR-ABL1 fusion protein; hypodiploidy
(<44 chromosomes);79 BCR-ABL1–like or Ph-like ALL;80 iAMP21;78 or
It should be noted that the recommendations included in the guidelines failure to achieve remission with induction therapy.26,62 KMT2A
represent a minimum set of workup considerations, and that other rearrangements and a poor response to induction chemotherapy also re-
evaluations or testing may be needed based on clinical symptoms. categorized patients into this group.81-83 Conversely, criteria were refined
Procurement of cells should be considered for purposes of future research for lower risk and included patients with hyperploidy, the t(12;21)
(in accordance with institutional practices or policies). chromosomal translocation (ETV6-RUNX1 subtype),84 or simultaneous
trisomies of chromosomes 4, 10, and 17.62,85 Presence of extramedullary
Prognostic Factors and Risk Stratification
disease and the early response to treatment also modified risk. Early
Various disease-related and patient-specific factors may have prognostic marrow response to therapy was a strong positive prognostic factor while
significance in patients with ALL. In particular, patient age, WBC count, the presence of extramedullary disease at diagnosis was correlated with a
immunophenotypic/cytogenetic subtype, presence of CNS disease, and poorer prognosis. Using the refined risk assessment, four risk categories
response to induction therapy have been identified as important factors in for B-ALL, designated as low risk, standard risk, high risk, and very high
defining risk and assessing prognosis for both adult and childhood ALL. risk, were identified encompassing 27%, 32%, 27%, and 4% of cases,
respectively.62
Prognostic Factors in AYA Patients with ALL
Initially, risk assessment for childhood ALL was individually determined by Risk stratification of T-ALL has been more difficult than in B-ALL. Although
the institution, complicating the interpretation of data. However, in 1993, a T-ALL is often categorized as very high risk depending on the institute,
common set of risk criteria was established by the Pediatric Oncology newer treatment options have resulted in improved survival outcomes for
Group (POG) and Children’s Cancer Group (CCG) at an international these patients. Furthermore, the identification of genetic mutations and the
conference hosted by the NCI.76 In this system, two risk groups were use of targeted therapies may change the way T-ALL is treated and
designated: standard risk and high risk. Standard risk was assigned to ultimately how these patients are assessed for risk.
patients age 1 to younger than 10 years of age and with a WBC count less

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Acute Lymphoblastic Leukemia

Historically, the AYA population has been treated on either a pediatric or compared to the cells from children younger than 10 years.97 The COG
an adult ALL regimen, depending on referral patterns and the institution. In AALL0232 study reported an initial delay in response to induction therapy
recent years, several retrospective studies from both the United States in older AYA patients (aged 16–30 years) compared to younger patients
and Europe have shown that AYA patients (15–21 years of age) treated (aged 1–15 years).98 There was a statistically significant reduction in the
on a pediatric protocol have substantially improved EFS compared to number of patients in the older cohort who had negative end-induction
same-aged patients treated on adult ALL regimens.26,50 Comparison of MRD compared to the younger cohort (59% vs. 74%; P < .0001) with
adult and pediatric protocols has shown that adults received lower doses fewer patients achieving M1 marrow on day 15 of induction (67% vs. 80%,
of nonmyelosuppressive chemotherapy and less intense intrathecal respectively; P = .0015). In addition to the biological differences, the social
chemotherapy regimens.86,87 Adult protocols also entail a greater use of component of treating AYA patients is important. Enrollment in clinical
allogeneic HCT compared to pediatric protocols, but the benefits of HCT in trials has been shown to improve patient outcomes;99 however, only 2% of
the AYA population have not been sufficiently studied, and the available AYA patients enroll in clinical trials compared to the 60% enrollment of
data have conflicting findings.88-92 However, there is a significant difference pediatric patients.100 Pediatric patients have been shown to be more
between the way adults and pediatric patients are treated and this may be compliant with treatment protocols compared to AYA patients,101 which
a variable in the treatment of AYA patients. Thus, the choice of initial may be due to greater parental supervision of the treatment and better
treatment regimen can have a profound impact on overall clinical insurance.102
outcomes in AYA patients.
Prognostic Factors in Adults with ALL
Despite improved outcomes for AYA patients treated on pediatric-inspired Both age and initial WBC count have historically been considered clinically
regimens versus adult ALL regimens, studies have shown poorer significant prognostic factors in the management of adult patients with
outcomes among patients in the AYA group compared with children ALL.38,44 Early prospective multicenter studies defined values for older age
younger than 10 years.93 This may be attributed to factors that are based (>35 years) and higher initial WBC count (>30 × 109/L for B-cell lineage;
on biology and social differences. Compared to the pediatric population, >100 x 109/L for T-cell lineage) that were predictive of significantly
AYA patients have a lower frequency of favorable decreased remission duration.103,104 Subsequent studies have confirmed
chromosomal/cytogenetic abnormalities, such as hyperdiploidy or ETV6- the prognostic importance of these clinical parameters, although the cutoff
RUNX1,94 and a greater incidence of poor-risk cytogenetics including Ph- values differed between studies.38,44
positive ALL, hypodiploidy, and complex karyotype,95 and a higher
incidence of ETP-ALL.45,96 Furthermore, the positive prognostic values of In one of the largest studies to date (n = 1521) conducted by the Medical
the ETV6-RUNX1 mutation and hyperdiploidy are greater in the pediatric Research Council (MRC) UKALL/ Eastern Cooperative Oncology Group
population, suggesting that the benefits decline with age.95 The effects of (ECOG), both age (>35 years) and WBC count (>30 × 109/L for B-cell
the treatment are also shown to be different in the AYA population lineage; >100 × 109/L for T-cell lineage) were found to be significant
compared to the pediatric population. In vitro studies showed that ALL independent prognostic factors for decreased DFS and OS among
cells from children older than 10 years are more resistant to chemotherapy patients with Ph-negative ALL; the independent prognostic value remained

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NCCN Guidelines Version 2.2020

Acute Lymphoblastic Leukemia

significant when these factors were evaluated as continuous variables in WBC count). Among patients with Ph-negative disease, the following
multivariate analysis.105 All patients, regardless of Ph status, had received cytogenetic subgroups had significantly decreased 5-year EFS (13%–
induction therapy followed by intensification (for patients with a complete 24%) and OS rates (13%–28%) based on univariate analysis: t(4;11)
response [CR] postinduction) with contemporary chemotherapy KMT2A translocation, t(8;14), complex karyotype (≥5 chromosomal
combination regimens. Patients with a CR after induction received abnormalities), and low hypodiploidy (30–39 chromosomes)/near triploidy
allogeneic HCT (for patients <50 years of age and with HLA-compatible (60–78 chromosomes).106 In contrast, del(9p) or high hyperdiploidy (51–65
siblings), autologous HCT, or consolidation/maintenance treatment. chromosomes) was associated with more favorable 5-year EFS (49%–
Because Ph-positive ALL is associated with a very poor prognosis, 50%) and OS rates (53%–58%).106 An earlier report of data from patients
patients with this subtype were assigned to undergo allogeneic HCT treated on the French ALL study group (LALA) protocols suggested that
(including matched, unrelated donor [URD] HCT) when possible. The 5- near triploidy (60–78 chromosomes) may be derived from duplication of
year OS rate among patients with Ph-positive and Ph-negative disease hypodiploidy (30–39 chromosomes); both aneuploidies were associated
was 25% and 41%, respectively.105 Among patients with Ph-negative ALL, with poor DFS and OS outcomes similar to that of patients with Ph-positive
those older than 35 years or with elevated WBC count (>30 × 109/L for B- ALL.107 Based on multivariate Cox regression analysis reported in the
cell lineage; >100 × 109/L for T-cell lineage) at diagnosis were initially MRC UKALL XII/ECOG E2993 study, t(8;14), low hypodiploidy/near
identified as high risk, whereas all others were classified as standard risk. triploidy, and complex karyotype remained significant independent
The 5-year OS rates for the Ph-negative high-risk and standard-risk predictors for risk of relapse or death; the prognostic impact of these
subgroups were 29% and 54%, respectively.105 Further analysis of the Ph- cytogenetic markers was independent of factors such as age, WBC count,
negative population according to risk factors showed that patients could be or T-cell immunophenotype, and their significance was retained even after
categorized as low risk (no risk factors based on age or WBC count), excluding patients who had undergone postinduction HCT.106
intermediate risk (either age >35 years or elevated WBC count), or high
risk (both age >35 years and elevated WBC count). The 5-year OS rates The importance of cytogenetics as a prognostic factor for survival
based on these risk categories were 55%, 34%, and 5%, respectively, outcomes was shown in other studies, including the Southwest Oncology
suggesting that patients with Ph-negative ALL in the high-risk subgroup Group (SWOG) study conducted with 200 adult patients with ALL.108 In
had even poorer survival outcomes than patients in the overall Ph-positive this study, the prognostic impact of the different cytogenetic categories
subgroup.105 outweighed that of the more traditional factors, such as age and WBC
count; in multivariate analysis for both relapse-free survival (RFS) and OS,
In a subsequent analysis from this MRC UKALL XII/ECOG E2993 study, cytogenetics remained a significant independent predictor of outcomes,
cytogenetic data were evaluated in approximately 1000 patients.106 The whereas factors such as age and WBC count lost prognostic
analysis confirmed the negative prognostic impact of Ph-positive status significance.108 Moreover, the subgroup (n = 19) of patients with “very high
compared with Ph-negative disease, with a significantly decreased 5-year risk” cytogenetic features [identified based on outcomes from the
EFS rate (16% vs. 36%; P < .001, adjusted for age, gender, and WBC MRC/ECOG study mentioned earlier: presence of t(4;11) MLL
count) and OS rate (22% vs. 41%; P < .001, adjusted for age, gender, and translocation; t(8;14); complex karyotype; or low hypodiploidy] had

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NCCN Guidelines Version 2.2020

Acute Lymphoblastic Leukemia

substantially decreased 5-year RFS and OS rates (22%, for both be considered high risk if they have positive MRD, an elevated WBC count
endpoints). Analysis by ploidy status was not possible because only 2 (≥30 × 109/L for B-cell lineage; ≥100 × 109/L for T-cell lineage), or
patients were considered to have low hypodiploidy/near triploidy. The 5- presence of poor-risk cytogenetics as previously defined. The absence of
year RFS and OS rates among patients with Ph-positive ALL (n = 36) all poor-risk factors is considered standard risk. Evaluation of WBC count
were 0% and 8%, respectively.108 and age for determination of prognosis should ideally be made in the
context of treatment protocol-based risk stratification. These additional risk
NCCN Recommendations for Risk Assessment in ALL stratification parameters are generally not used for patients aged 65 years
Although some debate remains regarding the risk stratification approach to or older (or for patients with substantial comorbid conditions) with Ph-
ALL, the panel suggests the following approaches for defining risk in these negative ALL. Similar to AYA patients, elevated WBC count (≥30 × 109/L
patients. for B-cell lineage; ≥100 × 109/L for T-cell lineage) has been considered a
high-risk factor based on some earlier studies. However, studies in adult
The NCI defines the age range for AYA patients as 15 to 39 years. patients have demonstrated that WBC counts may lose independent
Because AYA patients may benefit from pediatric-inspired ALL treatment prognostic significance when cytogenetic factors and MRD assessments
protocols, this patient population is considered separately from the adult are considered. Data showing the effect of WBC counts on prognosis in
population (defined as age ≥40 years). Given the poor prognosis adult patients with ALL are less firmly established than in the pediatric
associated with Ph-positive ALL and the wide availability of agents that population. Therefore, adult patients with ALL may not necessarily be
specifically target the BCR-ABL kinase, initial risk stratification for all classified as high risk based on high WBC count alone.
patients (AYA or adult) is based on the presence or absence of the t(9;22)
chromosomal translocation and/or BCR-ABL fusion protein. For adult Overview of Treatment Phases in ALL Management
patients with ALL (Ph-positive or Ph-negative), these guidelines further The treatment approach to ALL represents one of the most complex and
stratify patients by age, using 65 years as the cutoff, to guide treatment intensive programs in cancer therapy. Although the specific treatment
decisions. However, chronologic age alone is a poor surrogate for regimens and selection of drugs, dose schedules, and treatment durations
determining patient fitness for therapy. Patients should, therefore, be differ between AYA patients and adults, and among different subtypes of
evaluated on an individual basis. In the NCCN Guidelines for ALL, specific ALL, the basic treatment principles are similar. The most common
age references are not included for AYA and adult categories, considering treatment regimens used in patients with ALL include modifications or
that age is not a firm reference point and some of the recommended variations of multiagent chemotherapy regimens originally developed by
regimens have not been comprehensively tested across all ages. the Berlin-Frankfurt-Münster (BFM) group for pediatric patients (eg,
regimens used by COG for children and AYA patients, or the CALGB
AYA patients and adult patients younger than 65 years of age (or for those
regimen for adult patients), and the hyper-CVAD regimen developed at
with no substantial comorbidities) with Ph-negative ALL can be further
MD Anderson Cancer Center (MDACC). In general, the treatment phases
categorized as having high-risk disease, which may be particularly helpful
can be largely grouped into induction, consolidation, and maintenance. All
when consolidation with allogeneic HCT is being considered. Patients may
treatment regimens for ALL include CNS prophylaxis and/or treatment.

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Induction for CNS relapse and improved EFS, toxicities may be of concern, and an
The intent of initial induction therapy is to reduce tumor burden by clearing advantage for OS has yet to be conclusively shown.
as many leukemic cells as possible from the bone marrow. Induction
The hyper-CVAD regimen may be considered a less complex treatment
regimens are typically based on a backbone that includes a combination of
regimen compared with the CALGB regimen, and comprises eight
vincristine, anthracyclines (eg, daunorubicin, doxorubicin), and
alternating treatment cycles with the “A” regimen (hyper-CVAD:
corticosteroids (eg, prednisone, dexamethasone) with or without L-
hyperfractionated cyclophosphamide, vincristine, doxorubicin, and
asparaginase and/or cyclophosphamide.1,26,38,44,50
dexamethasone) and the “B” regimen (high-dose methotrexate and
The BFM/COG regimens are mainly based on a 4-drug induction regimen cytarabine).21,119,120 CNS prophylaxis and/or CNS-directed treatment
that includes a combination of vincristine, an anthracycline, a (which may include intrathecal chemotherapy, cranial irradiation, and/or
corticosteroid, and L-asparaginase.109-113 Some studies from the CALGB systemic therapy for patients with CNS leukemia at diagnosis) and
group have utilized a 5-drug regimen, which adds cyclophosphamide to maintenance treatment are also used with the hyper-CVAD regimen (see
the above 4-drug combination.114 Randomized studies comparing the use CNS Prophylaxis and Treatment and Maintenance).
of dexamethasone versus prednisone as part of induction therapy in
CNS Prophylaxis and Treatment
children with ALL showed that dexamethasone significantly decreased the
risk of isolated CNS relapse and improved EFS outcomes compared with The goal of CNS prophylaxis and/or treatment is to prevent CNS disease
prednisone.115,116 The observed advantage in outcomes with or relapse by clearing leukemic cells within sites that cannot be readily
dexamethasone may partly be attributed to improved penetration of accessed with systemic chemotherapy because of the blood-brain barrier.
dexamethasone into the CNS.117 In a meta-analysis comparing outcomes CNS-directed therapy may include cranial irradiation, intrathecal
with dexamethasone versus prednisone in induction regimens for chemotherapy (eg, methotrexate, cytarabine, corticosteroids), and/or
childhood ALL, dexamethasone was associated with a significantly systemic chemotherapy (eg, high-dose methotrexate, intermediate-/high-
reduced event rate (ie, death from any cause, refractory or relapsed dose cytarabine, L-asparaginase).1,50,117 CNS prophylaxis is typically given
leukemia, or second malignancy; risk ratio [RR], 0.80; 95% CI, 0.68–0.94) to all patients throughout the entire course of ALL therapy, from induction,
and CNS relapse (RR, 0.53; 95% CI, 0.44–0.65).118 However, no to consolidation, to the maintenance phases of treatment.
advantage was seen with dexamethasone regarding risk for bone marrow
Consolidation
relapse (RR, 0.90; 95% CI, 0.69–1.18) or overall mortality (RR, 0.91; 95%
CI, 0.76–1.09), and dexamethasone was associated with a significantly The intent of postinduction consolidation is to eliminate any leukemic cells
higher risk of mortality during induction therapy (RR, 2.31; 95% CI, 1.46– potentially remaining after induction therapy, further eradicating residual
3.66), neuropsychiatric adverse events (RR, 4.55; 95% CI, 2.45–8.46), disease. The postremission induction phase of treatment (but before long-
and myopathy (RR, 7.05; 95% CI, 3.00–16.58) compared with term maintenance therapy) may also be described as intensification
prednisone.118 Although dexamethasone was reported to reduce the risks therapy. The combination of drugs and duration of therapy for
consolidation regimens vary largely among studies and patient populations

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NCCN Guidelines Version 2.2020

Acute Lymphoblastic Leukemia

but can comprise combinations of drugs similar to those used during the Factors that affect the bioavailability of 6-MP can significantly impact
induction phase. High-dose methotrexate, cytarabine, 6-mercaptopurine patient care. Oral 6-MP can have highly variable drug and metabolite
(6-MP), cyclophosphamide, vincristine, corticosteroids, and L- concentrations among patients.122,123 Furthermore, age, gender, and
asparaginase are frequently incorporated into consolidation/intensification genetic polymorphisms can affect bioavailability.124-126 The concomitant
regimens.28,38,44,50,112,113 use of other chemotherapeutic agents such as methotrexate can alter
toxicity.127 The efficacy of maintenance therapy is determined by the
Hematopoietic Stem Cell Transplantation metabolism of 6-MP to the antimetabolite chemotherapeutic agent 6-
As part of postremission consolidative therapy, the decision to proceed thioguanine nucleotide (6-TGN); however, other pathways compete for 6-
with allogeneic/autologous HCT or prolonged maintenance are mutually MP, thereby reducing the amount of active metabolite produced. The three
exclusive approaches in ALL therapy. Each case will need to be enzymes that metabolize 6-MP are xanthine oxidase (XO), hypoxanthine-
individualized based on disease setting and features. Allogeneic HCT is guanine phosphoribosyltransferase (HPRT), and thiopurine
more likely to be a primary part of post-consolidative therapy in AYA and methyltransferase (TPMT). Because 6-MP is administered orally, it can be
adult patients with evidence of high-risk features (including Ph-positivity, converted to an inactive metabolite in the intestinal mucosa and liver.128,129
Ph-like disease, or persistent MRD). Notably, while younger patients may Diet has been shown to affect absorption of 6-MP.130,131 6-MP can undergo
experience lower transplant-related mortality, older age is by itself not a thiol methylation by TPMT. The balance between metabolism by HPRT is
contraindication. For this reason, HLA typing and bone marrow transplant inversely related to the activity of TPMT as demonstrated by the ability of
referral should be considered for all newly diagnosed and relapsed TPMT polymorphism to affect metabolite production.132 Compared to the
transplant-naïve patients to facilitate timely donor identification, and wild-type TPMT phenotype, patients who are homozygous TPMT-deficient
ultimately allogeneic transplant if warranted. require a 10- to 15-fold reduction in 6-MP to alleviate hematopoietic
toxicity.133,134 Heterozygosity at the TPMT gene locus occurs in 5% to 10%
Maintenance of the population and has been shown to have intermediate enzyme
The goal of extended maintenance therapy is to prevent disease relapse activity.132,135,136 Therefore, a 10% to 15% reduction in 6-MP dose is
after postremission induction and consolidation therapy. Most necessary in these patients to prevent toxicity.137,138 Determination of
maintenance regimens are based on a backbone of daily 6-MP and patient TPMT genotype using genomic DNA is recommended to optimize
weekly methotrexate (typically with the addition of periodic vincristine and 6-MP dosing, especially in patients who experience myelosuppression at
corticosteroids) for 2 to 3 years.26,38,44,50 Maintenance therapy is omitted for standard doses.139,140
patients with mature B-ALL (see the NCCN Guidelines for B-Cell
Lymphomas: Burkitt Lymphoma), given that long-term remissions are seen Dose reductions may be necessary if patients have genetic
early with short courses of intensive therapy in these patients, with polymorphisms and/or hepatotoxicity, whereas dose escalation may be
relapses rarely occurring beyond 12 months.38,121 necessary in patients who fail to demonstrate myelosuppression. This
should be performed in accordance with the protocol being used. In
general, protocols (including the ECOG/CALGB study) recommend a dose

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NCCN Guidelines Version 2.2020

Acute Lymphoblastic Leukemia

increase by 25% if an ANC greater than 1500 is observed for more than 6 as part of frontline induction, consolidation, and/or maintenance regimens
weeks. In 2014, the FDA approved an oral suspension of 6-MP, which during the course of initial ALL therapy, and in the relapsed or refractory
may be more amenable to dose adjustments than the tablet form.141 This disease settings.
may be especially beneficial for dose adjustment in pediatric patients.142
Outcomes are better in patients who achieve myelosuppression during Management of Ph-Positive ALL
maintenance compared with patients who have higher neutrophil Initial Treatment in AYA Patients with Ph-Positive ALL
counts,101,143 emphasizing the need for optimal dosing of 6-MP. Ph-positive ALL is rare in children with ALL, occurring in only
approximately 3% of pediatric cases compared with 25% of adult cases.39
Noncompliance also results in undertreatment, particularly in the AYA
The frequency of Ph-positive ALL among AYA patients ranges from 5% to
population. Compliance issues should be addressed for patients without
25% and increases with age,106,113 although this subtype is still uncommon
cytopenia. If increasing doses of 6-MP are given during maintenance but
relative to the incidence in older adults. Historically, children and
no drop in the counts is observed, this may be indicative of
adolescents with Ph-positive disease had a poorer prognosis compared
noncompliance.127 Quantification of 6-MP metabolites can be very useful
with patients with Ph-negative B-ALL. However, recent improvements in
in determining whether the lack of myelosuppression is due to non-
the treatment options are closing this gap.
compliance or hypermetabolism.
Hematopoietic Cell Transplant
Targeted Agents
In a retrospective analysis of children with Ph-positive ALL treated
The emergence of targeted therapies for hematologic malignancies, between 1986 and 1996 (n = 326) with intensive chemotherapy regimens
including the treatment of Ph-positive disorders with TKIs, including with or without allogeneic HCT, the 5-year EFS (calculated from time of
imatinib, dasatinib, nilotinib, and ponatinib, represents an important diagnosis) and OS rates were 28% and 40%, respectively, for the entire
advancement in ALL therapy.144-152 Incorporation of TKIs into treatment patient cohort.54 The 7-year EFS and OS rates were 25% and 36%,
regimens should include evaluation of clinical pharmacokinetics.153 respectively. Even among the subgroup of patients considered to have a
Clinicians should be aware of variation among the TKIs relating to better prognosis (ie, WBC count <50 × 109/L and age <10 years), the 5-
absorption from the gastrointestinal tract. Additionally, histamine-2 year DFS rate (calculated from time of first CR) was only 49%.54
antagonist or proton pump inhibitors can affect the bioavailability of some Compared with patients who received only chemotherapy, the subgroup of
TKIs. patients who underwent allogeneic HCT with an HLA-matched related
donor (n = 38) had significantly higher 5-year DFS (65% vs. 25%; P <
Other targeted agents include an anti-CD20 monoclonal antibody (eg,
.001) and OS (72% vs. 42%; P = .002) rates. This benefit with HCT versus
rituximab) for CD20-expressing B-cell lineage ALL (especially for mature
chemotherapy alone was not observed with autologous HCT or with HCT
B-ALL).154,155 In addition, the purine nucleoside analog nelarabine has
from matched URDs. This study showed that allogeneic HCT from a
been approved for the treatment of relapsed/refractory (R/R) T-cell lineage
matched related donor offered improvements in outcomes over
ALL or lymphoblastic lymphoma.156-158 These agents may be incorporated
chemotherapy alone.

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In a subsequent analysis of outcomes in children with Ph-positive ALL 60; aged 1–30 years), imatinib was replaced with dasatinib on induction
treated between 1995 and 2005 but also without targeted TKIs, the 7-year day 15 and combined with the same chemotherapy used in AALL-0031.162
EFS and OS rates were 32% and 45%, respectively.159 Outcomes with The 5-year overall OS and EFS rates (± standard deviation [SD]) were
allogeneic HCT from either matched related donors or URDs appeared 86% ± 5% and 60% ± 7%, respectively, and outcomes were similar to
similar, and HCT improved disease control over intensive chemotherapy those observed in AALL-0031.162
alone.159 Although this analysis showed an improved 7-year EFS rate,
EsPhALL
outcomes remained suboptimal in patients with Ph-positive ALL.
The European intergroup study of post-induction treatment of Ph-
Allogeneic HCT has been considered the standard of care for AYA chromosome positive ALL (EsPhALL) reported results of the randomized
patients with Ph-positive ALL; however, its role has become less clear with open-label trial designed to evaluate the safety and long-term efficacy of
the advent of BCR-ABL–targeted TKIs. Several studies evaluated the role discontinuous postinduction imatinib plus chemotherapy with the BFM
of allogeneic HCT in the era of imatinib and whether imatinib-based backbone intensive treatment versus chemotherapy alone.163 The study
therapies provided an additional benefit to HCT. enrolled 108 good-risk and 70 poor-risk patients aged 1 year to 18 years.
Good-risk patients were randomized 1:1 and poor-risk patients were all
COG AALL-0031 Regimen assigned to receive chemotherapy plus imatinib. There was a trend
In a multicenter COG study (AALL-0031) of children and adolescents with towards improved 4-year DFS for good-risk patients who received imatinib
high-risk ALL, the group of patients with Ph-positive ALL (n = 92; aged 1– plus chemotherapy versus those who received chemotherapy alone
21 years) was treated with an intensive chemotherapy regimen combined (72.9% vs. 61.7%; P = .24). In the as-treated analysis, good-risk patients
with imatinib (340 mg/m2/day; given during postremission induction who received imatinib with chemotherapy had a 4-year EFS of 75.2%
therapy and maintenance).160 Among the cohort (n = 44) who received versus 55.9% in patients who did not receive imatinib (P = .06). The
continuous imatinib exposure (280 consecutive days before maintenance incidence of serious adverse events was not statically different between
initiation), the 3-year EFS rate was 80.5% (95% CI, 64.5%–89.8%). This the two groups (P = .64).163 Enrollment in this trial was stopped in 2009
outcome compared favorably with that of a historical population of patients following results of the COG AALL0031 study that demonstrated a benefit
with Ph-positive ALL (n = 120) treated on a POG protocol, which showed a of continuous imatinib. The EsPhALL study was amended into a single-
3-year EFS rate of only 35% (P < .0001).160 Moreover, the 3-year EFS arm study to add continuous imatinib on induction day 15, with 97% of
rates were similar among the groups of patients who received patients achieving first CR.164 However, the 5-year EFS and OS rates
chemotherapy combined with continuous imatinib (88%; n = 25) or (57% and 71.8%, respectively) were similar in cohorts that received
allogeneic HCT from a related donor (57%; n = 21) or URD (72%; n = 11). discontinuous postinduction imatinib and continuous imatinib plus
No major toxicities were found to be associated with the addition of chemotherapy with the BFM backbone intensive treatment.163,164
imatinib to the intensive chemotherapy regimen.160 Subsequent follow-up Additionally, a phase II trial evaluated the safety and efficacy of adding
after 5 years confirmed these outcomes.161 In a phase II single-arm COG continuous dasatinib at day 15 to the intensive BFM regimen in pediatric
trial (AALL-0622) of children and young adults with Ph-positive ALL (n = patients with newly diagnosed Ph-positive ALL (n = 109 enrolled; age

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NCCN Guidelines Version 2.2020

Acute Lymphoblastic Leukemia

range, 1–17 years).165 The efficacy analysis included 104 patients, who all greater than or equal to 60 years were able to complete therapy with this
achieved CR; 15 of the patients received allogeneic HCT at first CR regimen, and were switched to alternate TKIs. The 2-year OS and EFS
(CR1). An interim analysis showed a 3-year EFS of 66.0% (95% CI, rates were 80% and 81%, respectively. A follow-up study (n = 76; age ≥18
54.8%–75.0%) and a 3-year OS of 92.3% (95% CI, 85.2%–96.1).165 years; median age, 47 years) demonstrated long-term efficacy for
ponatinib and hyper-CVAD with a 3-year EFS rate of 70%.167
TKIs Combined with Hyper-CVAD
A phase II study at MDACC evaluated imatinib combined with the hyper- TKIs Combined with Multiagent Chemotherapy
CVAD regimen in patients with previously untreated or minimally treated In the phase II study from the Group for Research on Adult ALL (GRAALL;
ALL (n = 54; median age, 51 years; range, 17–84 years); 14 patients GRAAPH-2003), patients with previously untreated Ph-positive ALL (n =
underwent subsequent allogeneic HCT.151 The 3-year OS rate with this 45; median age, 45 years; range, 16–59 years) received imatinib in
regimen was 54%. Among the patients aged 40 years or younger (n = 16), combination with chemotherapy during either induction or consolidation
a strong trend was observed for OS benefit with allogeneic HCT (3-year therapy.168,169 Patients in complete remission with a donor received
OS rate, 90% vs. 33%; P = .05).151 Among patients aged 60 years or allogeneic HCT (n = 24), whereas those in complete remission with good
younger, no statistically significant difference was observed in the 3-year molecular response but without a donor were eligible for autologous HCT
OS rate between patients who received HCT and those who did not (77% (n = 10). Nine patients did not receive HCT and were treated with imatinib-
vs. 57%). based maintenance therapy. The 4-year OS rate did not differ significantly
for patients with a sibling donor compared to patients undergoing
Studies have shown the promising activity of other TKIs, including autologous HCT (76% vs. 80%). The 4-year OS for patients who received
dasatinib and ponatinib when incorporated into frontline regimens for only maintenance imatinib was 33%.169 These data suggest that improved
patients with ALL. In a phase II study from MDACC, dasatinib was survival with imatinib-based therapy can be further enhanced by the
combined with hyper-CVAD and subsequent maintenance therapy in addition of HCT.
patients with previously untreated Ph-positive ALL (n = 35; median age, 53
years; range, 21–79 years; 31% were older than 60 years); four of the In the subgroup of patients with Ph-positive ALL (n = 94; median age, 47
patients received allogeneic HCT in CR1.166 The 2-year OS and EFS rates years; range, 19–66 years) from the Northern Italy Leukemia Group study
were 64% and 57%, respectively. The efficacy and safety of ponatinib (NILG-09/00), outcomes were compared among patients who received
combined with hyper-CVAD was examined in patients with Ph-positive chemotherapy with imatinib (n = 59) or without imatinib (n = 35), with or
ALL (n = 37; aged ≥18 years; median age, 51 years; 12 patients were ≥60 without subsequent HCT (allogeneic or autologous).170 The patients who
years) in a phase II prospective trial.145 Of the 32 patients with Ph-positive received imatinib (63% of eligible patients underwent allogeneic HCT) had
metaphases at the start of therapy, an overall complete cytogenetic significantly higher 5-year OS (38% vs. 23%; P = .009) and DFS rates
response was observed in 32 patients (100%). By multiparametric flow (39% vs. 25%; P = .044) compared with those who did not receive imatinib
cytometry, 35 of 37 patients (95%) had no MRD after a median of 3 weeks (39% of eligible patients underwent allogeneic HCT).170 The 5-year OS
of therapy.145 However, it is worth noting that only half of the patients rates by treatment type were 47% for allogeneic HCT (n = 45), 67% for

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NCCN Guidelines Version 2.2020

Acute Lymphoblastic Leukemia

autologous HCT (n = 9), 30% for imatinib without HCT (n = 15), and 7% newly diagnosed Ph-positive ALL (n = 90; median age, 47 years; range,
for no imatinib and no HCT (n = 13); the corresponding treatment-related 17–71 years).174 Chemotherapy combined with nilotinib was administered
mortality rates were 17%, 0%, 36%, and 23%, respectively. The 5-year during induction, consolidation, and maintenance phases. Of 90 evaluable
relapse rates were 43%, 33%, 87%, and 100%, respectively.170 patients, 82 (91%) experienced complete hematologic remission with a
median time of 27 days (range, 13–72). The 2-year hematologic RFS and
In a phase II study from the Spanish Cooperative Group, patients with Ph- OS rates were both 72%.174
positive ALL (n = 30; median age, 42 years; range, 8–62 years; only 1
patient was <15 years of age) were treated with intensive chemotherapy In a phase II multicenter trial (CALGB 10701), patients with newly
combined with imatinib, followed by HCT and imatinib maintenance.171 diagnosed Ph-positive ALL (n = 64; median age, 60 years; range, 22–87
Overall, 53% of patients proceeded to allogeneic HCT and 17% received years) were treated with multiagent chemotherapy combined with
autologous HCT. At a median follow-up of 4.1 years, the OS and DFS dasatinib, and the efficacy of different post-remission strategies were
rates were both 30%. The incidence of transplant-related mortality was evaluated including allogeneic HCT, autologous HCT, and chemotherapy
27%.171 Post-transplant maintenance with imatinib was not feasible in alone, followed by maintenance with dasatinib.175 The CR rate was 97%
most patients, primarily because of transplant-related complications. with no induction deaths. With a median follow-up of 48 months for
survivors, 3-year OS and DFS were 55% and 43%, respectively.175 For
The Japan Adult Leukemia Study Group (ALL-202) treated patients with patients who underwent consolidation with allogeneic HCT, autologous
Ph-positive ALL (n = 100) with chemotherapy combined with imatinib HCT, or chemotherapy, 3-year OS was 75%, 71%, and 55%, respectively,
administered during induction, consolidation, and maintenance with median OS not reached for all groups. The 3-year DFS was 55%,
phases.172,173 An early analysis (n = 80; median age, 48 years; range, 15– 43%, and 46%, respectively.175
63 years) reported a 1-year OS rate of 73% among patients who
underwent allogeneic HCT, compared with 85% for those who did not.173 A Initial Treatment in Adults with Ph-Positive ALL
subsequent analysis compared outcomes for the subgroup of patients who Historically, treatment outcomes for adult patients with Ph-positive ALL
received allogeneic HCT at first CR in this study (n = 51; median age, 38 have been extremely poor. Before the era of targeted TKIs, the 3-year OS
years; range, 15–64 years) versus those for a historical cohort of patients rates with chemotherapy regimens were generally less than 20%.176
who received allogeneic HCT without prior imatinib (n = 122).172 The 3-
year OS (65% vs. 44%; P = .015) and DFS rates (58% vs. 37%; P = .039) Hematopoietic Cell Transplant
were significantly higher among patients treated with imatinib compared Allogeneic HCT, in the pre-imatinib era, resulted in some improvements
with the historical cohort; the 3-year non-relapse mortality rate was similar over chemotherapy alone, with 2-year OS rates of 40% to 50%177,178 and
between cohorts (21% vs. 28%, respectively).172 3-year OS rates of 36% to 44%.89,172 In the large, international,
collaborative MRC UKALL XII/ECOG E2993 trial conducted in patients
A multicenter phase II study from the Adult Acute Lymphoblastic Leukemia with previously untreated ALL, the subgroup with Ph-positive disease (n =
Working Party of the Korean Society of Hematology investigated the 267; median age, 40 years; range, 15–60 years) was eligible for allogeneic
effects of multiagent chemotherapy combined with nilotinib in patients with

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HCT if its patients were younger than 50 (in the ECOG E2993 trial) or 55 previous section (see Initial Treatment in AYA Patients with Ph-Positive
(in the MRC UKALL XII trial) years of age and had a matched sibling or ALL).
matched URD.179 Among the Ph-positive patient cohort, postremission
TKIs Combined With Multiagent Chemotherapy
treatment included matched sibling allogeneic HCT (n = 45), matched
URD allogeneic HCT (n = 31), and chemotherapy alone (n = 86). The 5- Studies evaluating TKIs plus multiagent chemotherapy have been
year OS rate according to postremission therapy was 44%, 36%, and discussed in the previous section168-172,174,175 (see Initial Treatment in AYA
19%, respectively, and the 5-year EFS rate was 41%, 36%, and 9%, Patients with Ph-Positive ALL). Several studies evaluating the efficacy of
respectively.179 Both the OS and EFS outcomes for patients who TKIs combined with multiagent chemotherapy in patients with previously
underwent allogeneic HCT (related or unrelated) were significantly untreated ALL have shown improved outcomes, particularly when
improved compared with those who received only chemotherapy. The treatment was followed by allogeneic HCT.148,170,172,173,175 A multicenter trial
incidence of transplant-related mortality was 27% with matched sibling from the European Working Group for Adult ALL (EWALL; EWALL-PH02)
allogeneic HCT and 39% with matched URD HCT. An intent-to-treat evaluated the efficacy and safety of nilotinib with multiagent chemotherapy
analysis of patients with a matched sibling donor versus those without a in older patients with Ph-positive ALL (n = 79 [72 evaluable]; age range,
matched sibling donor showed no statistically significant difference in 5- 55–85 years).148 The CR rate was 94.4% and the MRD response (BCR-
year OS rates (34% vs. 25%, respectively).179 The incorporation of imatinib ABL/ABL ratio ≤0.1%) increased from 41% after induction to 86% after
in the treatment regimen for Ph-positive ALL has led to improvements in consolidation II. At 4 years, the EFS and OS rates were 42% and 47%,
outcomes over chemotherapy alone.151,173,176 respectively. By landmark analyses using median time to transplant as a
cutoff, the 4-year OS rate was 61% in patients who underwent allogeneic
Some retrospective studies suggest similar outcomes between HCT.
myeloablative conditioning (MAC) and reduced-intensity conditioning (RIC)
TKIs Combined With Corticosteroids
followed by allogeneic HCT in adult patients with Ph-positive ALL.180-182
The Center for International Blood and Marrow Transplant Research The treatment of older patients with Ph-positive ALL may pose a
(CIBMTR) group conducted a multicenter retrospective analysis examining challenge, because elderly patients or those with comorbidities may not
the efficacy RIC and MAC allogeneic HCT in adult patients with Ph- tolerate aggressive regimens with multiagent chemotherapy combined
positive ALL (n = 197).180 At a median follow-up of 4.5 years, the 1-year with TKIs.183 Several studies have evaluated outcomes with imatinib
transplant-related mortality was significantly lower in the RIC versus MAC induction, with or without concurrent corticosteroids, in the older adult
group (13% vs. 36%; P = .001), and 3-year OS rates were similar (39% vs. population with Ph-positive ALL. In a study that randomly assigned older
35%, respectively).180 patients with Ph-positive ALL (n = 55; median age, 68 years; range, 54–79
years; 94.5% were aged 60 years or older) to induction therapy with
TKIs Combined With Hyper-CVAD imatinib versus chemotherapy alone, followed by imatinib-containing
Studies evaluating TKIs plus hyper-CVAD have included both AYA and consolidation therapy, the estimated 2-year OS rate was 42%; no
adult patients.145,151,166 For discussion of these studies, refer to the significant difference was observed between induction treatment arms.184

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The median OS was numerically higher (but not statistically significant) received imatinib in combination with prednisone for induction. The
among patients who received imatinib induction compared with those estimated 1-year DFS and OS rates were 48% and 74%, respectively; the
randomized to receive chemotherapy induction (23.5 vs. 12 months). median OS was 20 months.186 In a separate study from GIMEMA (LAL-
However, the incidence of severe adverse events was significantly lower 1205), patients with Ph-positive ALL (n = 53 evaluable; age range, 24–
with imatinib induction (39% vs. 90%; P = .005), which suggested that 76.5 years) received induction therapy with dasatinib and prednisone.144
induction therapy with imatinib may be better tolerated than chemotherapy Postinduction therapy included no further therapy (n = 2), TKI only (n =
in older patients with Ph-positive ALL.184 19), TKI combined with chemotherapy (n = 10) with or without autologous
HCT (n = 4), or allogeneic HCT (n = 18). All patients experienced a CR
In a study by GIMEMA (LAL-1205), patients with Ph-positive ALL (n = 53 after induction therapy. The median OS was 31 months and the median
evaluable; median age, 54 years; range, 24–76.5 years) received DFS (calculated from day +85) was 21.5 months. At 20 months, the OS
induction therapy with dasatinib and prednisone.144 Twelve patients were and DFS rates were 69% and 51%, respectively.144
older than 60 years. Postinduction therapy included no further therapy (n =
2), TKI only (n = 19), TKI combined with chemotherapy (n = 10) with or A phase II study from GIMEMA (LAL1811) also evaluated the efficacy and
without autologous HCT (n = 4), or allogeneic HCT (n = 18). All patients safety of ponatinib and prednisone in older adult patients with untreated
experienced a CR after induction therapy. The median OS was 31 months Ph-positive ALL (n = 42 evaluable; median age, 68 years; range, 27–85
and the median DFS (calculated from day +85) was 21.5 months. At 20 years).187 Dose reduction of ponatinib was allowed for adverse events. At
months, the OS and DFS rates were 69% and 51%, respectively.144 T315I week 24, the primary endpoint of the study, complete hematologic
mutation was detected in 12 of 17 patients with relapsed disease (71%). response, was prematurely reached in 75% of patients. During the study,
75 adverse events were reported; 36 were related to ponatinib.187
In a small phase II study from GRAALL (AFR-09 study), older patients
(aged ≥55 years) with Ph-positive ALL (n = 29 evaluable; median age, 63 TKIs Combined with Vincristine and Dexamethasone
years) were treated with chemotherapy induction followed by a The phase II GRAALL study (GRAAPH-2005) compared induction therapy
consolidation regimen with imatinib and methylprednisolone.185 The 1-year with high-dose imatinib (800 mg daily, days 1–28) combined with
OS rate in this study was significantly higher compared with the historical vincristine and dexamethasone (arm A) versus imatinib (800 mg daily,
control population who received the same induction therapy but did not days 1–14) combined with hyper-CVAD (arm B) in patients younger than
receive imatinib as part of consolidation (66% vs. 43%; P = .005), and the 60 years with previously untreated Ph-positive ALL.188,189 Eligible patients
median OS in this study was longer than that of the control group (23 vs. proceeded to HCT (allogeneic or autologous) after induction/consolidation
11 months, respectively). In addition, the 1-year RFS rate was significantly phases. The primary endpoint was non-inferiority of the less intensive arm
increased with the addition of imatinib (58% vs. 11%; P < .001).185 A A regimen in terms of MRD response (BCR-ABL / ABL ratio <0.1% by
phase II study by GIMEMA (LAL0201-B study) also evaluated imatinib quantitative PCR) after induction/consolidation. In an early report from this
combined with corticosteroids in older patients (age >60 years) with Ph- study (n = 118; n = 83 evaluable; median age 42 years), 52 patients
positive ALL (n = 29 evaluable; median age, 69 years).186 Patients proceeded to HCT (allogeneic, n = 41; autologous, n = 11). The estimated

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Acute Lymphoblastic Leukemia

2-year OS rate was 62%, with no significant difference between patients older patients with Ph-positive ALL for whom intensive regimens are not
who received imatinib with vincristine and dexamethasone and those who appropriate.
received imatinib with hyper-CVAD (68% vs. 54%, respectively).188 The 2-
TKIs in Maintenance Therapy
year DFS rate was 43%, with no significant difference between induction
arms (54% vs. 32%, respectively). Collectively, the incorporation of TKIs into the therapeutic regimen has
demonstrated improved outcomes for adult patients with Ph-positive ALL,
In an updated analysis from the GRAAPH-2005 study with a median particularly when administered before allogeneic HCT. Given that patients
follow-up of 4.8 years (n = 268; median age, 47 years), the CR rate was can experience relapse following allogeneic HCT, strategies are needed to
higher in arm A compared to arm B (98% vs. 91%; P = .006), but MRD prevent disease recurrence. One strategy involves the incorporation of
response rates after two cycles of therapy were similar between arm A post-HCT maintenance therapy with TKIs, which has been investigated in
and arm B (66.1% vs. 64.5%).190 The estimated 5-year EFS and OS rates several studies. In a small prospective study in patients with Ph-positive
were 37.1% and 45.6%, respectively, and no significant differences were leukemias who underwent allogeneic HCT (n = 15 with ALL; median age,
observed between arm A and arm B.190 Among patients who proceeded to 37 years; range, 4–49 years), imatinib was administered from the time of
allogeneic HCT or autologous HCT after MRD response, the outcomes engraftment until 1 year after HCT.192 The median time after HCT until
were similar in terms of the 5-year post-transplant RFS (48.3 % vs. 46.1 initiation of imatinib was short, at 27 days (range, 21–39 days). Molecular
%) and OS (56.7% vs. 55.1%) rates. This study suggests that outcomes remission (by PCR) was observed in 46% of patients (6 of 13) prior to
with less intensive chemotherapy regimens (using high-dose imatinib) may HCT and 80% (12 of 15) after HCT. Two patients died after hematologic
offer similar benefits to more intensive imatinib-containing chemotherapy relapse and one patient died due to acute respiratory distress syndrome
regimens.190 approximately 1 year post-HCT. At a median follow-up of 1.3 years, 12
patients (80%) were alive without detectable disease.192 This was one of
In the EWALL-Ph-01 study, induction therapy with dasatinib combined with the first prospective studies to show the feasibility of administering imatinib
low-intensity chemotherapy (vincristine and dexamethasone) was maintenance early in the post-HCT period (<90 days) when the leukemic
evaluated in older patients (aged ≥55 years) with Ph-positive ALL (n = 71; tumor burden tends to be low.
median age, 69 years; range, 58–83 years). The CR rate after induction
was 96% and MRD response (BCR-ABL/ABL ratio ≤0.1%) occurred in Maintenance therapy with imatinib was also evaluated in a prospective
65% of patients.191 At 3 years, the RFS, EFS, and OS were 33% (95% CI, study in patients who underwent allogeneic HCT (n = 82; median age,
22%–44%), 31% (95% CI, 21%–42%), and 41% (95% CI, 29%–52%), 28.5 years; range, 3–51 years).193 Imatinib was scheduled for a period of 3
respectively.191 At 5 years, the cumulative incidence of relapse was 54% to 12 months (until three consecutive tests were negative for BCR-ABL
(95% CI, 42%–66%). These studies suggest that the use of TKIs, either transcripts or sustained molecular CR for at least 3 months). Among the
alone or in combination with less intensive therapies (eg, corticosteroids patients who received imatinib (n = 62), the median time after HCT until
with or without vincristine), may provide an alternative treatment option for initiation of imatinib was 70 days (range, 20–270 days). In this group of
patients, 84% were alive with a molecular CR at a median follow-up of 31

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months.193 Imatinib was discontinued in 16% of patients receiving .017). Moreover, early MRD positivity (within 100 days after HCT) was
treatment due to toxicities. The remaining patients (n = 20) who did not associated with significantly decreased EFS compared with late MRD
receive maintenance with imatinib (due to cytopenias, infections, graft- detection (median, 39 months vs. not reached [NR]; 4-year EFS, 39% vs.
versus-host disease [GVHD], or patient choice) constituted the non- 65%; P = .037).194 This trial suggested that imatinib given post-allogeneic
imatinib group. The estimated 5-year relapse rate was significantly lower HCT (either prophylactically or based on MRD detection) resulted in low
with imatinib compared with no imatinib (10% vs. 33%; P = .0016) and the relapse rates and durable remissions. However, imatinib may not provide
estimated 5-year DFS (81.5% vs. 33.5%; P < .001) and OS rates (87% vs. benefit for patients who experience early molecular relapse or persistent
34%; P < .001) were significantly longer with imatinib compared with no MRD following HCT. Although no randomized controlled trials have yet
imatinib.193 been conducted to establish the efficacy of TKIs (compared with
observation only or other interventions) following allogeneic HCT, the
The previous study was not designed as a randomized controlled trial, and collective results from these studies suggest that TKI maintenance may
the number of patients in the non-imatinib group was small. A multicenter have a potential role in reducing the relapse risk in this setting.
randomized trial evaluated imatinib given prophylactically (n = 26)
compared with imatinib given at the time of MRD detection (ie, molecular Treatment of Relapsed Ph-Positive ALL
recurrence; n = 29) in patients who underwent allogeneic HCT with a The treatment of patients who experience relapse after initial therapy for
planned duration of imatinib therapy for 1 year.194 MRD was defined by the ALL remains a challenge, because these patients have a very poor
appearance of BCR-ABL transcripts, as assessed by quantitative RT-PCR prognosis. Several large studies using conventional chemotherapy for
performed at a central laboratory. In the prophylactic arm, imatinib was relapsed adult patients have reported a median OS of 4.5 to 6 months,
started in 24 patients (92%) at a median time of 48 days (range, 23–88 and a 5-year OS rate of 3% to 10%.195-198 One major factor associated with
days) after HCT. In the MRD-triggered arm, imatinib was started in 14 poorer survival outcomes after subsequent therapy for relapsed ALL is the
patients (48%) at a median time of 70 days (range, 39–567 days) after duration of response to frontline treatment. In an analysis of data from the
HCT. Imatinib was discontinued prematurely in the majority of patients in PETHEMA (Programa Español de Tratamientos en Hematologia) trials,
both arms (67% in the prophylaxis arm; 71% in the MRD-triggered arm), patients with disease that relapsed more than 2 years after frontline
primarily because of toxicities.194 Ongoing CR was observed in 81% of therapy had significantly higher 5-year OS rates than the groups of
patients in the prophylaxis arm (median follow-up, 30 months) and in 78% patients who relapsed within 1 to 2 years or within 1 year of frontline
of patients in the MRD-triggered arm (median follow-up, 32 months). No therapy (31% vs. 15% vs. 2%; P < .001).196 Similarly, in the MRC UKALL
significant differences were found between the prophylaxis and MRD- XII/ECOG E2993 trial, patients with disease that relapsed more than 2
triggered arms in terms of relapse rate (8% vs. 17%), 5-year DFS (84% vs. years after initial diagnosis and frontline therapy had a significantly higher
60%), EFS (72% vs. 54%), or OS (80% vs. 74.5%).194 However, MRD 5-year OS rate than those who relapsed within 2 years (11% vs. 5%; P <
positivity was predictive of relapse regardless of treatment arm; the 5-year .001).195 In the pre-imatinib era, patients with Ph-positive ALL who
RFS rate was significantly lower among patients with detectable MRD relapsed after frontline therapy had dismal outcomes; subgroup data from
compared with those who remained MRD negative (70% vs. 100%; P = the large, prospective trials LALA-94 and MRC UK XII/ECOG E2993

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Acute Lymphoblastic Leukemia

showed a median OS of 5 months and a 5-year OS rate of 3% to 6% intrathecal therapy or cranial irradiation, 12% developed CNS leukemia.210
among patients subsequently treated for relapsed Ph-positive ALL.195,197 Patients with imatinib-resistant disease who developed CNS disease
rapidly died from progressive disease (PD); conversely, patients with
Hematopoietic Cell Transplant
imatinib-sensitive disease who developed isolated CNS relapse could be
Treatment options are extremely limited for patients with Ph-positive ALL successfully treated with intrathecal therapy with or without cranial
who experience relapse after receiving consolidation with allogeneic HCT. irradiation.208,210
Some investigators have reported on the feasibility of inducing a second
molecular CR with dasatinib in those who have experienced an early The emergence of resistance poses a challenge for patients relapsing
relapse after first allogeneic HCT, which allowed for a second allogeneic after initial treatment with TKI-containing regimens. Point mutations within
HCT.199,200 Studies that include donor lymphocyte infusion (DLI) to induce the ABL kinase domain and alternative signaling pathways mediated by
further graft-versus-leukemia effect in those who relapse after allogeneic the SRC family kinase have been implicated as mechanisms of
HCT have reported little to no benefit, though it has been suggested that resistance.212-214 The former has been identified in a large proportion of
this is due to excessively high leukemic burden.201,202 Indeed, published patients who experience disease recurrence after imatinib-containing
case reports have suggested that the use of DLI for residual disease or therapy.215,216 Moreover, ABL kinase domain mutations may be present in
molecular relapse (as noted by levels of BCR-ABL fusion mRNA a small group of imatinib-naïve patients even before initiation of any TKI
measured with PCR) after allogeneic HCT may eliminate residual therapy.217,218
leukemic clones and thereby prevent overt hematologic relapse.203-205
Moreover, case reports have described using newer TKIs, such as Dasatinib and nilotinib are second-generation TKIs that have shown
dasatinib and nilotinib, along with DLI to manage relapse after allogeneic greater potency in inhibiting BCR-ABL compared with imatinib, and
HCT.206,207 Although these approaches are promising, only limited data are retention of antileukemic activity in cells with certain imatinib-resistant ABL
available. Evidence from prospective studies is needed to establish the mutations.149,219-221 Both TKIs have been evaluated as single-agent
role of DLI, with or without TKIs, in the treatment of relapsed disease. therapy in patients with Ph-positive ALL that is resistant to imatinib
treatment.222-224 A randomized phase III study examined the activity of
Tyrosine Kinase Inhibitors dasatinib administered as once-daily (140 mg daily) versus twice-daily (70
CNS relapse has been reported in both patients with disease responsive mg twice daily) dosing in patients with Ph-positive leukemia resistant to
to imatinib therapy (isolated CNS relapse with CR in marrow) and patients imatinib;223 the once-daily dosing resulted in a higher response rate (major
with disease resistant to imatinib therapy.208-211 The concentration of cytogenetic response) than the twice-daily dosing (70% vs. 52%).
imatinib in the cerebrospinal fluid (CSF) has been shown to be Although the median OS was shorter with the once-daily dosing (6.5 vs. 9
approximately 2 logs lower than that achieved in the blood, suggesting months), the median progression-free survival (PFS) was longer (4 vs. 3
that this agent does not adequately penetrate the blood-brain barrier to months).223 These differences in outcomes between the dosing arms were
ensure CNS coverage.209,211 A study showed that among patients with ALL not statistically significant.
treated with imatinib and who did not receive routine prophylactic

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Dasatinib in combination with the hyper-CVAD regimen (hyper- ponatinib distribution resumed in December 2013 following revision to both
fractionated cyclophosphamide, vincristine, doxorubicin, and the prescribing information and risk evaluation and mitigation strategies
dexamethasone) was investigated in a phase II trial that included patients program to address the risk for serious cardiovascular adverse events.
with Ph-positive relapsed ALL (n = 19) and lymphoid blast phase (BP) This TKI has been shown to inhibit both native and mutant forms of BCR-
chronic myelogenous leukemia (CML) (n = 15).225 An overall response rate ABL (including those resulting from T315I mutation) in preclinical
(ORR) of 91% was obtained with 26 patients (84%) achieving complete studies.230 In a multicenter, open-label, phase II study (PACE trial; n =
cytogenetic remission, 13 patients (42%) having complete molecular 449), ponatinib showed substantial activity in patients with Ph-positive
response, and 11 patients (35%) having a major molecular response. leukemias resistant or intolerant to second-generation TKIs.231 Major
There were 9 patients who went on to receive allogeneic HCT, including 2 hematologic response was observed in 41% of the subgroup with Ph-
patients with ALL. In the patients with relapsed ALL, 30% remained in positive ALL (n = 32). In the subset of patients with Ph-positive ALL with
complete remission at 3 years with a 3-year OS of 26%. At the median ABL T315I mutation (n = 22), major hematologic response was observed
follow-up of 52 months (range, 45–59 months), 2 patients (11%) with ALL in 36%.231 Common overall treatment-related adverse events in the PACE
were still alive. trial included thrombocytopenia (37%), rash (34%), and dry skin (32%).
Additionally, arterial thrombotic events were observed and 7.1% of
Bosutinib, a second-generation TKI that acts as a dual inhibitor of BCR- patients experienced cardiovascular events,231 though dose reduction may
ABL and SRC family kinases,226,227 was approved in September 2012 by impart a lower risk.
the FDA for the treatment of chronic, accelerated phase (AP), or BP Ph-
positive CML in adult patients with resistance to prior TKI treatment based Not all imatinib-resistant ABL mutations are susceptible to the newer TKIs.
on an open-label, multicenter phase I/II trial.227 Efficacy and safety For instance, dasatinib is not as active against cells harboring the ABL
analyses of bosutinib monotherapy included patients with advanced mutations T315I, V299L, and F317L.214,220,232,233 Thus, for patients with
leukemia [AP CML (n = 79), BP CML (n = 64), or ALL (n = 24)] who were disease resistant to TKI therapy, it becomes important to identify potential
previously treated with at least one TKI.228,229 Of the 22 evaluable patients ABL mutations that may underlie the observed resistance to treatment. A
with ALL, 2 patients (9%) attained or maintained a confirmed overall panel of experts from the European LeukemiaNet published
hematologic response by 4 years.228 Common overall treatment-related recommendations for the analysis of ABL kinase domain mutations in
adverse events reported in patients with advanced leukemia included patients with CML, and treatment options according to the presence of
diarrhea (74%), nausea (48%), and vomiting (44%).228,229 different ABL mutations.234 (See Principles of Systemic Therapy in the
algorithm for TKI treatment options for Treatment Options Based on BCR-
Ponatinib is a third-generation TKI that was initially approved by the FDA ABL1 Mutation Profile).
in December 2012 for the treatment of adult patients with chronic, AP, or
BP Ph-positive CML or Ph-positive ALL, with resistance to prior therapy, Blinatumomab
and was added as a treatment option for R/R Ph-positive ALL in 2013. In December 2014, the FDA approved blinatumomab for the treatment of
Though temporarily removed from the market in November 2013, relapsed or refractory Ph-negative precursor B-ALL (see Treatment of

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Relapsed Ph-Negative ALL for a detailed discussion of blinatumomab). In OS (13.9 vs. 9.9 months; P = .005).237 In August 2017, InO received full
July 2017, blinatumomab received full approval from the FDA for the approval from the FDA for the treatment of R/R precursor B-ALL.
treatment of R/R precursor B-ALL (Ph-negative and Ph-positive). A follow-
CAR T Cells
up, open-label, single-arm, multicenter, phase II study evaluated the
efficacy and safety of blinatumomab in patients with R/R Ph-positive ALL Currently, bone marrow transplant is the only cure for R/R ALL, but many
who had progressed after imatinib and at least one second- or third- patients are not eligible for transplant based on age or progression of the
generation TKI (n = 45).235 During the first two cycles of blinatumomab, disease. The generation of chimeric antigen receptor (CAR) T cells to treat
36% achieved complete remission or complete remission with partial ALL represents a significant advance in the field and has shown
hematologic recovery, and 88% of the latter responders achieved a significantly greater OS than current regimens.238 The pre-treatment of
complete MRD response.235 Notably, responses were independent of patients with CAR T cells has served as a bridge for transplant, and
T315I mutation status (see Initial Treatment in AYA Patients with Ph- patients who were formerly unable to be transplanted due to poor
Negative ALL for a discussion of studies related to blinatumomab and remission status have a CR and ultimately transplantation. CAR T-cell
chemotherapy-resistant MRD). therapy relies on the genetic manipulation of a patients’ T cells to
engender a response against a leukemic cell-surface antigen, most
Inotuzumab ozogamicin commonly CD19239 (see Treatment of Relapsed Ph-Negative ALL for a
Inotuzumab ozogamicin (InO) is a calicheamicin-based antibody-drug detailed discussion of CAR T cells). CAR T-cell therapy/tisagenlecleucel
conjugate targeting CD22. Following the generation of encouraging was recommended for accelerated approval by the FDA oncologic drug
single-agent phase II data,236 a randomized study was conducted advisory committee in July 2017 and fully approved by the FDA in August
comparing InO with standard intensive chemotherapy regimens in Ph- 2017 for the treatment of patients up to age 25 years (aged <26 years)
negative or Ph-positive ALL in first or second relapse, defined as >5% with R/R precursor B-ALL.
marrow blasts (n = 326). Compared to standard therapy, InO produced a
MOpAD Regimen
significantly higher CR/CRi rate (80.7% vs. 29.4%; P < .001), and higher
MRD-negative rates (78.4% vs. 28.1%; P < .001).237 Notably, responses A single-arm trial evaluating the efficacy of the MOAD regimen
were consistent across most subgroups, including those with high (methotrexate, vincristine, L-asparaginase, and dexamethasone) in
marrow burden, and those with Ph-positive leukemia. The overall newly diagnosed adults with ALL (n = 55) demonstrated a CR rate of
incidence of severe adverse events were similar across treatment arms, 76% with a median CR duration of over 12 months.240 A phase II trial
with a higher incidence of hepatic veno-occlusive disease observed in incorporated a new PEGylated formulation of L-asparaginase due to
the inotuzumab group, related in part to dual alkylator-based transplant improved tolerability,241 and examined the safety and efficacy of the
conditioning administered in remission. These data translated into a MOpAD regimen (methotrexate, vincristine, PEG-L-asparaginase, and
significant benefit in the median duration of remission (4.6 vs. 3.1 dexamethasone) in adults with relapsed or refractory ALL (n = 37).242 For
months; P = .03), median PFS (5 vs. 1.8 months; P < .001), and mean patients with Ph-positive ALL, TKIs (ie, imatinib, dasatinib, nilotinib) were
added to the regimen and if patients had CD20-positive B-ALL, rituximab

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Acute Lymphoblastic Leukemia

was added to the regimen. The CR and ORR rates were 28% and 39%, combined with TKIs.160 Maintenance therapy with a TKI, with or without
respectively, with a median duration of response of 4.3 months.242 monthly pulses of vincristine/prednisone (for 2–3 years), is recommended.
Patients with Ph-positive ALL had CR and ORR rates of 50% and 67%, Although the optimal duration of post-transplant or maintenance TKI is
respectively.242 This regimen may be considered in patients who have unknown, the minimum suggested duration is 1 year. Periodic MRD
received a maximal dose of anthracycline and have cardiac dysfunction assessments should be considered (no more than every 3 months) for
and limited performance status. patients with complete molecular remission (undetectable levels). The
frequency may be increased if MRD levels are detectable. For patients
NCCN Recommendations for Ph-Positive ALL with CD20-positive disease, consider adding rituximab to chemotherapy.
AYA Patients with Ph-Positive ALL
The panel recommends that AYA patients with Ph-positive ALL be treated For patients without a donor, consolidation therapy after a CR should
in a clinical trial, when possible. In the absence of an appropriate clinical comprise a continuation of multiagent chemotherapy combined with a TKI.
trial, the recommended induction therapy would comprise multiagent These patients should continue to receive post-consolidation maintenance
chemotherapy or corticosteroids combined with a TKI. Dasatinib and therapy with a regimen that includes a TKI. Weekly methotrexate and daily
imatinib are the preferred TKIs for induction therapy, and ponatinib is 6-MP may be added to the maintenance regimen, as tolerated; however,
preferred for the hyper-CVAD regimen. However, the panel notes that not the doses of these antimetabolite agents may need to be reduced in the
all TKIs have been studied within the context of each regimen, and there setting of hepatotoxicity or myelosuppression. Individuals who inherit a
are limited data for bosutinib in Ph-positive ALL. Use of a specific TKI nonfunctional variant allele of the TPMT gene are known to be at high risk
should account for anticipated or prior TKI intolerance and disease-related of developing hematopoietic toxicity (in particular, severe neutropenia)
features. Treatment regimens should include adequate CNS prophylaxis after treatment with 6-MP.138 Testing for the TPMT gene polymorphism
for all patients. It is also important to adhere to the treatment regimens for should be considered in patients receiving 6-MP as part of maintenance
a given protocol in its entirety, from induction therapy to therapy, particularly those who experience severe bone marrow toxicities
consolidation/delayed intensification to maintenance therapy. (see Role of MRD Evaluation).

For AYA patients experiencing a CR after initial induction therapy, an MRD The treatment approach for AYA patients experiencing less than a CR
assessment should be performed prior to consolidation with allogeneic after initial induction therapy (ie, having primary refractory disease) would
HCT in appropriate candidates. Many variables determine eligibility for be similar to that for patients with R/R ALL (see Patients with
allogeneic HCT including donor availability, depth of remission, Relapsed/Refractory Ph-Positive ALL).
comorbidities, and social support.243 The optimal time for a patient to
Adult Patients with Ph-Positive ALL
receive allogeneic HCT is unclear; however, for fit patients, additional
For adult patients with Ph-positive ALL, the panel recommends treatment
therapy may be considered to eliminate MRD before transplant. In
in a clinical trial, when possible. In the absence of an appropriate clinical
younger AYA patients (aged ≤21 years), emerging data suggest that
trial, the recommended induction therapy would initially depend on the
allogeneic HCT may not confer an advantage over chemotherapy
patient’s age and/or presence of comorbid conditions. Treatment regimens

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should include adequate CNS prophylaxis for all patients, and a given therapy with a regimen that includes a TKI. Weekly methotrexate and daily
treatment protocol should be followed in its entirety. Although the age 6-MP may be added to the maintenance regimen, as tolerated; however,
cutoff indicated in the guidelines has been set at 65 years, it should be the doses of these antimetabolite agents may need to be reduced in the
noted that chronologic age alone is not a sufficient surrogate for defining setting of hepatotoxicity or myelosuppression. Again, testing for TPMT
fitness; patients should be evaluated on an individual basis to determine gene polymorphism should be considered for patients receiving 6-MP as
fitness for therapy based on factors such as performance status, end- part of maintenance therapy, especially those who develop severe bone
organ function, and end-organ reserve. marrow toxicities after its initiation. For patients with less than a CR after
induction, the treatment approach would be similar to that for patients with
For relatively fit adult patients (age <65 years without substantial R/R disease (see Patients with Relapsed/Refractory Ph-Positive ALL).
comorbidities), the recommended treatment approach is similar to that for
AYA patients. Induction therapy would comprise multiagent chemotherapy For adult patients who are less fit (aged ≥65 years or with substantial
or corticosteroids combined with a TKI, with the same treatment comorbidities), the recommended induction therapy options include a TKI
preferences and considerations noted for AYA patients (see NCCN with corticosteroids or with low-intensity chemotherapy regimens. Dose
Recommendations for Ph-Positive ALL; AYA Patients with Ph-Positive modifications may be required for chemotherapy agents, as needed. In
ALL). For patients experiencing a CR after induction, an MRD assessment patients with a CR after induction, an MRD assessment should be
should be performed prior to consolidation with allogeneic HCT if a performed prior to consolidation therapy including continuing therapy with
matched donor is available. Similar to the treatment strategy for AYA a TKI with or without corticosteroids or low-intensity chemotherapy.
patients, the optimal time for a patient to receive allogeneic HCT is Allogeneic HCT may be considered based on performance status, donor
unclear; however, for fit patients, additional therapy may be considered to availability, and transplant center expertise in treating older patients with
eliminate MRD before transplant. Maintenance therapy with a TKI, with or allogeneic HCT. Post-consolidation maintenance TKI therapy is
without monthly pulses of vincristine/prednisone for 2 to 3 years, is recommended for at least 2 to 3 years with or without monthly pulses of
recommended. As previously mentioned, although the optimal duration of vincristine/prednisone. Weekly methotrexate and daily 6-MP may be
post-transplant TKI is unknown, the minimum suggested duration is 1 added to the maintenance regimen, as tolerated; however, the doses of
year. Periodic MRD assessments should be considered (no more than antimetabolites may need to be reduced in the setting of hepatotoxicity or
every 3 months) for patients with complete molecular remission myelosuppression. As previously mentioned, although the optimal duration
(undetectable levels). The frequency may be increased if MRD levels are of post-transplant TKI is unknown, the minimum suggested duration is 1
detectable. For patients with CD20-positive disease, consider adding year. Adult patients with less than a CR after induction should be
rituximab to chemotherapy, especially if younger than 60 years. managed similarly to those with R/R disease (see Patients with
Relapsed/Refractory Ph-Positive ALL).
For patients without a donor, consolidation therapy after a CR should
comprise a continuation of multiagent chemotherapy combined with a TKI.
These patients should continue to receive post-consolidation maintenance

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NCCN Guidelines Version 2.2020

Acute Lymphoblastic Leukemia

Patients with Relapsed/Refractory Ph-Positive ALL may include a second allogeneic HCT and/or DLI. However, the role of
Mutation testing for the ABL1 kinase domain is recommended in patients allogeneic HCT following treatment with tisagenlecleucel is unclear. While
with Ph+ ALL that has relapsed after or is refractory to initial TKI- persistence of tisagenlecleucel in peripheral blood and persistent B-cell
containing therapy. The panel has largely adopted the recommendations aplasia has been associated with durable clinical responses without
for treatment options based on ABL mutation status for CML, as published subsequent allogeneic HCT, further study will be required before
by the European LeukemiaNet.234 If not administered during initial conclusive recommendations can be made.245 For patients with Ph-
induction, TKIs (imatinib, dasatinib, nilotinib, bosutinib, or ponatinib) are positive ALL that is refractory to TKIs, regimens for R/R Ph-negative ALL
recommended options for patients with R/R Ph+ ALL. For second- and can be considered. (See Treatment of Relapsed Ph-Negative ALL).
third-generation TKIs, relevant BCR-ABL1 mutations should be considered
as outlined in the algorithm table titled, Treatment Options Based on BCR- Management of Ph-Negative ALL
ABL1 Mutation Profile. Due to the high frequency of serious vascular Initial Treatment in AYA Patients with Ph-Negative ALL
events with ponatinib therapy, the FDA indication is restricted to the The AYA population with ALL can pose a unique challenge given that
treatment of patients with the T315I mutation or in patients with disease patients may be treated with either a pediatric or an adult protocol,
resistant to other TKI therapies. depending on local referral patterns and institutional practices.
Retrospective analyses based on cooperative group studies from both the
For all patients with R/R Ph-positive ALL, participation in a clinical trial is
United States and Europe have consistently shown the superior outcomes
preferred. In the absence of an appropriate trial, patients may be
for AYA patients (aged 15–21 years) treated on pediatric versus adult ALL
considered for second-line therapy with an alternative TKI (ie, different
regimens. In the AYA population, 5-year EFS rates ranged from 63% to
from the TKI used as part of induction therapy) alone, TKI combined with
74% for patients treated on a pediatric study protocol versus 34% to 49%
multiagent chemotherapy, or TKI combined with corticosteroids (especially
for those receiving the adult protocol.86,87,113,246,247 In a retrospective
for elderly patients who may not tolerate multiagent combination therapy).
comparative study that analyzed outcomes of AYA patients (aged 16–20
Blinatumomab and InO are treatment options if the patient is refractory or
years) treated on a pediatric CCG study protocol (n = 197; median age, 16
intolerant to TKIs. Compared to standard care, InO is associated with
years) versus an adult CALGB study protocol (n = 124; median age, 19
increased hepatotoxicity, including fatal and life-threatening hepatic veno-
years), patients treated on the pediatric regimen compared with those on
occlusive disease, and increased risk of post-HCT non-relapse
the adult regimen had significantly improved 7-year EFS (63% vs. 34%,
mortality.244 Tisagenlecleucel is also an option for patients up to age 25
respectively; P < .001) and OS (67% vs. 46%, respectively; P < .001)
years (aged <26 years) and with refractory disease or greater than or
rates.113 Moreover, AYA patients treated on the adult protocol experienced
equal to 2 relapses and failure of 2 TKIs.
a significantly higher rate of isolated CNS relapse at 7 years (11% vs. 1%;
If transplant-naïve patients experience a second CR prior to transplant, P = .006). The substantial improvements in outcomes observed with the
consolidative allogeneic HCT should be strongly considered. For patients pediatric regimen in this study, and in the earlier retrospective analyses
with disease that relapses after an initial allogeneic HCT, other options from other cooperative groups, may be largely attributed to the use of
greater cumulative doses of drugs, such as corticosteroids (prednisone
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NCCN Guidelines Version 2.2020

Acute Lymphoblastic Leukemia

and/or dexamethasone), vincristine, and L-asparaginase, and to earlier, Outcomes were improved in patients with Ph-negative high-risk ALL and
more frequent, and/or more intensive CNS-directed therapy compared those with CNS involvement allocated to allogeneic HCT. The median
with adult regimens.113 Given the success seen with multiagent intensive DFS was 21 months for these patients, and the median OS has not yet
chemotherapy regimens for pediatric patients with ALL, several clinical been reached; the 5-year OS rate was 51%.89 Thus, it appears that in
trials have evaluated pediatric-inspired regimens for the AYA patient patients with Ph-negative high-risk disease, allogeneic HCT in first CR
population. improved DFS outcomes, whereas autologous HCT did not result in
significant benefit compared with chemotherapy alone.
Hematopoietic Cell Transplant
For AYA patients with Ph-negative ALL in first CR, allogeneic HCT may be In the PETHEMA ALL-93 trial, adult patients with high-risk ALL [defined as
considered for high-risk cases—particularly for patients with disease that having at least one of the following criteria: 30–50 years of age; WBC
is MRD positive any time after induction; or patients with elevated WBC count ≥25 × 109/L; presence of t(9;22), t(4;11), or other 11q
counts; or patients with B-ALL and poor-risk cytogenetics (eg, rearrangements; and t(1;19)] received postremission induction therapy (n
hypodiploidy, MLL rearrangement) at diagnosis. A large multicenter trial = 222 eligible; median age, 27 years; range, 15–50 years) with allogeneic
(LALA-94 study) evaluated the role of postinduction HCT as one of the HCT (n = 84; if matched related donor available), autologous HCT (n =
study objectives in adolescent and adult ALL patients receiving therapy for 50), or chemotherapy alone (n = 48).248 Based on intent-to-treat analysis
previously untreated ALL (n = 922; median age, 33 years; range, 15–55 of data from patients with Ph-negative high-risk disease, no significant
years).89 Patients were stratified into four risk groups: 1) Ph-negative advantage was observed in a donor versus no-donor comparison of
standard-risk disease [defined as achievement of CR after 1 course of median DFS (21 months vs. 38 months), median OS (32 months vs. 67
chemotherapy; absence of CNS disease; absence of t(4;11), t(1;19), or months), 5-year DFS rate (37% vs. 46%), or 5-year OS rate (40% vs.
other 11q23 rearrangements; WBC count <30 × 109/L]; 2) Ph-negative 49%). In addition, when the analysis was conducted based on the actual
high-risk ALL (defined as patients with non–standard-risk disease and postremission treatment received, no significant differences were noted
without CNS involvement); 3) Ph-positive ALL; and 4) evidence of CNS between treatment arms for 5-year DFS rates (50% for allogeneic HCT;
disease. After induction therapy, patients with Ph-negative high-risk ALL 55% for autologous HCT; and 54% for chemotherapy alone).248
were eligible to undergo allogeneic HCT if a matched sibling donor was
available; those without a sibling donor were randomized to undergo The role of allogeneic HCT in adults with ALL was also evaluated in the
autologous HCT or chemotherapy alone.89 Among the subgroup of large multicenter MRC UKALL XII/ECOG E2993 study (n = 1913; aged
patients with Ph-negative high-risk ALL (n = 211), the 5-year DFS and OS 15–59 years).90 In this study, high risk was defined as 35 years of age or
rates were 30% (median, 16 months) and 38% (median, 29 months), older; time to CR greater than 4 weeks from induction; elevated WBC
respectively. Based on intent-to-treat analysis, outcomes in patients with counts (>30 × 109/L for B-ALL; >100 × 109/L for T-ALL); or the presence of
Ph-negative high-risk ALL were similar for autologous HCT (n = 70) and Ph chromosome. All other patients were considered to be standard risk.
chemotherapy alone (n = 59) in terms of median DFS (15 vs. 11 months), Patients experiencing a remission with induction therapy were eligible to
median OS (28 vs. 26 months), and 5-year OS rate (32% vs. 21%).89 undergo allogeneic HCT if a matched sibling donor was available or, in the

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NCCN Guidelines Version 2.2020

Acute Lymphoblastic Leukemia

absence of a sibling donor, were randomized to undergo autologous HCT As evidenced by the previously described studies, matched sibling HCT
or chemotherapy. The 5-year OS rate was higher for patients randomized has been established as a valuable treatment strategy for patients with
to chemotherapy alone compared with autologous HCT (46% vs. 37%; P = high-risk Ph-negative ALL, but subsequent studies have examined the role
.03). A donor versus no-donor comparison in all patients with Ph-negative of URD transplants. In a retrospective analysis of 169 patients who
ALL showed that the 5-year OS rate was significantly higher in the donor underwent URD HCT during first CR, 60 patients (36%) had one poor
group than in the no-donor group (53% vs. 45%; P = .01). This advantage prognostic factor and 97 (57%) had multiple risk factors. The 5-year
in OS outcomes for the donor group was observed for patients with survival was 39%, which is higher than survival reported in studies of high-
standard risk (62% vs. 52%; P = .02) but not for those with Ph-negative risk patients receiving chemotherapy alone.250 The most significant
high-risk disease (41% vs. 35%).90 This was partly because of the high percentage of treatment-related mortality occurred in patients who were
rate of non-relapse mortality observed with the donor group compared with given mismatched donors compared to partially or well-matched donors.
the no-donor group in patients with high-risk disease (36% vs. 14% at 2 There was no significant difference in outcome between older and younger
years). Among patients with standard risk, the non-relapse mortality rate at patients, suggesting that URD transplants may be an option for older
2 years was 19.5% for the donor group and 7% for the no-donor group. patients. In a follow-up retrospective study by the same group, RIC was
Relapse rate was significantly lower in the donor group than in the no- evaluated to lower treatment-related mortality.251 RIC conditioning most
donor group for both patients with standard risk (24% vs. 49%; P < .001) commonly comprised busulfan (9 mg/kg or less), melphalan (150 mg/m2),
and those with high risk (37% vs. 63%; P < .001).90 Nevertheless, the high low-dose total body irradiation (TBI) (less than 500 cGy single dose or less
non-relapse mortality rate in the donor group among patients with high-risk than 800 cGy fractionated), or fludarabine plus TBI of 200 cGy. RIC is
disease seemed to diminish the advantage of reduced risk for relapse in more prominent in the treatment of older patients; therefore, the median
this group. This study suggested that allogeneic HCT in first CR was age for patients receiving full-intensity (FI) conditioning was 28 years
beneficial in patients with standard-risk ALL. (range, 16–62 years), and for patients receiving RIC, the median age was
45 years (range, 17–66 years). Despite the variation in age, results from
The benefit of matched sibling allogeneic HCT in adult patients with the study have shown no difference in relapse (35% vs. 26%, P = .08) or
standard-risk ALL was also reported by the HOVON cooperative group. In in treatment-related mortality (FI, 33%; 95% CI, 31%–36% vs. RIC, 32%;
a donor versus no-donor analysis of patients with standard-risk ALL 95% CI, 23%–43%; P = .86) at 3 years.251 The 3-year survival for HCT
undergoing postremission therapy with matched sibling allogeneic HCT or was similar following first CR (FI, 51%; 95% CI, 48%–55% vs. RIC, 45%;
autologous HCT, the donor arm was associated with a significantly 95% CI, 31–59%) and second CR (FI, 33%; 95% CI, 30%–37% vs. RIC,
reduced 5-year relapse rate (24% vs. 55%; P < .001) and a higher 5-year 28%; 95% CI, 14%–44%). The DFS was similar in both groups following
DFS rate (60% vs. 42%; P = .01) compared with the no-donor arm.249 In first CR (FI, 49%; 95% CI, 45%–53% vs. RIC, 36%; 95% CI, 23%–51%)
the donor group, the non-relapse mortality rate at 5 years was 16% and and in second CR (FI, 32%; 95% CI, 29%–36% vs. RIC, 27%; 95% CI,
the 5-year OS rate was 69%.249 14%–43%).251

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NCCN Guidelines Version 2.2020

Acute Lymphoblastic Leukemia

A systematic review and meta-analysis of published randomized trials on rapid early responders, the augmented-intensity (n = 88) and standard-
postremission induction therapy in adults with ALL reported a significant intensity (n = 76) arms showed no statistically significant differences in
reduction in all-cause mortality with allogeneic HCT in first CR (RR, 0.88; rates of 5-year EFS (82% vs. 67%, respectively) or OS (83% vs. 76%,
95% CI, 0.80–0.97) compared with autologous HCT or chemotherapy.252 A respectively). For the AYA patients who were considered slow early
subgroup analysis showed a significant survival advantage with allogeneic responders (all of whom received the augmented-intensity regimen), the 5-
HCT in standard-risk ALL, whereas a nonsignificant advantage was seen year EFS rate was 71%.255
in high-risk ALL.252 Autologous HCT in first remission was not shown to be
COG AALL0232
beneficial relative to chemotherapy in several large studies and meta-
analyses.89,90,252,253 The AALL0232 trial enrolled 2154 patients between the ages of 1 and 30
years who were diagnosed with high-risk B-ALL.256 In this study patients
CCG-1961 were randomly assigned to receive dexamethasone versus prednisone
The CCG-1961 trial was a seminal study that allowed comparison of adult during induction and high-dose methotrexate versus Capizzi escalating-
versus pediatric regimens in AYA patients. In an analysis of outcomes in dose methotrexate plus pegaspargase (PEG) during interim maintenance
children and AYA patients treated in the Dana-Farber Cancer Institute 1. High-dose methotrexate showed improved 5-year EFS (80% vs. 75%; P
(DFCI) ALL Consortium Protocols (1991–2000), the 5-year EFS rate = .008) and OS (88.9% ± 1.2% vs. 86.1% ± 1.4%; P = 0.25) rates
among younger AYA patients (age 15–18 years; n = 51) was 78%, which compared to Capizzi escalating-dose methotrexate. No statistically
was not significantly different from the EFS rates observed for children significant difference was reported in the occurrence of mucositis,
aged 10 to 15 years (77%; n = 108) or those aged 1 to 10 years (85%; n = neurotoxicity, osteonecrosis, or other toxicities. The ALL0232 trial
685).254 The CCG 1961 study was designed to evaluate the benefit of compared dexamethasone 10 mg/m2/day for 14 days to 60 mg/m2/day of
augmented versus standard postinduction intensification therapy in prednisone for 28 days. Dexamethasone showed improved outcomes
children aged 1 to 9 years with high WBC counts (≥50 × 109/L) or in older during induction in patients younger than 10 years of age; however, it was
children and adolescents aged 10 to 21 years.112 Patients were stratified associated with a higher risk of osteonecrosis in patients aged 10 years or
by their initial response to induction therapy as either slow early older. These data suggest that age may be an important factor for the
responders (patients with >25% bone marrow blasts on day 7 of induction) selection of a corticosteroid.256
or rapid early responders. Among the patients who were rapid early
PETHEMA ALL-96 Regimen
responders to induction (n = 1299), the augmented postinduction intensity
arm was associated with significantly increased rates of 5-year EFS (81% In the PETHEMA ALL-96 trial, adolescent (n = 35; aged 15–18 years) and
vs. 72%; P < .0001) and OS (89% vs. 83%; P = .003) compared with the young adult (n = 46; aged 19–30 years) patients with standard-risk Ph-
standard-intensity arm.112 In the subgroup of AYA patients (age 16–21 negative ALL [defined as WBC count <30 × 109/L; absence of t(9;22),
years; n = 262) from the CCG 1961 study treated with either augmented or t(1;19), t(4;11), or any other 11q23 rearrangements] received frontline
standard-intensity regimens, the 5-year EFS and OS rates were 71.5% therapy with a 5-drug induction regimen (vincristine, daunorubicin,
and 77.5%, respectively.255 Among the AYA patients who were considered prednisone, L-asparaginase, and cyclophosphamide),

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NCCN Guidelines Version 2.2020

Acute Lymphoblastic Leukemia

consolidation/reinduction, and maintenance, along with triple intrathecal asparaginase during induction and a dose-reduction of pegylated-
therapy throughout the treatment period.257 The 6-year EFS and OS rates asparaginase during consolidation. After 4 weeks, the CR rate was 89%,
for the entire patient cohort were 61% and 69%, respectively. No and with a median follow-up of 39 months, the estimated 3-year DFS and
difference in EFS rate was observed between adolescents (60%; 95% CI, OS rates are 73% and 75%, respectively.260 These data suggest that
43%–77%) and young adults (63%; 95% CI, 48%–78%); similarly, no intensive pediatric regimens are feasible, with potential modifications, in
significant difference was observed in OS for adolescents (77%; 95% CI, young adults with previously untreated ALL; however, further follow-up
63%–91%) versus young adults (63%; 95% CI, 46%–80%).257 Based on data are needed to evaluate long-term survival outcomes.
multivariate regression analysis, slow response to induction therapy
GRAALL-2005 Regimen
(defined as having >10% blast cells in the bone marrow aspirate
performed on day 14 of treatment) was the only factor associated with a The prospective phase II GRAALL-2003 study evaluated a pediatric-
poor EFS (odds ratio [OR], 2.99; 95% CI, 1.25–7.17) and OS (OR, 3.26; inspired regimen using intensified doses of vincristine, prednisone, and
95% CI, 1.22–8.70).257 asparaginase for adolescents and adults with Ph-negative ALL (n = 225;
median age, 31 years; range, 15–60 years).261 The induction regimen
DFCI ALL Regimen Based on DFCI Protocol 00-01 comprised vincristine, daunorubicin, prednisone, L-asparaginase, and
A multicenter phase II trial evaluated the pediatric-inspired regimen based cyclophosphamide. Patients with high-risk disease and donor availability
on the DFCI Childhood ALL Consortium Protocol 00-01 in AYA and adult were allowed to proceed to allogeneic HCT. The EFS and OS rates at 42
patients (aged 18–50 years) with previously untreated ALL; 20% of the months were 55% and 60%, respectively. When data from patients who
patients in this study had Ph-positive disease.258 The treatment regimen underwent transplantation at first CR were censored, the DFS rates at 42
comprised induction (vincristine, doxorubicin, prednisone, L-asparaginase, months were 52% for patients with high-risk disease and 68% for patients
and high-dose methotrexate), triple intrathecal therapy, intensification, and with standard-risk disease (risk assignment based on GRAALL protocol);
maintenance. Among the 75 patients with evaluable data, the estimated 2- these DFS outcomes by risk groups were similar to outcomes using the
year EFS and OS rates were 72.5% and 77%, respectively.258 Adverse MRC UKALL/ECOG definition for risk classification.261 Advanced age was
events included 1 death from sepsis (during induction), pancreatitis in 9 predictive of poorer survival outcomes on this study; the OS rate at 42
patients (12%; including 1 death), osteonecrosis in 2 patients (3%), months was 41% for patients older than 45 years compared with 66% for
thrombosis/embolism in 14 patients (19%), and neutropenic infection in 23 those aged 45 years or younger. Moreover, compared to the younger
patients (31%).258 After a median follow-up of 4.5 years, the 4-year DFS cohort, patients older than 45 years had a higher cumulative incidence of
rate for patients with Ph-negative ALL (n = 64) and those who achieved therapy-related deaths (23% vs. 5%) and deaths in first CR (22% vs.
CR was 71% (95% CI, 58%–81%), and the 4-year OS rate for all patients 5%).261 Thus, it seems that the benefit of this pediatric-inspired regimen
with Ph-negative ALL was 70% (95% CI, 58%–79%).259 A phase II outweighed the risks for therapy-related deaths only for those patients up
successor trial was initiated to determine whether pegylated-asparaginase to 45 years of age with Ph-negative ALL. The design of the GRAALL-2005
could be substituted for L-asparaginase in this regimen.260 A high study was similar to the GRAALL-2003 trial, with the addition of
frequency of asparaginase toxicities precipitated reverting to L- randomized evaluation of hyperfractionated cyclophosphamide during

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NCCN Guidelines Version 2.2020

Acute Lymphoblastic Leukemia

induction and late intensification, as well as randomized evaluation of patients (in regard to age and disease characteristics) treated by pediatric
rituximab in patients with CD20-positive Ph-negative ALL (n = 209; median oncologists in the COG trial (AALL-0232). The treatment protocol includes
age, approximately 40 years; range, 18–59 years).262 The estimated 2- a 4-drug induction regimen with intrathecal cytarabine and intrathecal
year EFS rate in the rituximab group was 65% (95% CI, 56%–75%) methotrexate, consolidation, interim maintenance, delayed intensification,
compared to the control group at 52% (95% CI, 43%–63%). After a maintenance (for 2–3 years), and radiotherapy (for patients with testicular
median follow-up of 30 months, EFS was longer in the rituximab group or CNS disease or those with T-ALL). Results from 295 evaluable patients
than in the control group (HR, 0.66; 95% CI, 0.45–0.98; P = .04).262 (median age, 24 years; range 17–39 years) report 2 post-remission deaths
and 3% overall treatment-related mortality.264 The median EFS is 78.1
USC ALL Regimen Based on CCG-1882 Regimen
months (95% CI, 41.8 months to NR) and the 3-year EFS rate is 59%
The USC ALL trial based on the pediatric CCG-1882 regimen has studied (95% CI, 54%–65%). The estimated 3-year OS rate is 73% (95% CI,
the regimen of daunorubicin, vincristine, prednisone, and methotrexate 68%–78%).264 It was also noted that Ph-like gene expression signatures
with augmented PEG in patients between the ages of 18 years and 57 and obesity were associated with worse treatment outcomes.264
years of age with newly diagnosed ALL (n = 51).263 The augmented arm
included one long-lasting PEG dose in each cycle of the 6 total scheduled COG AALL0434 Regimen
doses. Each dose of PEG (2000 IU/m2 IV) was preceded with Nelarabine is a nucleoside metabolic inhibitor and a prodrug of ara-G,
hydrocortisone for hypersensitivity prophylaxis followed by 1 to 2 weeks of approved for the treatment of patients with T-ALL with disease that has not
oral steroids. Patients on this trial received a mean of 3.8 doses per responded to or that has relapsed after at least 2 chemotherapy regimens.
patient with 45% of patients receiving all 6 doses, while 20% of patients The randomized phase III COG study (AALL0434) evaluated the safety of
discontinued treatment based on toxicity. The 7-year OS was 51% (58% of nelarabine as part of frontline therapy, using the augmented BFM
these patients were Ph-negative) and the 7-year DFS was 58%. The dose chemotherapy regimen, with or without nelarabine, and showed that the
of PEG was lower than the FDA-approved dose of 2500 IU/m2 and toxicity profiles were similar between patients with high-risk T-ALL who
adjustments to the dosing interval were made to be greater than or equal received nelarabine (n = 47) and those who did not (n = 47).265 No
to 4 weeks. This deviated from the pediatric protocol to account for the significant differences were observed in the occurrence of neurologic
difference in drug enzymatic activity in adults. Study data suggest that adverse events between these groups, including peripheral motor
adaptation of the pediatric regimen to the adult population may be feasible neuropathy, peripheral neuropathy, or CNS neurotoxicity. The incidence of
with modifications to reduce toxicity. adverse events such as febrile neutropenia and elevation of liver enzymes
was also similar between treatment groups. These initial safety data
CALGB 10403 Regimen
suggest that nelarabine may be better tolerated in frontline regimens than
A multicenter phase II Intergroup study (CALGB 10403) is currently in the R/R setting.265
ongoing to evaluate a pediatric-inspired regimen in the treatment of AYA
patients with Ph-negative ALL. One of the study objectives is to compare Results from the efficacy phase of this study evaluated data from 1,895
the outcomes of patients treated in this trial with those of a similar group of patients with newly diagnosed T-ALL and T-LL.266 Patients were

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NCCN Guidelines Version 2.2020

Acute Lymphoblastic Leukemia

randomized to receive escalating dose methotrexate without leucovorin 5-year OS rate was 38%, with a median follow-up of 63 months. Among
rescue and PEG or high-dose methotrexate with leucovorin rescue. the patients with Ph-negative ALL (n = 234), the 5-year OS rate was
Intermediate and high-risk patients with T-ALL and T-LL all received 42%.21 Among patients who experienced a CR (92% of all patients), the 5-
prophylactic or therapeutic cranial irradiation and were randomized into year CR duration rate was 38%.21 Death during induction therapy occurred
arms with or without nelarabine (650 mg/m2/day). The 4-year DFS rate for in 5% of patients, and was more frequent among patients aged 60 years
T-ALL patients in the nelarabine arm (n = 323) versus those who did not or older. Notably, this was not associated with an increase in 5-year OS
receive nelarabine (n = 336) was 88.9% ± 2.2% and 83.3% ± 2.5%, (17%).21 A subsequent retrospective review from the same institution
respectively (P = .0332).266 Compared to the high-dose methotrexate and suggested that this may be related to higher rates of death in remission
nelarabine arm, use of escalating-dose methotrexate and nelarabine (34%) relative to younger patients (7%).270
appeared to enhance the 4-year DFS rates.266 Another report from the
COG AALL0434 study determined that compared to high-dose Based on retrospective analyses of data from adults with B-ALL treated in
methotrexate, escalating-dose methotrexate combined with augmented clinical trials, CD20 positivity (generally defined as CD20 expression on
BFM chemotherapy improves DFS and OS outcomes in patients with T- >20% of blasts) was found to be associated with adverse outcomes
ALL.267 measured by a higher cumulative incidence of relapse, decreased CR
duration, or decreased survival.43,271 Given the prognostic significance of
A single-arm phase II study from the MDACC evaluated the efficacy of CD20 expression in these patients, treatment regimens incorporating the
hyper-CVAD plus nelarabine as frontline therapy in adult patients with T- CD20 monoclonal antibody rituximab have been evaluated. A phase II
ALL (n = 23).268 With a median follow-up of 30.4 months (range, 2.4–69.2 study from MDACC evaluated hyper-CVAD with or without rituximab in
months), the CR rate for patients with T-ALL was 89%; however, a trend previously untreated patients with Ph-negative B-lineage ALL (n = 282;
for inferior DFS and OS was observed for patients with ETP ALL.268 After a median age, 41 years; range, 13–83 years).155 Among the subgroup of
median follow-up of 42.5 months, the 3-year complete remission duration patients with CD20-positive ALL who were treated with hyper-CVAD
and OS rates were 66% (95% CI, 52%–77%) and 65% (95% CI, 51%– combined with rituximab, the 3-year CR duration and OS rates were 67%
76%), respectively.269 These studies suggest that for patients with T-ALL, and 61%, respectively. In addition, among the younger patients (age <60
the addition of nelarabine to frontline therapy may be a promising years) with CD20-positive disease, modified hyper-CVAD plus rituximab
approach. resulted in a significantly improved CR duration (70% vs. 38%; P < .001)
and OS rate (75% vs. 47%; P = .003) compared with the standard hyper-
Hyper-CVAD With or Without Rituximab
CVAD regimen without rituximab.155 No significant differences in outcomes
The hyper-CVAD regimen constitutes another commonly used ALL with the addition of rituximab were noted for the subgroup of patients with
treatment regimen for adult patients. A phase II study from MDACC CD20-negative disease. Notably, older patients (aged ≥60 years) with
evaluated hyper-CVAD in adolescents and adults with previously CD20-positive disease demonstrated higher rates of MRD negativity with
untreated ALL (n = 288; median age, 40 years; range, 15–92 years; Ph- the inclusion of rituximab; however, this did not translate into a survival
positive in 17%).21 The median OS for all patients was 32 months and the benefit, again largely due to increased mortality in CR. It is worth noting

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NCCN Guidelines Version 2.2020

Acute Lymphoblastic Leukemia

that this high rate of death in CR for older patients may relate to to induce CR (including rapid MRD-negative responses) in patients with
anthracycline intensification as opposed to rituximab.272 R/R B-precursor ALL.277-279 In March 2018, the FDA approved
blinatumomab use for the treatment of adult and pediatric patients with B-
Linker 4-Drug Regimen
cell precursor ALL in first or second CR with MRD defined as disease
Linker et al273 evaluated an intensified chemotherapy regimen that ≥0.1% (see Treatment of Relapsed Ph-Negative ALL for discussion of
incorporated a 4-drug induction regimen (comprising vincristine, studies related to blinatumomab use in R/R B-ALL).
daunorubicin, prednisone, and asparaginase) in adolescent and adult
patients with ALL (n = 84; Ph-positive in 16%; median age, 27 years; Initial Treatment in Adults with Ph-Negative ALL
range, 16–59 years). The 5-year EFS and OS rates for all patients were Hematopoietic Cell Transplant
48% and 47%, respectively. Among the patients who experienced a CR Studies evaluating HCT in first CR for AYA patients with Ph-negative ALL
(93% of all patients), the 5-year EFS rate was 52%. The 5-year EFS rate have generally been inclusive of adult patients and therefore have been
was 60% for the subgroup of patients without high-risk features (n = 53).273 discussed previously (see Initial Treatment in AYA Patients with Ph-
Negative ALL). More aggressive therapies are being considered for older
Blinatumomab
or less fit patients. A retrospective study of 576 adults, 45 years of age or
Blinatumomab first showed promising clinical efficacy as a means of
older, compared RIC or MAC allogeneic HCT from HLA-matched
eradicating persistent MRD following upfront chemotherapy. In a multi-
siblings.182 Patients who received RIC (n = 127) versus MAC (n = 449) did
center, single-arm, phase II study, Topp et al274 evaluated the efficacy of
not show any statistically significant difference in leukemia-free survival (P
blinatumomab in MRD-positive patients with Ph-negative B-ALL (n = 21;
= .23; HR, 0.84), thereby supporting the incorporation of more aggressive
age range, 20–77 years). Patients were considered MRD-positive if they
treatments for this population.182
had never achieved MRD negativity before blinatumomab, or had
experienced a hematologic CR with MRD ≥10-4. After blinatumomab CALGB 8811 Larson Regimen
treatment, 16 of 20 evaluable patients were determined to be MRD- Typically, induction regimens for adult ALL are also based on a backbone
negative at a detection threshold of 10-4.274 After a median follow-up of 33 of vincristine, corticosteroids, and anthracyclines. The CALGB 8811 trial
months, the hematologic RFS of the evaluable cohort was 61%.275 evaluated a 5-drug induction regimen (comprising vincristine,
Gökbuget et al276 examined the efficacy of blinatumomab in an expanded daunorubicin, prednisone, L-asparaginase, and cyclophosphamide) as
cohort (n = 116) using a higher threshold for MRD positivity (hematologic part of an intensive chemotherapy regimen for patients with previously
CR with MRD ≥10-3). After one 28-day cycle of blinatumomab, 88 of 113 untreated ALL (n = 197; Ph-positive in 29%; median age, 32 years; range,
evaluable patients achieved a complete MRD response, and the RFS rate 16–80 years).114 Patients aged ≥60 years received a dose-adjusted
at 18 months was 54%.276 In both of these trials, most patients achieving regimen with a prednisone pulse for only 7 days and a 33% reduction of
MRD negativity after blinatumomab proceeded to allogeneic HCT, daunorubicin and cyclophosphamide doses. The median OS for all
establishing blinatumomab as an effective “bridge to transplant” in MRD- patients was 36 months, after a median follow-up of 43 months. Among
positive patients. Subsequent studies of blinatumomab evaluated its ability patients who experienced a CR (85% of all patients), the median

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Acute Lymphoblastic Leukemia

remission duration was 29 months. The estimated 3-year OS rate was the previous section (see Initial Treatment in AYA Patients with Ph-
higher for the subgroup of patients younger than 30 years compared with Negative ALL). The role of standard-dose versus hyperfractionated
those aged 30 to 59 years or patients 60 years and older (69% vs. 39% cyclophosphamide during first induction and late intensification in adults
vs. 17%; P < .001). This was largely due to high induction-related mortality with newly diagnosed Ph-negative ALL was evaluated in a subsequent
(50%) in patients aged ≥60 years, contributing to a median OS of 1 month report from the GRAALL-2005 trial.281 After a median follow-up of 5.2
in this population.114 Among the subgroup of patients negative for the years, randomization to the hyperfractionated cyclophosphamide arm did
Philadelphia chromosome by both cytogenetics and molecular testing (n = not increase the CR rate or prolong EFS or OS rates, and tolerability to
29), median OS was 39 months and the 3 year OS rate was 62%.114 this regimen was poor in patients aged ≥55 years.281

The CALGB 9111 study evaluated the impact of adding granulocyte Linker 4-Drug Regimen
colony-stimulating factor (G-CSF) after intensive therapy (CALGB 8811 The referenced study evaluating the Linker 4-drug regimen included both
Larson regimen) on neutrophil recovery in adult patients with ALL (n = AYA and adult patients.273 For a summary of this study, refer to the
198; median age, 35 years; range, 16–83 years).280 Patients were previous section (see Initial Treatment in AYA Patients with Ph-Negative
randomized to receive either placebo or G-CSF beginning 4 days after ALL). In a phase II study, Wieduwilt et al investigated whether the Linker
induction, and the G-CSF group continued G-CSF treatment during 4-drug regimen could be safely intensified with the addition of pegylated
consolidation. Although the addition of G-CSF did not result in a significant asparaginase, cyclophosphamide, rituximab, dasatinib, and intrathecal
impact in OS or DFS, patients in the G-CSF group had significantly shorter liposomal cytarabine in adult patients with ALL or lymphoblastic lymphoma
durations of neutropenia and thrombocytopenia, a higher CR rate, and (n = 29; median age, 28 years; range, 20–54 years).282 The CR rate for
lower induction mortality (P = .04) compared to patients in the placebo ALL was 88%. For Ph-negative B-ALL (n = 16), the CR rate was 86%, and
group.280 Among the 41 patients aged ≥60 years randomized to G-CSF (n for Ph-positive B-ALL (n = 7), the CR rate was 88%.282 With a median
= 21) or placebo (n = 20), G-CSF use was associated with lower induction follow-up of 32 months, the 2- and 3-year EFS were 59%, and EFS was
mortality (10% vs. 25%); however, this failed to meet statistical similar for B-ALL, T-ALL, lymphoblastic lymphoma, Ph-negative B-ALL,
significance. The reduction observed with induction mortality was and Ph-positive B-ALL.282
accompanied by a similarly non-significant increase in CR rate for those
MRC UKALL XII/ECOG E2993
receiving G-CSF (81% vs. 55%; P = 0.1). For the entire elderly group,
median OS was improved to 12 months, but 3-year OS remained poor at In one of the largest multicenter prospective trials conducted to date (MRC
UKALL XII/ECOG E2993 study), previously untreated adolescent and
17%.280
adult patients (n = 1521; aged 15–59 years) received induction therapy
GRAALL-2005 Regimen consisting of vincristine, daunorubicin, prednisone, and L-asparaginase for
Studies evaluating the GRAALL-2003 regimen and GRAALL-2005 4 weeks (phase I) followed by cyclophosphamide, cytarabine, oral 6-MP,
regimen with the addition of rituximab for CD20-positive disease included and intrathecal methotrexate for 4 weeks (phase II).105 After completion of
both AYA and adult patients.261,262 For discussion of these studies, refer to induction therapy, patients who experienced a CR received intensification

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NCCN Guidelines Version 2.2020

Acute Lymphoblastic Leukemia

therapy with three cycles of high-dose methotrexate (with standard and 3). In this study, inotuzumab ozogamicin was given on day 3 of the
leucovorin rescue) and L-asparaginase. After intensification, those first 4 courses at 1.3–1.8 mg/m2 for cycle 1, followed by 1.0–1.3 mg/m2
younger than 50 years who had an HLA-compatible sibling underwent for subsequent cycles.284 In addition, maintenance therapy with dose-
allogeneic HCT; all others were randomized to receive autologous HCT or reduced POMP (6-MP, vincristine sulfate, methotrexate, and prednisone)
consolidation/maintenance treatment.105 For Ph-negative disease, high was given for 3 years. With a median follow-up of 29 months, the 2-year
risk was defined as having any of the following factors: aged 35 years or PFS was 59% (95% CI, 43–72%).284 Some of the most frequent grade 3
older; time to CR greater than 4 weeks; or elevated WBC count (>30 × and 4 adverse events were prolonged thrombocytopenia (81%),
109/L for B-cell lineage; >100 × 109/L for T-cell lineage). All other Ph- infections during induction and consolidation (52% and 69%,
negative patients were considered to have standard-risk disease. The 5- respectively), and hyperglycemia (54%).284 In this study, veno-occlusive
year OS rate for all patients with Ph-negative ALL was 41%; the OS rates disease occurred in 4 patients (8%).
for the subgroups with standard risk (n = 533) and high risk (n = 590) were
GRAALL-SA1 Regimen
54% and 29%, respectively.105 In the subgroup of patients with T-ALL (n =
356), the 5-year OS rate was 48%; the OS rate was improved to 61% for In an effort to decrease toxicity, the GRAALL-SA1 study compared the
those with a matched sibling donor, primarily because of a lower incidence efficacy and toxicity of pegylated liposomal doxorubicin (Peg-Dox) to
of cumulative relapse.283 Among the patients with T-ALL, those with continuous infusion doxorubicin (CI-Dox) in elderly patients (≥55 years)
complex cytogenetic abnormalities had a poor 5-year OS outcome (19%). with ALL.285 In this moderate-intensity regimen containing vincristine,
dexamethasone, and cyclophosphamide, patients were randomized to
Hyper-CVAD With or Without Rituximab receive either CI-Dox (n = 31; 12 mg/m2/day), or Peg-Dox (n = 29; 40
Studies evaluating hyper-CVAD with or without rituximab have included mg/m2).285 Compared to the CI-Dox arm, the Peg-Dox arm was
both AYA and adult patients.21,155 For discussion of these studies, refer to significantly associated with reduced toxicity and fewer infections, but
the previous section (see Initial Treatment in AYA Patients with Ph- there was no survival benefit: the induction mortality rate was 8% (CI-
Negative ALL). Dox arm, 7% vs. Peg-Dox arm, 10%), the frequency of refractory disease
after induction was 10% (CI-Dox arm, 17% vs. Peg-Dox arm, 3%; P =
Inotuzumab Ozogamicin With Mini-Hyper-CVD
.1), and the CR rate was 82% (CI-Dox arm, 90% vs. Peg-Dox arm, 72%;
In a phase II study, the efficacy and safety of inotuzumab ozogamicin P = .1).285 At 2 years, the estimated death in CR was 26.5% (CI-Dox arm,
combined with low-intensity chemotherapy (mini-hyper-CVD) was 37% vs. Peg-Dox arm, 19%), and the OS and EFS rates were
evaluated in older adults with newly diagnosed Ph-negative ALL and an statistically similar at 35% and 24% in the CI-Dox and Peg-Dox arms,
ECOG performance status less than or equal to 3 (n = 52; median age, respectively.285
68 years; interquartile range, 64–72 years).284 Compared to hyper-
CVAD, mini-hyper-CVD has no anthracycline and is composed of GMALL Regimen
reduced doses of dexamethasone (50% reduction), methotrexate (75% In a prospective trial, the GMALL group evaluated the efficacy of a
reduction), and cytarabine (given every 12 hours at 0.5 g/m2 on days 2 moderate-intensity regimen in older adult patients with Ph-negative ALL

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NCCN Guidelines Version 2.2020

Acute Lymphoblastic Leukemia

(n = 268; age range, 55–85 years).286 The induction therapy consisted of Ph-positive ALL and mature B-ALL groups, but the outcomes were
induction I (dexamethasone, vincristine, idarubicin) and induction II poorest in the Ph-negative ALL group.288
(cyclophosphamide, cytarabine), with rituximab added for patients with
Modified DFCI 91-01 Protocol
CD20-positive disease. The original treatment protocol (group 1) was
modified to evaluate CNS prophylaxis with liposomal cytarabine and A retrospective analysis examined the efficacy of a modified version of a
alternative consolidation with asparaginase (group 2); and after Dana Farber Cancer Institute (DFCI) pediatric protocol, DFCI 91-01,254,289
induction, one cycle with 500 U/m2 pegylated asparaginase was in adult patients with newly diagnosed ALL (n = 51; age range, 60–79
scheduled to evaluate feasibility (group 3). The reported overall CR rate years).290 Induction consisted of dexamethasone (in place of
was 76% (n = 203), and the CR rates in groups 1, 2, and 3 were 72%, prednisone), doxorubicin, cytarabine, and reduced doses of
86%, and 82%, respectively.286 The 5-year OS rate was 23%, and the 2- methotrexate, vincristine, and native asparaginase. For patients who
year OS rates observed in groups 1 and 2 were 33% and 52%, achieved CR, the median time to recurrence was 30 months (range, 1–
respectively.286 A major finding from this study included the importance of 94 months).290 In patients with Ph-negative disease (n = 35), the CR rate
the ECOG performance status before the onset of ALL (ECOGb) at was 71%, with induction mortality and primary refractory rates of 20%
predicting induction mortality. Patients with an ECOGb score greater and 9%, respectively.290 The DFS rate amongst those achieving CR was
than or equal to 2 correlated with higher induction mortality rates 57.4% (95% CI, 32.8–75.8%), while the overall estimated 5-year OS was
compared to those with an ECOGb score of 0 to 1 (53% vs. 7%, 40.5% (95% CI, 20–60.2%).290
respectively; P < .0001).286 In addition, the study showed that Low-Intensity Chemotherapy and Corticosteroids
consolidation with native Escherichia coli (E. coli) asparaginase and For older adult patients with ALL who may also have multiple
pegylated asparaginase was feasible and well tolerated, and was comorbidities, the utility of traditional chemotherapy backbones based on
associated with improvements in CR rates and 2-year OS in this older vincristine, corticosteroids, and an anthracycline is limited largely due to
patient subset.286 treatment-related toxicities.291 Attempts to identify optimal therapy in this
PETHEMA-Based Regimen population have included adaptations of palliative regimens including
The Spanish PETHEMA group conducted phase II prospective studies in vincristine and corticosteroids, and POMP.292-295 While these regimens are
older patients with Ph-negative ALL (ALLOLD07; n = 56; age range, 56– unlikely to generate cure, they can palliate the disease and extend
79 years).287,288 The ALLOLD07 protocol was based on a protocol from survival, with clinical outcomes similar to those achieved with more
EWALL, and treatment comprised a 4-week induction with intensive protocols. It is important to note that older adult patients with ALL
dexamethasone, vincristine, idarubicin, cyclophosphamide, and and multiple comorbidities have not typically qualified for clinical trials. To
cytarabine, followed by consolidation with intermediate-dose improve clinical outcomes, trials designed specifically for this population
methotrexate and native E. coli asparaginase. The CR rate was 74% are needed. These should include novel, personalized approaches based
with an early death rate of 13%. The median DFS was 8 months with a on immunophenotype and/or genetic mutation status.
median OS of 12 months. This trial included other adapted regimens for

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NCCN Guidelines Version 2.2020

Acute Lymphoblastic Leukemia

Blinatumomab years and WBC count <50 × 109/L).301 Early bone marrow relapse
The referenced studies evaluating the efficacy of blinatumomab at (duration of first CR <36 months) was associated with significantly shorter
eradicating MRD during or after multiagent chemotherapy included both estimated 3-year EFS (30% vs. 44.5%; P = .002) and OS (35% vs. 58%; P
AYA and adult patients.274-276 For a discussion of these studies, refer to the = .001) rates compared with late bone marrow relapse.301 Similarly, early
previous section (see Initial Treatment in AYA Patients with Ph-Negative isolated extramedullary relapse (duration of first CR <18 months) was
ALL). associated with significantly shorter estimated 3-year EFS (37% vs. 71%;
P = .01) and OS (55% vs. 81.5%; P = .039) rates compared with late
Treatment of Relapsed Ph-Negative ALL extramedullary relapse. In a multivariate regression analysis, early bone
Despite major advances in the treatment of childhood ALL, approximately marrow and extramedullary relapse were independent predictors of poorer
20% of pediatric patients experience relapse after initial CR to frontline EFS outcomes.301
treatment regimens.296-298 Among those who experience relapse, only
approximately 30% experience long-term remission with subsequent Data from patients with disease relapse after frontline therapy in the MRC
therapies.156,299,300 Based on a retrospective analysis of historical data from UKALL XII/ECOG E2993 study and PETHEMA studies showed that the
COG studies (for patients enrolled between 1998 and 2002; n = 9585), median OS after relapse was only 4.5 to 6 months; the 5-year OS rate was
early relapse (<18 months from diagnosis) was associated with very poor 7% to 10%.195,196 Approximately 20% to 30% of patients experience a
outcomes, with an estimated 5-year survival (from time of relapse) of second CR with second-line therapies.196,198 Factors predictive of more
21%.296 For cases of isolated bone marrow relapse, the 5-year survival favorable outcomes after subsequent therapies included younger age and
estimates among early (n = 412), intermediate (n = 324), and late (n = a first CR duration of more than 2 years.179,196 Among younger patients
387) relapsing disease were 11.5%, 18.0%, and 43.5%, respectively (P < (aged <30 years) whose disease relapsed after experiencing a first CR
.0001). Intermediate relapse was defined as relapse occurring between 18 duration longer than 2 years with frontline treatment in PETHEMA trials,
and 36 months from time of diagnosis; late cases were defined as relapse the 5-year OS rate from the time of first relapse was 38%.196
occurring 36 months or more from time of diagnosis. For cases of isolated
Hematopoietic Cell Transplant
CNS relapse, the 5-year survival estimates among early (n = 175),
HCT is the only potentially curative modality for R/R ALL. Based on
intermediate (n = 180), and late (n = 54) relapsing disease were 43.5%,
findings from evidence-based review of the published literature, the
68.0%, and 78.0%, respectively (P < .0001).296 Based on multivariate
American Society for Blood and Marrow Transplantation guidelines
analysis (adjusted for both timing and site of relapse), age (>10 years),
recommend HCT over chemotherapy alone for adult patients with ALL
presence of CNS disease at diagnosis, male gender, and T-cell lineage
experiencing a second CR.302 Several studies have shown that for AYA
disease were found to be significant independent predictors of decreased
patients in second CR, allogeneic HCT may improve outcomes,
survival after relapse.296 In a separate analysis of data from one of the
particularly for patients who have early bone marrow relapse or have other
above COG studies (CCG-1952), the timing and site of first relapse were
high-risk factors.299,300,303 Seemingly contradictory data were reported in
significantly predictive of EFS and OS outcomes, even among the patients
the COG CCG-1952 study that showed prognosis after early bone marrow
with standard-risk ALL (n = 347; based on NCI criteria: aged 1 to <10

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NCCN Guidelines Version 2.2020

Acute Lymphoblastic Leukemia

relapse in patients with standard-risk ALL (aged 1 to <10 years and WBC compared to the standard chemotherapy group, with median OS at 4.0
count <50 × 109/L) remained poor with no apparent advantage of HCT, months (95% CI, 0.55–0.93, P = .01).277 Remission rates within 12 weeks
regardless of timing (ie, early or late) of bone marrow relapse.301 However, after treatment initiation were significantly higher in the blinatumomab
data were not available on the conditioning regimen used for HCT in this group than in the standard chemotherapy group with respect to both CR
study for comparison with other trials. The UKALLXII/ECOG2993 trial (n = with full hematologic recovery (CR, 34% vs. 16%; P < .001) and CR with
609; age range, 15–60 years) examined the efficacy of transplantation full, partial, or incomplete hematologic recovery (CR, CRh, or CRi, 44% vs.
after relapse in a subgroup of patients with relapsed ALL who had not 25%; P < .001).277 Of note, prespecified subgroup analyses of patients
received prior transplant.195 Patients treated with HCT demonstrated a with high bone marrow count (≥50%) at relapse demonstrated lower
superior OS at 5 years compared to those treated with chemotherapy blinatumomab-mediated median survival and remission rates.277
alone.195 The CIBMTR group conducted an analysis of outcomes of
patients with ALL (n = 582; median age, 29 years; range, <1–60 years) There are significant and unique side effects to blinatumomab treatment
who underwent transplant during relapse.304 At 3 years, OS rates were compared to the current standard-of-care regimens. The most significant
16% (95% CI, 13%–20%).304 Response to salvage therapy prior to HCT toxicities noted in clinical studies are CNS events and cytokine release
may also predict outcome. One retrospective study has shown 3-year OS syndrome (CRS). Neurologic toxicities have been reported in 50% of
and EFS estimates of 69% and 62% (respectively) for patients in second patients (median onset, 7 days) and grade 3 or higher neurologic
or later MRD-negative remission at the time of HCT, similar to the toxicities, including encephalopathy, convulsions, and disorientation, have
outcomes of those who underwent HCT in MRD-negative first remission at occurred in 15% of patients.307 CRS typically occurs within the first 2 days
the same center.181 following initiation of blinatumomab infusion.307 Symptoms of CRS include
pyrexia, headache, nausea, asthenia, hypotension, increased
Blinatumomab transaminases, and increased total bilirubin. The incidence of adverse
A component of the growing arsenal of immunotherapies for cancer events can be reduced with monitoring for early intervention at onset of
treatment, blinatumomab is a bispecific anti-CD3/CD19 monoclonal symptoms. However, the serious nature of these events underscores the
antibody that showed high CR rates (69%; including rapid MRD-negative importance of receiving treatment in a specialized cancer center that has
responses) in patients with R/R B-precursor ALL (n = 25).279,305 experience with blinatumomab.
Blinatumomab was approved by the FDA based on data from a large
phase II confirmatory study of 189 patients with R/R Ph-negative B-ALL Inotuzumab Ozogamicin
that demonstrated a CR or CR with incomplete platelet recovery (CRp) in Clinical studies described earlier include patients with relapsed or
43% of patients within the first two cycles of treatment.278,306 In a follow-up refractory Ph-positive and Ph-negative ALL.236,237 For discussion of these
prospective, multicenter, randomized, phase III trial, patients with R/R B- studies, see Treatment of Relapsed Ph-Positive ALL.
cell precursor ALL (n = 405) were assigned to receive either
In a phase II study, the efficacy and safety of inotuzumab ozogamicin
blinatumomab (n = 271) or standard chemotherapy (n = 134).277 The OS
combined with low-intensity chemotherapy (mini-hyper-CVD) was
was longer in the blinatumomab group, with median OS at 7.7 months,
evaluated in adults with R/R B-ALL (n = 59; median age, 35 years; range,

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NCCN Guidelines Version 2.2020

Acute Lymphoblastic Leukemia

18–87 years).308 The response rate was 78%, with 35 of these patients to generate a response against a leukemic cell-surface antigen, most
achieving CR (59%).308 The overall MRD negativity rate among commonly CD19.239 Briefly, T cells from the patient are harvested and
responders was 82%. With a median follow-up of 24 months, the median engineered with a receptor that targets a cell surface tumor-specific
RFS and OS were 8 and 11 months, respectively. The 1-year RFS and OS antigen (eg, CD19 antigen on the surface of leukemic cells). The ability of
rates were 40% and 46%, respectively. When using this regimen, the risk CAR T cells to be reprogrammed to target any cell-surface antigen on
of veno-occlusive disease should be considered in patients with previous leukemic cells is advantageous and avoids the issue of tumor evasion of
liver damage and among transplant candidates. In this study, veno- the immune system via receptor down regulation.239 The manufacture of
occlusive disease occurred in 9 patients (15%).308 CAR T cells requires ex vivo viral transduction, activation, and expansion
over several days to produce a sufficient cell number to engender disease
In a subsequent report, to reduce the risk of veno-occlusive disease and response.312 Following infusion, debulking of tumors occurs in less than a
improve outcomes, the investigators amended the protocol by lowering the week and these cells may remain in the body for extended periods of time
weekly inotuzumab ozogamicin doses and including 4 cycles of to provide immunosurveillance against relapse.
blinatumomab in the consolidation phase.309 In a cohort of adult patients There are several clinical trials using CAR T cells that differ in the receptor
with Ph-negative B-ALL treated in first relapse (n = 48; median age, 39 construct for patients with relapsed or refractory ALL. The modified
years; range, 18–87 years), the rates of veno-occlusive disease prior to receptor, termed 19-28z—which links the CD19 binding receptor to the
the protocol amendment and after the protocol amendment were 13% (n = costimulatory protein CD28—demonstrated an overall CR in 14 out of 16
5 of 38) and 0% (n = 0 of 10), respectively.309 In addition, based on patients with relapsed or refractory B-ALL following infusion with CAR T
propensity score matching, the combination of inotuzumab ozogamicin cells.313 This average remission rate is significantly improved compared to
with mini-hyper-CVD with or without blinatumomab resulted in better the average remission rate for patients receiving standard-of-care
outcomes than inotuzumab alone or intensive salvage chemotherapy.309 chemotherapy following relapse (88% vs. approximately 30%).195,313-315
Furthermore, 7 out of 16 patients were able to receive an allogeneic HCT,
CAR T Cells
suggesting that CAR T cells may provide a bridge to transplant.313 No
One of the early treatments for patients with advanced ALL included
relapse has been seen in patients who had allogeneic HCT (follow-up, 2–
adoptive cell therapy to induce a graft-versus-leukemia effect through
24 months); however, 2 deaths occurred from transplant complications.
allogeneic HCT or DLI. However, this method resulted in a significant risk
Follow-up data of adult patients enrolled on this trial (n = 53) showed an
of GVHD. To circumvent this issue, current advances are focused on the
83% CR rate after the infusion and 32 patients achieved an MRD-negative
use of the patient’s own T cells to target the tumor. The generation of CAR
CR.316 At a median follow-up of 29 months (range, 1–65), the median OS
T cells to treat ALL is a significant advancement in the field.238,310,311 The
was 12.9 months (95% CI, 8.7–23.4 months) and subsequent allogeneic
pre-treatment of patients with CAR T cells has served as a bridge for
HCT did not appear to improve survival.316 KTE-C19 uses a similar anti-
transplant, and patients who were formerly unable to receive a transplant
CD19 CAR construct, and demonstrated an MRD-negative CR in 6 of 8
due to poor remission status have a CR and ultimately transplantation.
efficacy-evaluable adult patients with R/R ALL.317
CAR T-cell therapy relies on the genetic manipulation of a patients’ T-cells

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NCCN Guidelines Version 2.2020

Acute Lymphoblastic Leukemia

A second receptor construct defined by the attachment of an alternative monitoring has shown successful treatment of these symptoms with the
costimulatory protein, 4-1BB, to the CD19 binding protein has shown monoclonal antibody tocilizumab, an antagonist of interleukin-6.313
similar results to the 19-28z CAR T cells in terms of overall CR.318 These Nelarabine
cells, more simply referred to as CTL019, were infused into 16 children Nelarabine is a nucleoside analog that is currently approved for the
and 4 adults with R/R ALL; a CR following therapy was achieved in 14 treatment of patients with T-ALL who have unresponsive or relapsed
patients.318 There was no response of the disease to treatment in 3 disease after at least two chemotherapy regimens. A phase II study of
patients and disease response to therapy was still under evaluation for 3 nelarabine monotherapy in children and adolescents with R/R T-ALL or T-
patients.318 A follow-up study of 25 children and 5 adults showed a cell non-Hodgkin lymphoma (n = 121) showed a 55% response rate
morphologic CR of 90% (27 out of 30) of patients within a month of among the subgroup with T-ALL with first bone marrow relapse (n = 34)
treatment and an OS of 78% (95% CI, 65%–95%) and EFS of 78% (95% and a 27% response rate in the subgroup with a second or greater bone
CI, 51%–88%) at 6 months.319 There were 19 patients in sustained marrow relapse (n = 36).156 Major toxicities included grade 3 or higher
remission, of which 15 received no further therapy. Together these data neurologic (both peripheral and CNS) adverse events in 18% of patients.
inspired the development of larger multicenter trials of CAR T-cell Nelarabine as single-agent therapy was also evaluated in adults with R/R
therapy.320 Relevant in this context are data from the ELIANA trial of T-ALL or T-cell lymphoblastic leukemia in a phase II study (n = 39; median
CTL019/ tisagenlecleucel in 75 children and young adults with R/R B-ALL, age, 34 years; range, 16–66 years; median 2 prior regimens; T-ALL, n =
which demonstrated an overall remission rate of 81% within 3 months of 26).158 The CR rate (including CRi) was 31%; an additional 10% of
infusion, all of which were notably MRD negative.245 This high response patients experienced a partial remission. The median DFS and OS were
rate was associated with OS rates of 90% and 76% at 6 and 12 months, both 20 weeks and the 1-year OS rate was 28%. Grade 3 or 4
respectively. As with blinatumomab, T-cell activation was accompanied by myelosuppression was common, but only one case of grade 4 CNS
severe CRS and neurologic toxicity, as well as higher infectious risks— toxicity (reversible) was observed.158
though treatment-related mortality remains low.245 Given these data,
CTL019/tisagenlecleucel was recommended for accelerated approval by There are limited studies of nelarabine combination regimens in adults
the FDA oncologic drug advisory committee in July 2017 and fully with R/R T-ALL. In a study by Commander et al, pediatric patients with
approved by the FDA in August 2017 for the treatment of patients up to R/R T-ALL (n = 7; range, 1–19 years) were treated with nelarabine,
age 25 years (aged <26 years) with R/R precursor B-ALL. etoposide and cyclophosphamide.321 In addition, all patients received
intrathecal prophylaxis with methotrexate or triple intrathecal therapy with
There are fewer side effects to this treatment compared to the current methotrexate, cytarabine, and hydrocortisone. All patients experienced a
standard-of-care regimens; while side effects from CAR T cells may be CR after 1 or 2 courses of therapy. The most common adverse events
severe, they have been reversible. Adverse events are attributed to CRS attributed to nelarabine were grade 2 and 3 sensory and motor neuropathy
and macrophage activation that occur in direct response to adoptive cell and musculoskeletal pain.321 In phase I of the NECTAR trial, pediatric
transplant resulting in high fever, hypotension, breathing difficulties, patients with R/R T-ALL and T-LL (range, 1–21 years) were also treated
delirium, aphasia, and neurologic complications. Improvement in patient with nelarabine, etoposide and cyclophosphamide.322 Of nine evaluable T-

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NCCN Guidelines Version 2.2020

Acute Lymphoblastic Leukemia

ALL patients, there were two CRs, one partial CR, and one CR in the bone early induction death, 30%).315,326 The most common grade 3 or greater
marrow/PR in an extramedullary site for a response rate of 44%.322 treatment-related toxicities with VSLI included neuropathy (23%),
neutropenia (15%), and thrombocytopenia (6%).315 Based on phase II data
Augmented Hyper-CVAD
from the RALLY study, VSLI was given accelerated FDA approval in
A phase II study from the MDACC evaluated an augmented hyper-CVAD September 2012 for the treatment of adult patients with Ph-negative B-
regimen (that incorporated asparaginase, intensified vincristine, and ALL in second or greater relapse. Confirmation of benefit from phase III
intensified dexamethasone) as therapy in adults with R/R ALL (n = 90; studies is pending.
median age, 34 years; range, 14–70 years; median 1 prior regimen).323
Among evaluable patients (n = 88), the CR rate was 47%; an additional Clofarabine
13% experienced a CRp and 5% experienced a partial remission. The 30- Clofarabine is a nucleoside analog approved for the treatment of pediatric
day mortality rate was 9% and median remission duration was 5 months. patients (aged 1–21 years) with ALL that is relapsed or refractory after at
The median OS for all evaluable patients was 6.3 months; median OS was least two prior regimens. In a phase II study of single-agent clofarabine in
10.2 months for patients who experienced a CR. In this study, 32% of heavily pretreated pediatric patients with R/R ALL (n = 61; median age, 12
patients were able to proceed to HCT.323 years; range, 1–20 years), the response rate (CR + CRp) was 20%.327
Single-agent clofarabine in this setting was associated with severe liver
Vincristine Sulfate Liposomal Injection
toxicities (generally reversible) and frequent febrile episodes including
Vincristine sulfate liposome injection (VSLI) is a novel nanoparticle grade 3 or 4 infections and febrile neutropenia.327 Phase II studies
formulation of vincristine encapsulated in sphingomyelin and cholesterol evaluating the combination of clofarabine with cyclophosphamide and
liposomes; the liposome encapsulation prolongs the exposure of active etoposide in pediatric patients with R/R ALL have resulted in response
drug in the circulation and may allow for delivery of increased doses of rates ranging from 44% to 52%.328,329 This combination has been
vincristine without increasing toxicities.324,325 VSLI was evaluated in an associated with prolonged and severe myelosuppression, febrile episodes,
open-label, multicenter, phase II study in adult patients with Ph-negative severe infections (including sepsis or septic shock), mucositis, and liver
ALL (n = 65; median age, 31 years; range, 19–83 years) in second or toxicities including fatal veno-occlusive disease (the latter occurring in the
greater relapse, or with disease that progressed after 2 or more prior lines post-allogeneic HCT setting).328
of therapy (RALLY study).315 The CR (CR + CRi) rate with single-agent
VSLI was 20%. The median duration of CR was 23 weeks (range, 5–66 There are limited studies of clofarabine combination regimens in adults
weeks) and the median OS for all patients was 20 weeks (range, 2–94 with R/R disease. In a study by Miano et al,330 pediatric patients with R/R
weeks); median OS for patients achieving a CR was 7.7 months.315 The ALL (n = 24; median age, 7.6 years; range, 1–20 years) were treated with
incidence of early induction death (30-day mortality rate) was 12%.315 clofarabine, etoposide, and cyclophosphamide, and 42% (10 of 24) of
These outcomes appeared favorable compared with published single- patients responded to treatment, with a 24-month OS rate of 25%.330 In a
center historical data in patients with Ph-negative ALL treated with other study from GRAALL, adult patients with R/R ALL (n = 55) were treated
agents at second relapse (n = 56; CR rate, 4%; median OS, 7.5 weeks; with clofarabine in combination with conventional chemotherapy

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NCCN Guidelines Version 2.2020

Acute Lymphoblastic Leukemia

(cyclophosphamide [ENDEVOL cohort; median age, 53 years; range, 18– regimens for a given protocol in its entirety. Testing for TPMT gene
78 years], or a more intensive regimen with dexamethasone, polymorphism should be considered for patients receiving 6-MP as part of
mitoxantrone, etoposide, and PEG-asparaginase [VANDEVOL cohort; maintenance therapy, especially in those who experience severe bone
median age, 34 years; range, 19–67 years]). Patients in the ENDEVOL marrow toxicities.
cohort achieved a CR of 50% (9 of 18) and patients in the VANDEVOL
cohort yielded a CR rate of 41% (15 of 37); the median OS was 6.5 For patients experiencing a CR following initial induction therapy,
months after a median follow-up of 6 months.331 The most common grade monitoring for MRD should be initiated (see NCCN Recommendations for
3 or 4 toxicities included infection (58%) and liver toxicities (24%), with an MRD Assessment). If the resulting MRD status is negative, continuation of
early death rate of 11%.331 Because the use of clofarabine-containing the multiagent chemotherapy protocol for consolidation and maintenance
regimens require close monitoring and intensive supportive care would be appropriate. Consolidation with allogeneic HCT may also be
measures, patients should only be treated in centers with expertise in the considered, especially if the patient has high-risk features. If the MRD
management of ALL, preferably in the context of a clinical trial. status is positive, blinatumomab (for B-ALL) is recommended or allogeneic
HCT may be considered. Although long-term remission after
MOpAD Regimen blinatumomab treatment is possible, allogeneic HCT should be considered
Clinical studies described earlier include patients with relapsed or as consolidative therapy. If the MRD status is unknown, allogeneic HCT is
refractory Ph-positive and Ph-negative ALL.240-242 For discussion of these recommended, especially if the patient has high-risk features. A
studies, see Treatment of Relapsed Ph-Positive ALL. continuation of multiagent chemotherapy may also be considered, and
MRD assessments should be performed at the earliest subsequent
NCCN Recommendations for Ph-Negative ALL opportunity. In all cases, the optimal timing of HCT is unclear. For fit
AYA Patients with Ph-Negative ALL patients, additional therapy may be considered to eliminate MRD prior to
The panel recommends that AYA patients with Ph-negative ALL transplant. For AYA patients experiencing less than a CR after initial
(regardless of risk group) be treated in a clinical trial, where possible. In induction therapy (ie, presence of primary refractory disease), the
the absence of an appropriate clinical trial, the recommended induction treatment approach would be similar to that for patients with
therapy should comprise multiagent chemotherapy regimens based on relapsed/refractory ALL (see Patients with Relapsed/Refractory Ph-
pediatric-inspired protocols and data from multi-institutional studies, such Negative ALL).
as the COG AALL0232, PETHEMA ALL-96, GRAALL-2005 (with rituximab
for CD20-positive disease), COG AALL0434 (for T-ALL), DFCI-00-01, or Adult Patients with Ph-Negative ALL
the ongoing CALGB 10403 regimens. Multiagent chemotherapy protocols For adult patients with Ph-negative ALL, the panel recommends treatment
based on data from single-institution studies, including CCG-1882, the in a clinical trial, where possible. In the absence of an appropriate clinical
Linker regimen, and hyper-CVAD (with or without rituximab), are also trial, the recommended treatment approach would initially depend on the
recommended.155 Treatment regimens should include adequate CNS patient’s age and/or presence of comorbid conditions. Treatment regimens
prophylaxis for all patients. It is important to adhere to the treatment should include adequate CNS prophylaxis for all patients, and a given

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NCCN Guidelines Version 2.2020

Acute Lymphoblastic Leukemia

treatment protocol should be followed in its entirety, from induction therapy patients, additional therapy may be considered to eliminate MRD prior to
to consolidation/delayed intensification to maintenance therapy. Again, transplant.
testing for TPMT gene polymorphism should be considered for patients
receiving 6-MP as part of maintenance therapy, especially in those who For adult patients experiencing less than a CR after initial induction
develop severe bone marrow toxicities. therapy, the treatment approach would be similar to that for patients with
relapsed/refractory ALL (see Patients with Relapsed/Refractory Ph-
Although the age cutoff indicated in the guidelines has been set at 65 Negative ALL).
years, it should be noted that chronologic age alone is not a sufficient
surrogate for defining fitness; patients should be evaluated on an For patients who are less fit (aged ≥65 years or patients with substantial
individual basis to determine fitness for therapy based on factors such as comorbidities), the recommended induction therapy includes multiagent
performance status, end-organ function, and end-organ reserve. chemotherapy regimens or palliative corticosteroids. Dose modifications
may be required for chemotherapy agents, as needed. Patients with a CR
For relatively fit patients (aged <65 years without substantial to induction should be monitored for MRD to identify potential candidates
comorbidities), the recommended treatment approach is similar to that for for blinatumomab. If the resulting MRD status is positive, blinatumomab
AYA patients. Induction therapy should comprise multiagent (for B-ALL) is recommended. If the MRD status is negative or unknown,
chemotherapy such as those based on protocols from the CALGB 8811 continuation of consolidation with chemotherapy regimens and
study (Larson regimen), the Linker regimen, GRAALL-2005 (with rituximab maintenance therapy (typically weekly methotrexate, daily 6-MP, and
for CD20-positive disease), hyper-CVAD (with or without rituximab), or the monthly pulses of vincristine/prednisone for 2–3 years) is recommended.
MRC UKALL XII/ECOG E2993 regimen. For patients experiencing a CR For patients with less than a CR to induction, the treatment options are
after initial induction therapy, monitoring for MRD should be initiated (see similar to those outlined for patients with relapsed/refractory ALL (see
NCCN Recommendations for MRD Assessment). If the resulting MRD Patients with Relapsed/Refractory Ph-Negative ALL).
status is negative, continuation of the multiagent chemotherapy protocol
for consolidation and maintenance is recommended. Consolidation with For recommendations on the treatment of adult patients with mature B-
allogeneic HCT may also be considered, especially if the patient has high- ALL, refer to the NCCN Guidelines for B-Cell Lymphomas.
risk features. The effect of WBC counts on prognosis in adult patients with
Patients with Relapsed/Refractory Ph-Negative ALL
ALL is less firmly established than in pediatric populations. If the MRD
For patients with R/R Ph-negative ALL, the approach to second-line
status is positive, blinatumomab (for B-ALL) is recommended or allogeneic
treatment may depend on the duration of the initial response. For late
HCT may be considered. After blinatumomab treatment, consolidative
relapses (ie, relapses occurring ≥36 months from initial diagnosis), re-
therapy with allogeneic HCT should be considered. If the MRD status is
treatment with the same induction regimen is a reasonable option. For
unknown, allogeneic HCT is recommended, especially if the patient has
other patients, participation in a clinical trial is preferred, when possible. In
high-risk features. A continuation of multiagent chemotherapy may also be
the absence of an appropriate trial, for patients with R/R Ph-negative
considered. In all cases, the optimal timing of HCT is unclear. For fit
precursor B-ALL, recommended category 1 options include blinatumomab

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NCCN Guidelines Version 2.2020

Acute Lymphoblastic Leukemia

or InO. As previously mentioned, InO is associated with increased cytarabine) is also a common regimen used for lymphoblastic lymphoma.
hepatotoxicity, including fatal and life-threatening hepatic veno-occlusive A response rate of 100% was seen in a singular study, with 91% of
disease, and increased risk of post-HSCT non-relapse mortality.244 patients achieving a CR and a 3-year PFS of 66%.150 However, it should
be noted that 40% to 60% of adults relapse, suggesting that other
Tisagenlecleucel is also an option for patients up to age 25 years/less than treatments including HCT may be warranted.
26 years and with refractory disease or greater than or equal to 2
relapses. Other options that may be considered include subsequent Evaluation and Treatment of Extramedullary Disease
chemotherapy, with regimens containing clofarabine, nelarabine [for T- CNS Involvement in ALL
ALL], VSLI, augmented hyper-CVAD, MOpAD regimen, or other
Although the presence of CNS involvement at diagnosis is uncommon
fludarabine-, cytarabine-, or alkylator-containing regimens.332-335 If
(approximately 3%–7% of cases), a substantial proportion of patients
transplant-naïve patients experience a second CR prior to transplant,
(>50%) will eventually develop CNS leukemia in the absence of CNS-
consolidative allogeneic HCT should be strongly considered. For patients
directed therapy.1,50 CNS leukemia is defined by a WBC count of 5
with disease that relapses after an initial allogeneic HCT, other options
leukocytes/mcL or greater in the CSF with the presence of
may include a second allogeneic HCT and/or DLI. However, the role of
lymphoblasts.1,50 In children with ALL, CNS leukemia at diagnosis was
allogeneic HCT following treatment with tisagenlecleucel is unclear. While
associated with significantly decreased EFS rates.111,339,340 Factors
persistence of tisagenlecleucel in peripheral blood and persistent B-cell
associated with an increased risk for CNS relapse in children include T-
aplasia has been associated with durable clinical responses without
cell immunophenotype, high WBC counts at presentation, Ph-positive
subsequent allogeneic HCT, further study will be required before
disease, t(4;11) translocation, and presence of leukemic cells in the
conclusive recommendations can be made.245
CSF.117 In adults with ALL, CNS leukemia at diagnosis has been
Management of Lymphoblastic Lymphoma associated with a significantly higher risk for CNS relapse in large trials,
although no differences were observed in 5-year EFS or DFS rates
As previously discussed, patients with lymphoblastic lymphoma generally
compared with subgroups without CNS leukemia at presentation.341,342
benefit from treatment with ALL-like regimens and should be treated in a
CNS leukemia at diagnosis was associated with a significantly decreased
center that has experience with lymphoblastic lymphoma. Chemotherapy
5-year OS rate in one trial (29% vs. 38%; P = .03)341 but not in another trial
should be initiated as soon as possible; combination chemotherapy has
(35% vs. 31%).342 Factors associated with an increased risk for CNS
shown improved response though relapse is common.336 In patients with
leukemia in adults include mature B-cell immunophenotype, T-cell
lymphoblastic lymphoma, a 5-year DFS rate between 60% and 80% in
immunophenotype, high WBC counts at presentation, and elevated serum
children and between 55% and 95% in adults was seen following a
LDH levels.44,341 CNS-directed therapy may include cranial irradiation,
regimen of cyclophosphamide, doxorubicin, vincristine, and prednisone
intrathecal chemotherapy (eg, methotrexate, cytarabine, corticosteroids),
(CHOP) or other CHOP-like regimens.337,338 Hyper-CVAD (cycles of
and/or high-dose systemic chemotherapy (eg, methotrexate, cytarabine, 6-
fractionated cyclophosphamide, vincristine, doxorubicin, and
MP, L-asparaginase).1,50,117
dexamethasone alternating with cycles of high-dose methotrexate and

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NCCN Guidelines Version 2.2020

Acute Lymphoblastic Leukemia

Although cranial irradiation is an effective treatment modality for CNS therapy and effective CNS-directed intrathecal regimens, AYA patients
leukemia, it can be associated with serious adverse events, such as can obtain long-term EFS without the need for cranial irradiation or routine
neurocognitive dysfunctions, secondary malignancies, and other long-term allogeneic HCT.340,343
complications.1,117 With the increasing use of effective intrathecal
chemotherapy and high-dose systemic chemotherapy regimens, studies In adult patients with ALL who received intrathecal chemotherapy and
have examined the feasibility of eliminating cranial irradiation as part of intensive systemic chemotherapy for CNS prophylaxis, the overall CNS
CNS prophylaxis. In studies of children with ALL who only received relapse rate was 2% to 6%.21,119,344,345 Therefore, with the incorporation of
intrathecal and/or intensive systemic chemotherapy for CNS prophylaxis, adequate systemic chemotherapy (eg, high-dose methotrexate and
the 5-year cumulative incidence of isolated CNS relapse or any CNS cytarabine) and intrathecal chemotherapy regimens (eg, methotrexate
relapse was 3% to 4% and 4% to 5%, respectively.109,340 alone or with cytarabine and corticosteroid, which constitutes the triple
intrathecal regimen), the use of upfront cranial irradiation can be avoided
Data from the Total Therapy (XV) study by the St. Jude Children’s except in cases of overt CNS leukemia at presentation, and the use of
Research Hospital showed dramatic improvements in survival outcomes irradiation can be reserved for advanced disease. CNS prophylaxis is
for the AYA population. In this study, patients were primarily risk-stratified typically given throughout the course of ALL therapy starting from
based on treatment response; patients were treated according to risk- induction, to consolidation, to the maintenance phases of treatment.
adjusted intensive chemotherapy, with the incorporation of MRD
evaluation during induction (day 19) to determine the need for additional NCCN Recommendations for Evaluation and Treatment of
Extramedullary Involvement
doses of asparaginase.340,343 The 5-year EFS rate for the AYA population
(aged 15–18 years; n = 45) was 86% (95% CI, 72%–94%), which was not CNS involvement should be evaluated with lumbar puncture at timing in
significantly different from the 87% EFS rate (95% CI, 84%–90%; P = .61) accordance with the specific treatment protocol used for each patient.
observed for the younger patients (n = 448). The 5-year OS rates for the Pediatric-inspired treatment regimens typically include lumbar puncture at
AYA patients and younger patients were 88% and 94%, respectively (P = diagnostic workup. The panel recommends that lumbar puncture, if
not significant).340,343 The favorable EFS and OS outcomes in AYA patients performed, be conducted concomitantly with initial intrathecal therapy. All
in this study were attributed partly to the use of intensive dexamethasone, patients being treated for ALL should receive adequate CNS prophylaxis
vincristine, and asparaginase, in addition to early intrathecal therapy (ie, with intrathecal therapy and/or systemic therapy that incorporates
triple intrathecal chemotherapy with cytarabine, hydrocortisone, and methotrexate.
methotrexate) for CNS-directed therapy. In addition, the use of
The classification of CNS status includes the following: CNS-1 refers to no
prophylactic cranial irradiation was safely omitted in this study; the 5-year
lymphoblasts in the CSF regardless of WBC count; CNS-2 is defined as a
cumulative incidence of isolated CNS relapse and any CNS relapse was
WBC count less than 5 leukocytes/mcL in the CSF with the presence of
3% and 4%, respectively, for the entire study population (n = 498).340
blasts; and CNS-3 is defined as a WBC count of 5 leukocytes/mcL or
Moreover, all 11 patients with isolated CNS relapse were children younger
greater with the presence of blasts. If the patient has leukemic cells in the
than 12 years of age. This study showed that, with intensive risk-adjusted
peripheral blood and the lumbar puncture is traumatic (containing ≥5
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NCCN Guidelines Version 2.2020

Acute Lymphoblastic Leukemia

WBC/mcL in CSF with blasts), then the Steinherz-Bleyer algorithm can be infiltration, testicular mass, CNS involvement, other sites of disease). A
used to determine the CNS classification (if the WBC/RBC ratio in the CSF bone marrow assessment should show trilineage hematopoiesis and fewer
is at least 2-fold greater than the WBC/RBC ratio in the blood, then the than 5% blasts. For a CR, absolute neutrophil counts (ANCs) should be
classification would be CNS-3; if not, the classification would be CNS-2). greater than 1.0 × 109/L and platelet counts should be greater than 100 ×
109/L. In addition, no recurrence should be observed for at least 4 weeks.
In general, patients with CNS involvement at diagnosis (ie, CNS-3 and/or A patient is considered to have a CRi if criteria for CR are met except the
cranial nerve involvement) or with CNS disease that fails to clear after ANC remains less than 1.0 × 109/L or the platelet count remains less than
induction intrathecal chemotherapy should receive 18 Gy (in 1.8–2 100 × 109/L.
Gy/fraction) of cranial irradiation. The entire brain and posterior half of the
globe should be included. The inferior border should include C2. Notably, Refractory disease is defined as failure to achieve a CR at the end of
areas of the brain targeted by the radiation field in the management of induction therapy. PD is defined as an increase in the absolute number of
patients with ALL are different from those targeted for brain metastases of circulating blasts (in peripheral blood) or bone marrow blasts by at least
solid tumors. In addition, patients with CNS leukemia at diagnosis should 25%, or the development of extramedullary disease. Relapsed disease is
receive adequate systemic therapy as well as intrathecal therapy defined as the reappearance of blasts in the blood or bone marrow (>5%)
containing methotrexate throughout the treatment course. Adequate or in any extramedullary site after achievement of a CR.
systemic therapy should also be given in the management of patients with
Response in CNS Disease
isolated CNS relapse.
Remission of CNS disease is defined as achievement of CNS-1 status (no
A testicular examination should be performed for all male patients at lymphoblasts in CSF regardless of WBC count) in a patient with CNS-2 or
diagnostic workup; testicular involvement is especially common among CNS-3 at diagnosis. CNS relapse is defined as development of CNS-3
patients with T-ALL. Patients with clinical evidence of testicular disease at status or development of clinical signs of CNS leukemia (eg, facial nerve
diagnosis that is not fully resolved by the end of induction therapy should palsy, brain/eye involvement, hypothalamic syndrome) without an
be considered for radiation to both testes in the scrotal sac. Radiation alternative explanation.
therapy is typically performed concurrently with the first cycle of
Response in Lymphomatous Extramedullary Disease
maintenance chemotherapy. Testicular total dose should be 24 Gy (in 2.0
To assess treatment response, a CT of the neck/chest/abdomen/pelvis
Gy/fraction).
with IV contrast and PET/CT imaging should be performed. A CR in this
Response Assessment and Surveillance context is defined as complete resolution of lymphomatous enlargement
by CT scan. For patients with a previous positive PET scan, a post-
Response Criteria
treatment residual mass of any size is considered a CR if it is PET
Response in Bone Marrow and Peripheral Blood
negative. A partial response (PR) is defined as a greater than 50%
A CR requires the absence of circulating blasts and absence of
decrease in the sum product of the greatest perpendicular diameters
extramedullary disease (ie, no lymphadenopathy, splenomegaly, skin/gum
(SPD) of mediastinal enlargement. PD is defined as a greater than 25%

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NCCN Guidelines Version 2.2020

Acute Lymphoblastic Leukemia

increase in the SPD. No response indicates failure to meet the criteria for reproductive health, risks for secondary malignancies, and other important
a PR and absence of PD (as defined earlier). For patients with a previous health issues) that may arise during the lifetime of an AYA cancer survivor
positive PET scan, the post-treatment PET must be positive in at least one as a result of the therapeutic agents used during the course of antitumor
previously involved site. treatment.

Surveillance Role of MRD Evaluation

After completion of the ALL treatment regimen (including maintenance MRD in ALL refers to the presence of leukemic cells below the threshold
therapy), the panel recommends surveillance at regular intervals to assess of detection using conventional morphologic methods. Patients who
disease status. During the first year after completion of therapy, patients experienced a CR according to morphologic assessment alone can
should undergo a complete physical examination (including a testicular potentially harbor a large number of leukemic cells in the bone marrow: up
examination) and blood tests (CBC with differential). Liver function tests to 1010 malignant cells.38,347
should be performed until normal values are achieved. An assessment of
bone marrow aspirate should be performed as clinically indicated; if a The most frequently used methods for MRD quantification include
bone marrow aspirate is performed, flow cytometry with additional studies multiparameter flow cytometry (eg, 6-color or higher) to detect leukemia-
that may include comprehensive cytogenetics, FISH, molecular tests, and associated immunophenotypes, PCR assays to detect fusion genes (eg,
MRD assessments should be carried out. If relapse is suspected, a full BCR-ABL1), and next-generation sequencing (NGS)-based assays to
workup should be considered. For Ph-positive ALL, periodic quantification detect clonal rearrangements in immunoglobulin and/or T-cell receptor
of the BCR-ABL1 transcript should be determined. During the second year genes.348-355 Assays to detect alternative leukemia-specific fusion genes
after completion of therapy, a physical examination (including a testicular specifically using NGS (as opposed to PCR) are also in development, but
examination) and blood tests (CBC with differential) should be performed are not recommended for MRD quantification outside the context of a
every 3 to 6 months. During the third year (and beyond) after completion clinical trial. The NCCN Panel acknowledges FDA approval of an NGS-
of therapy, physical examination (including a testicular examination) and based MRD test based on quantification of immunoreceptor genes in
blood tests (CBC with differential) can be performed every 6 to 12 months patients with ALL, but panel members agreed that both multiparameter
or as clinically indicated. Recommendations for survivorship are available flow cytometry or this FDA-approved NGS approach are suitable methods
in the NCCN Guidelines for Adolescent and Young Adult (AYA) Oncology for MRD quantification.
and NCCN Guidelines for Survivorship.
Current multi-parameter flow cytometry methods can detect leukemic cells
The COG has published guidelines on long-term survivorship issues for at a sensitivity threshold of fewer than 10-4 (<0.01%) bone marrow
survivors of childhood cancers.346 These guidelines serve as a resource mononuclear cells (MNCs), and PCR/NGS methods can detect leukemic
for clinicians and family members/caretakers, and have the goal of cells at a sensitivity threshold of fewer than 10-6 (<0.0001%) bone marrow
providing screening and management recommendations for late effects MNCs.349,351,354,355 The concordance rate for quantifying MRD between
(those that may impact growth, cognitive function, emotional concerns, these methods is generally high at disease burdens 10-4 (>0.01%), but

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NGS is able to detect MRD at lower thresholds.350,352,355-359 In a study that patients with detectable MRD (flow cytometry sensitivity level <1 × 10-4) at
analyzed MRD using both flow cytometry and PCR techniques in 1375 the end of induction therapy had a significantly higher 3-year cumulative
samples from 227 patients with ALL, the concordance rate for MRD incidence of relapse than those who were MRD negative (33% vs. 7.5%; P
assessment (based on a detection threshold of <1 × 10-4 for both < .001).364 Subsequent studies have confirmed these findings. In a study
methods) was 97%.357 In another study, both flow cytometry and high- of 165 patients, the 5-year relapse rate was significantly higher among
throughput sequencing techniques were used to analyze MRD at a patients with MRD (flow cytometry sensitivity <1 x 10-4) versus those
threshold of 0.01% in samples from 619 patients with pediatric B-ALL.355 without detectable disease (43% vs. 10%; P < .001).362 Persistence of
At the 0.01% threshold, the concordance between both methods was high, MRD during the course of therapy was associated with risk of relapse; the
but high-throughput sequencing was able to detect MRD at lower cumulative rate of relapse was significantly higher among patients with
thresholds.355 The combined or tandem use of both methods would allow MRD persisting through week 14 of continued treatment compared with
for MRD monitoring in all patients, thereby avoiding potential false- patients who became MRD-negative by 14 weeks (68% vs. 7%; P =
negative results.351,357,360 However, this practice could lead to an increase .035).362 MRD evaluation was shown to be a significant independent
in cost without a clear directive in terms of modification of treatment. predictor of outcome.
Numerous studies in both childhood and adult ALL have shown the
prognostic importance of postinduction (and/or post-consolidation) MRD MRD assessments at an earlier time point in the course of treatment (eg,
measurements in predicting the likelihood of disease relapse. New during induction therapy) have been shown to be highly predictive of
multiplexed PCR and NGS for MRD are emerging methodologies. outcomes in children with ALL. In one study, nearly 50% of patients had
MRD clearance (MRD <1 × 10-4 by flow cytometry) before day 19 of
MRD Assessment in Childhood ALL induction therapy (about 2–3 weeks from initiation of induction); the 5-year
Among children with ALL who achieve a CR according to morphologic cumulative incidence of relapse was significantly higher among patients
evaluation after induction therapy, approximately 25% to 50% may still with MRD at day 19 of treatment than those without detectable MRD (33%
have detectable MRD based on sensitive assays (in which the threshold of vs. 6%; P < .001).361 The prognostic significance of MRD detection at
MRD negativity is <1 × 10-4 bone marrow MNCs).361,362 An early study in lower levels (sensitivity threshold, ≤1 × 10-5, or ≤0.001%, according to
children with ALL (n = 178) showed that patients with detectable MRD PCR measurements) was evaluated in children with B-cell lineage ALL
after initial induction therapy (42% of patients) had significantly shorter treated with contemporary regimens.354 At the end of induction therapy,
time to relapse than patients with MRD-negative status (P < .001), defined 58% of patients had undetectable disease based on PCR values. Among
by a PCR sensitivity level of less than 1.5 × 10-4.363 Patients with MRD the remaining patients with detectable MRD, 17% had MRD of 0.01% or
after induction had a 10-fold increase in risk of death compared with those greater, 14% had less than 0.01% (but ≥0.001%), and 11% had less than
without detectable MRD. Moreover, the level of detectable MRD was 0.001%. The 5-year cumulative incidence of relapse was significantly
found to correlate with relapse; patients with MRD of 1 × 10-2 or greater higher among patients with MRD of 0.01% or greater versus patients with
had a 16-fold higher risk of relapse compared with those who had MRD less than 0.01% or undetectable disease (23% vs. 6%; P < .001).354
levels less than 1 × 10-3.363 In another study in children with ALL (n = 158), Furthermore, the 5-year cumulative incidence of relapse was higher

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among the subgroup of patients with MRD less than 0.01% (but ≥0.001%) scale study, MRD remained a significant and powerful independent
versus those with MRD less than 0.001% or undetectable disease (13% prognostic factor for relapse in the overall population.365
vs. 5%; P < .05). MRD status at the end of induction therapy strongly
correlated with MRD levels (flow cytometry sensitivity level <0.01%) at day A randomized controlled trial in children and young adults with low-risk
19 during induction; all patients who had MRD of 0.01% or greater at the ALL according to MRD compared treatment reduction to standard
end of induction had MRD of 0.01% or greater at day 19. Although this induction (n = 521).366 Patients were randomized to receive either one or
study showed that a higher risk of relapse was seen among patients with two delayed intensification courses consisting of PEG on day 4;
MRD below the generally accepted threshold level (<0.01% but ≥0.001%) vincristine, dexamethasone (alternate weeks), and doxorubicin for 3
compared with those with very low MRD (<0.001%) or no detectable weeks; and 4 weeks of cyclophosphamide and cytarabine. The 5-year
disease, further studies are warranted to determine whether this MRD EFS between the two cohorts was not statistically significant (94.4% vs.
threshold at day 19 should be used to risk stratify patients or guide 95.5%; OR, 1; 95% CI, 0.43–2.31; two-sided P = .99). No statistical
decisions surrounding treatment intensification.354 difference was seen regarding relapse or serious adverse events;
however, there was a singular treatment-related death in the second
In one of the largest collaborative studies conducted in Europe (the delayed intensification cohort and 74 episodes of grade 3 or 4 toxic
AIEOP-BFM ALL 2000 study), children with Ph-negative B-cell lineage events. The results suggest that treatment reduction is reasonable for
ALL (n = 3184 evaluable) were risk stratified according to MRD status children and young adults with ALL who have a low risk of relapse based
(PCR sensitivity level ≤0.01%) at two time points (days 33 and 78), which on MRD at the end of induction.
were used to guide postinduction treatment.365 Patients were considered
standard risk if MRD negativity (≤0.01%) was achieved at both days 33 A randomized study investigated whether improved outcome could be
and 78, intermediate risk if MRD was greater than 0.01% (but <0.1%) on seen with augmented post-remission therapy for children and young adults
either day 33 or 78 (the other time point being MRD-negative) or on both stratified by MRD.367 In this trial, 533 patients with a high risk of MRD
days 33 and 78, and high risk if MRD was 0.1% or greater on day 78. (defined as clinical standard-risk and intermediate-risk patients with MRD
Nearly all patients with favorable cytogenetic/molecular markers such as of 0.01% or higher at day 29 of induction) were randomized to receive
the ETV6-RUNX1 subtype or hyperdiploidy were either standard risk or standard therapy or augmented post-remission therapy. The augmented
intermediate risk based on MRD evaluation.365 The 5-year EFS rate was treatment regimen included 8 doses of PEG, 18 doses of vincristine, and
92% for patients categorized as standard risk (n = 1348), 78% for escalated dosing of intravenous methotrexate without folinic acid rescue
intermediate risk (n = 1647), and 50% for high risk (n = 189), resulting in a during the interim maintenance courses. The 5-year EFS was higher in
statistically significant difference among the groups (P < .001); the 5-year patients receiving the augmented regimen versus the standard treatment
OS rates were 98%, 93%, and 60%, respectively. MRD-based risk group (89.6% vs. 82.8%; OR, 0.61; 95% CI, 0.39–0.98; P = .04). However,
stratification significantly differentiated risks for relapse (between it should be noted that more adverse events were seen with the
standard- and intermediate-risk subgroups) even among patient augmented regimen, and no statistically significant benefit was seen in OS
populations with ETV6-RUNX1 or hyperdiploidy. Importantly, in this large- at 5 years (92.9% vs. 88.9%; OR, 0.67; 95% CI, 0.38–1.17; P = .16).

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Stratification based on MRD may also indicate which patients should 28% among those with MRD less than 0.01% (P = .008).371 In addition, in
undergo allogeneic HCT versus continued chemotherapy. Children with an the subgroup of patients who experienced first relapse after cessation of
intermediate risk of relapse based on MRD were stratified based on a treatment, the 2-year cumulative incidence of second relapse was 49% in
cutoff MRD level of 10-3.368 Patients with greater than or equal to MRD of patients with MRD of 0.01% or greater versus 0% for those with MRD less
10-3 were allocated to receive HCT (n = 99). In this group, 83% had donors than 0.01% (P = .014). Both the presence of MRD at day 36 of reinduction
and underwent HCT versus 17% who had no suitable donor and therefore therapy and at first relapse occurring during therapy were significant
continued chemotherapy. The EFS was higher for patients receiving HCT independent predictors of second relapse based on multivariate
(64% ± 5%) versus patients remaining on chemotherapy (24% ± 10%). analysis.371 In another study, MRD (PCR sensitivity level <0.01%) was
Patients who had a low level of MRD (less than 10-3) were directed to evaluated in high-risk children with ALL (n = 60) who experienced first
receive continued chemotherapy (n = 109). Within this cohort, 83 patients relapse within 30 months from the time of diagnosis.372 Categories based
received either chemotherapy or radiotherapy alone and 22 patients on MRD evaluation after the first chemotherapy cycle (3–5 weeks after
received an allogenic HCT. There was no significant difference in EFS initiation of reinduction treatment) included MRD negative (undetectable
between these two groups (66% ± 6% vs. 80% ± 9%; P = .45). Results MRD), MRD positive but unquantifiable (levels <0.01%), and MRD of
indicate that MRD can be useful to further risk stratify patients with 0.01% or greater. The 3-year EFS rates based on these MRD categories
intermediate risk of relapse to the appropriate treatment regimen. were 73%, 45%, and 19%, respectively (P < .05).372 Thus, MRD
However, the study acknowledges that MRD cutoff values are regimen assessment can identify patients with a high probability of second relapse,
dependent as indicated by the divergence from the earlier ALL R3 trial. which may offer an opportunity for risk-adapted second-line treatment
While the earlier trial advocated for the use of MRD to stratify patients for strategies.
HCT, a higher threshold for MRD level was used (10-4), a difference that
may reflect the more intensive induction regimen.369 Therefore, MRD Several studies suggest early assessment of MRD during induction
levels may influence treatment decisions, but the application of this treatment (eg, day 15 from initiation of treatment) may be highly predictive
prognostic factor must be carefully evaluated on a regimen-by-regimen of subsequent relapse in children with ALL.373,374 This raises the possibility
basis. of identifying patients with high-risk disease who may potentially benefit
from earlier intensification or tailoring of treatment regimens, or for
Approximately 20% of children treated with intensive therapies for ALL will potentially allowing less-intensive treatments to be administered in
ultimately experience disease relapse.370 MRD assessment may play a patients at low risk for relapse based on early MRD measurements. Large
prognostic role in the management of patients in the relapsed setting.371,372 trials are warranted to address these possibilities, although serial MRD
In patients (n = 35) who experienced a second remission (morphologic measurements may likely be needed to monitor leukemic cell kinetics
CR) after reinduction treatment, MRD (measured by flow cytometry with during the long course of treatment.
sensitivity level <0.01%) after reinduction (day 36) was significantly
associated with risks for relapse; the 2-year cumulative incidence of
relapse was 70% among patients with MRD of 0.01% or greater versus

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MRD Assessment in Adult ALL the following criteria for standard risk were enrolled in this study: absence
Studies in adults with ALL have shown the strong correlation between of t(4;11) MLL translocation or t(9;22) BCR-ABL translocation; WBC count
MRD and risk for relapse, and the prognostic significance of MRD less than 30 × 109/L for B-cell lineage ALL or less than 100 × 109/L for T-
measurements during and after initial induction therapy.347,375-378 In an cell lineage ALL; age 15 to 65 years; and achievement of morphologic CR
analysis of postinduction MRD (flow cytometry sensitivity level <0.05%) in after phase I of induction treatment. At the end of initial induction therapy
adult patients with ALL (n = 87), median RFS was significantly longer (day 24), patients with MRD of 0.01% or greater had a 2.4-fold higher risk
among patients with MRD less than 0.05% at day 35 compared with those (95% CI, 1.3–4.2) of relapse than those with MRD of less than 0.01%.375
with MRD of 0.05% or greater (42 vs. 16 months; P = .001).378 A similar Moreover, this study identified distinct risk groups according to MRD
pattern emerged when only the subgroup of patients with morphologic CR status at various time points. Patients categorized as low risk (10% of
at day 35 was included in the MRD evaluation. Although patient numbers study patients) had MRD of less than 0.01% on days 11 and 24 (during
were limited, 90% of patients with MRD less than 0.03% at an earlier time and after initial induction), and had 3-year DFS and OS rates of 100% (for
point (day 14 during induction therapy) remained relapse-free at 5 both endpoints). Patients in the high-risk group (23%) had MRD of 0.01%
years.378 MRD after induction therapy was a significant predictor of relapse or greater persisting through week 16, and 3-year DFS and OS rates of
in a subgroup analysis from the MRC UKALL/ECOG study of patients with 6% and 45%, respectively. All other patients (67%) categorized as
Ph-negative B-cell lineage ALL (n = 161).377 The 5-year RFS rate was intermediate risk had 3-year DFS and OS rates of 53% and 70%,
significantly higher in patients with MRD negativity versus those with MRD respectively.375 Importantly, MRD was the only independently significant
of 0.01% or greater (71% vs. 15%; P = .0002).377 predictor of outcome in a multivariate Cox regression analysis that
included gender, age, WBC count, B- or T-cell lineage, and MRD. In a
Postinduction MRD can serve as an independent predictor of relapse even prospective study from the MDACC, adult patients with B-ALL (n = 340;
among adult patients considered to be standard risk based on traditional median age, 52 years; range, 15–84 years) were monitored for MRD by
prognostic factors. In a study of adult patients with Ph-negative ALL (n = multi-parameter flow cytometry (sensitivity level = 0.01%) at CR and at
116), MRD status after induction therapy (flow cytometry sensitivity level approximately 3-month intervals after CR.379 MRD negative status at CR
<0.1%) was significantly predictive of relapse regardless of whether the significantly correlated with improved DFS and OS, and was an
patient was standard risk or high risk at initial evaluation.376 Among independent predictor of DFS (P < .05).379
patients who were initially classified as standard risk, those with MRD of
less than 0.1% after induction had a significantly lower risk of relapse at 3 A prospective study (Japan ALL MRD2002) evaluated outcomes by MRD
years compared with patients who had higher levels of MRD (9% vs. 71%; status in adult patients with Ph-negative ALL.380 Among the patients who
P = .001). Interestingly, MRD measured during post-consolidation within achieved a CR after induction/consolidation (n = 39), those who were
this protocol was not significantly predictive of outcomes.376 In the GMALL MRD negative (<0.1%) after induction had a significantly higher 3-year
06/99 study, patients with standard-risk disease (n = 148 evaluable) were DFS (69% vs. 31%; P = .004) compared with patients who were MRD
monitored for MRD (PCR sensitivity level <0.01%) at various time points positive; 3-year OS was higher among patients with MRD-negative status
during the first year of treatment.375 Only patients with ALL who met all of after induction, although the difference was not statistically significant

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(85% vs. 59%). Based on multivariate Cox regression analysis, older age subsequent hematologic relapse and introduced the concept of molecular
(>35 years) and MRD positivity after induction were significant relapse in ALL.
independent factors predictive of decreased DFS. WBC counts and MRD
status after consolidation were not significant predictors of DFS GMALL investigators evaluated the potential advantage of intensifying or
outcomes.380 modifying treatment regimens (eg, incorporation of allogeneic HCT) based
on post-consolidation MRD status. In one of the largest studies to assess
MRD assessment after consolidation therapy has been shown to have the prognostic impact of MRD on treatment outcomes in adult patients with
prognostic significance, offering the possibility to adjust post-consolidation Ph-negative ALL (n = 580 with CR and evaluable MRD results; patients
treatment approaches. In a study that evaluated MRD (PCR sensitivity from GMALL 06/99 and 07/03 studies; age 15–55 years), molecular CR
level <0.01%) after consolidation therapy (weeks 16–22 from initiation of (defined as MRD <0.01%) after consolidation was associated with
induction) in adult patients with ALL (n = 142), patients with MRD of less significantly higher probabilities of 5-year continuous CR (74% vs. 35%; P
than 0.01% (n = 58) were primarily allotted to receive maintenance < .0001) and OS (80% vs. 42%; P = .0001) compared with molecular
chemotherapy for 2 years, whereas those with MRD of 0.01% or greater (n failure (MRD ≥0.01%).383 Based on multivariate analysis, molecular
= 54) were eligible to undergo allogeneic HCT after high-dose therapy.381 response status was a significant independent predictor of both 5-year
The 5-year DFS rate was significantly higher among patients with MRD continuous CR and OS outcomes. Among the patients with disease that
negativity versus those with MRD of 0.01% or greater (72% vs. 14%; P = did not result in a molecular CR, the subgroup who underwent allogeneic
.001). Similarly, the 5-year OS rate was significantly higher for patients HCT in clinical CR (n = 57) showed a significantly higher 5-year
with MRD-negative status post-consolidation (75% vs. 33%; P = .001).381 continuous CR (66% vs. 12%; P < .0001) and a trend for higher OS (54%
In a follow-up to the GMALL 06/99 study mentioned earlier, patients with vs. 33%; P = .06) compared with the subgroup without HCT (n = 63).383 In
standard-risk ALL (as defined by Bruggemann et al375) who experienced this latter subgroup of patients with disease that did not result in a
MRD negativity (PCR sensitivity <0.01% leukemic cells) during the first molecular CR and who did not undergo HCT, the median time from MRD
year of treatment underwent sequential MRD monitoring during detection to clinical relapse was approximately 8 months.383 This analysis
maintenance therapy and follow-up.382 Among the patients included in this showed that MRD status following consolidation was an independent risk
analysis (n = 105), 28 (27%) became MRD-positive after the first year of factor for poorer outcomes in adults with ALL, and may identify high-risk
therapy; MRD was detected before hematologic relapse in 17 of these patients who could potentially benefit from allogeneic HCT.
patients.382 The median RFS was 18 months (calculated from the end of
initial treatment) among the subgroup that became MRD positive, whereas Studies in children and adult patients with ALL suggest that differences
the median RFS has not yet been reached among patients who remained may exist in the kinetics of leukemic cell eradication between these patient
MRD-negative. The median time from MRD positivity (at any level, populations. Among children treated on contemporary regimens, 60% to
including non-quantifiable cases) to clinical relapse was 9.5 months; the 75% experienced clearance of MRD at the end of induction therapy
median time from quantitative MRD detection to clinical relapse was only 4 (typically 5–6 weeks after initiation of induction).354,361-364,384 In one study,
months.382 Detection of post-consolidation MRD was highly predictive of nearly 50% of children had MRD clearance (<0.01% by flow cytometry) at

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Acute Lymphoblastic Leukemia

day 19 of induction therapy.361 Adult patients seem to have a slower rate MRD evaluation should be guided by the treatment protocol or regimen
of leukemic cell clearance compared with children, with 30% to 50% of used.385,386 Importantly, both immunophenotype (B- vs. T-lineage) and
adult patients having MRD negativity after initial induction.375,378 genotype may impact the prognostic significance of various levels of MRD
Approximately 50% of cases remained MRD positive at 2 months after at different time points, reflecting the influence of these variables on the
initiation of induction, with further reductions in the proportion of MRD- kinetics of response to therapy.383,387-389 This further highlights the
positive cases occurring beyond 3 to 5 months.347,375 Possible importance of referring to the protocol or regimen being used when
determinants for differences in the kinetics of leukemic cell reduction in the interpreting MRD results.
bone marrow may be attributed to the therapeutic regimens, variations in
the distribution of immunophenotypic or cytogenetic/molecular features, An increase in the frequency of serial monitoring of MRD may be useful in
and other host factors. patients with molecular relapse and low-level disease.390 In general, MRD
positivity at the end of induction predicts high relapse rates and should
NCCN Recommendations for MRD Assessment prompt an evaluation for allogeneic HCT. When possible, therapy aimed at
Collectively, studies show the high prognostic value of MRD in assessing eliminating MRD prior to allogeneic HCT is preferred.
risk for relapse in patients with ALL, and the role of MRD monitoring in
Supportive Care for Patients with ALL
identifying subgroups of patients who may benefit from further intensified
therapies or alternative treatment strategies. The optimal sample for MRD Given the highly complex and intensive treatment protocols used in the
assessment is the first pull or early pull of the bone marrow aspirate. If the management of ALL, supportive care issues are important considerations
patient is not treated at an academic medical center, there are to ensure that patients derive the most benefit from ALL therapy. Although
commercially available tests that should be used for MRD assessment. differences may exist between institutional standards and practices,
Six-color flow cytometry can detect leukemic cells at a sensitivity threshold supportive care measures for patients with ALL generally include the use
of fewer than 1 × 10-4 (<0.01%) bone marrow MNCs, and PCR or NGS of antiemetics for prevention of nausea and vomiting, blood product
methods can detect leukemic cells at a sensitivity threshold of fewer than transfusions or cytokine support for severe cytopenias, nutritional support
1 × 10-6 (<0.0001%) bone marrow MNCs.349,351,385,386 The concordance for prevention of weight loss, gastroenterology support, pain management,
rate for detecting MRD between these methods is generally high. For flow prevention and management of infectious complications, and prophylaxis
cytometric analysis of MRD, if immunotherapy has been used (eg, for TLS. In addition, both short- and long-term consequences of potential
rituximab, blinatumomab, inotuzumab ozogamicin, or tisagenlecleucel), toxicities associated with specific agents used in ALL regimens should be
the lab performing the MRD assessment should be notified. considered, such as with steroids (eg, risks for hyperglycemia or peptic
ulcerations in the acute setting; risks for avascular necrosis with long-term
The timing of MRD assessment varies depending on the ALL treatment use) and asparaginase (risks for hypersensitivity reactions, hyperglycemia,
protocol used, and may occur during or after completion of initial induction coagulopathy, hepatotoxicity, and/or pancreatitis). Supportive care
therapy. Therefore, it is recommended that the initial measurement be measures should be tailored to meet the individual needs of each patient
performed on completion of induction therapy; additional time points for based on factors such as age, performance status, extent of cytopenias

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before and during therapy, risks for infectious complications, disease For recommendations for the prevention and management of infections in
status, and the specific agents used in the ALL treatment regimen. patients with cancer, see the NCCN Guidelines for the Prevention and
Treatment of Cancer-Related Infections.
NCCN Recommendations for Supportive Care
Most chemotherapy regimens used in ALL contain agents that are at least High doses of methotrexate can result in toxic plasma methotrexate
moderately emetogenic, which may necessitate antiemetic support before concentrations in patients with significant renal dysfunction, large
initiating emetogenic chemotherapy. Antiemesis prophylaxis may include effusions/ascites, and delayed methotrexate clearance (plasma
the use of agents such as serotonin receptor antagonists, corticosteroids, methotrexate concentrations >2 standard deviations of the mean
and/or neurokinin-1–receptor antagonists. Recommendations for methotrexate excretion curve specific for the dose of methotrexate
antiemetic support for patients receiving chemotherapy are available in the administered). Toxic plasma methotrexate concentrations in patients may
NCCN Guidelines for Antiemesis. For patients with ALL, the routine use of also be observed due to other interacting medications. While this is more
corticosteroids as part of antiemetic therapy should be avoided given that commonly seen in osteosarcoma and soft tissue tumors due to the higher
steroids constitute a major component of ALL regimens. For patients dose of methotrexate in treatment, the FDA has approved the use of
experiencing greater than 10% weight loss, enteral or parenteral nutritional glucarpidase as a rescue product in patients with ALL. Leucovorin should
support should be considered. Regimens to maintain bowel movement also be given as part of the treatment of methotrexate toxicity (see
and prevent the occurrence of constipation may need to be considered if Supportive Care in the algorithm). Drug interactions with trimethoprim-
receiving vincristine. For patients requiring transfusion support for severe sulfamethoxazole (TMP/SMX) and methotrexate can worsen methotrexate
or prolonged cytopenias, only irradiated blood products should be used. toxicity,391 so the panel recommends holding TMP/SMX when high-dose
Growth factor support is recommended during blocks of myelosuppressive methotrexate is administered, and re-starting when methotrexate
therapy or as directed by the treatment protocol being followed for clearance is achieved per treatment protocol or institutional guidelines.
individual patients (see NCCN Guidelines for Hematopoietic Growth
Patients with ALL may be at high risk for developing acute TLS,
Factors).
particularly those with highly elevated WBC counts before induction
Patients with ALL undergoing intensive chemotherapy or allogeneic HCT chemotherapy. TLS is characterized by metabolic abnormalities stemming
are highly susceptible to infections. Immunosuppression caused by the from the sudden release of intracellular contents into the peripheral blood
underlying disease and therapeutic regimens can predispose patients to because of cellular disintegration induced by chemotherapy. If left
common bacterial and viral infections, and to various opportunistic untreated, TLS can result in profound metabolic changes leading to
infections (eg, candidiasis, invasive mold infections, Pneumocystis cardiac arrhythmias, seizures, loss of muscle control, acute renal failure,
jirovecii, CMV reactivation and infection), particularly during periods of and even death. Recommendations for the management of TLS are
prolonged neutropenia. Patients with ALL should be closely monitored for available in the Tumor Lysis Syndrome section of the NCCN Guidelines
any signs or symptoms of infections. Cases of febrile neutropenia should for B-Cell Lymphomas. Standard prophylaxis for TLS includes hydration
be managed promptly with empiric anti-infectives and inpatient admission. with diuresis, alkalinization of the urine, and treatment with allopurinol or

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NCCN Guidelines Version 2.2020

Acute Lymphoblastic Leukemia

rasburicase. Rasburicase should be considered as initial treatment in osteonecrosis/avascular necrosis.396,397 Osteonecrosis most often affects
patients with rapidly increasing blast counts, high uric acid, or evidence of weight-bearing joints, such as the hip and/or knee, and seems to have a
impaired renal function. Although relatively uncommon in patients with higher incidence among adolescents (presumably because of the period of
ALL, symptomatic hyperleukocytosis (leukostasis) constitutes a medical skeletal growth) than younger children or adults.396,398-402 In children and
emergency and requires immediate treatment, as recommended in the adolescents (aged 1–21 years) with ALL evaluated in large studies of the
NCCN Guidelines for Acute Myeloid Leukemia. Leukostasis is CCG, the cumulative incidence of symptomatic osteonecrosis increased
characterized by highly elevated WBC count (usually >100 × 109/L) and with age, from approximately 1% in patients younger than 10 years, to
symptoms of decreased tissue perfusion that often affect respiratory and 10% to 13.5% in patients between the ages of 10 and 15 years, to 18% to
CNS function. Although leukapheresis is not typically recommended in the 20% in patients aged 16 years and older.398,399 In the Total XV study in
routine management of patients with high WBC counts, it can be children with ALL, symptomatic osteonecrosis occurred in 18% of patients,
considered with caution in cases of leukostasis that is unresponsive to with most cases occurring within 1 year of treatment initiation.396 Older
other interventions. children (aged >10 years) had a significantly higher cumulative incidence
of osteonecrosis (45% vs. 10%; P < .001) compared with younger children
Key components of the ALL treatment regimen, such as corticosteroids, (aged ≤10 years). In this study, factors such as older age, lower serum
immunotherapies, and asparaginase, are associated with unique toxicities albumin levels, higher serum lipid levels, and higher exposure to
that require close monitoring and management. Corticosteroids, such as dexamethasone were associated with risks for osteonecrosis. Moreover,
prednisone and dexamethasone, constitute a core component of nearly higher plasma exposure to dexamethasone (as measured by area under
every ALL induction regimen, and are frequently incorporated into the concentration curve at Week 8 of therapy) and lower serum albumin
consolidation and/or maintenance regimens. Acute side effects of steroids were significant factors associated with the development of severe (grade
may include hyperglycemia and steroid-induced diabetes mellitus. Patients 3 or 4) osteonecrosis, even after adjusting for age and treatment arm.396
should be monitored for glucose control to minimize the risk of developing
infectious complications. Another acute side effect of steroid therapy In a DFCI ALL Consortium study in children and adolescents that included
includes peptic ulceration and dyspeptic symptoms; the use of histamine-2 randomization to postinduction therapy with dexamethasone versus
receptor antagonists or proton pump inhibitors should be considered prednisone, dexamethasone was associated with a significantly increased
during steroid therapy to reduce these risks. There may also be important 5-year EFS but, in older children, the increased cumulative incidence of
drug interactions between PPIs and methotrexate that need to be osteonecrosis was comparable with prednisone.402 An earlier CCG study
considered prior to initiation of methotrexate-based therapy. Although (CCG-1882) had reported a higher incidence of symptomatic
uncommon, the use of high-dose corticosteroids can be associated with osteonecrosis among children randomized to receive an augmented ALL
mood alterations, psychosis, and other neuropsychiatric complications in regimen with 2 courses of dexamethasone compared with those who
patients with malignancies;392-395 in this context, consider anti-psychotics. If received 1 course (23% vs. 16%; P = not significant).399 These studies
no response, dose reductions may be required in these situations. A appeared to suggest that dexamethasone, particularly in higher doses,
potential long-term side effect associated with steroid therapy includes may be associated with increased risks for osteonecrosis in older children

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NCCN Guidelines Version 2.2020

Acute Lymphoblastic Leukemia

and adolescents. To further investigate these findings, the CCG-1961 trial with severe symptoms according to manufacturer guidelines and
randomized patients (n = 2056; aged 1–21 years) to postinduction prescribing information. During the first month after tisagenlecleucel
intensification treatment with intermittent dose scheduling of infusion, prophylaxis with anti-seizure medication may be considered.408,409
dexamethasone (10 mg/m2 daily on days 0–6 and days 14–20) versus For additional information regarding guidelines for immunotherapy-related
continuous doses of dexamethasone (10 mg/m2 daily on days 0–20).398 toxicities, see NCCN Guidelines for Management of Immunotherapy-
Among older children and adolescents (aged ≥10 years) who had rapid Related Toxicities.
response to induction, use of intermittent dexamethasone during the
intensification phase was associated with significantly decreased Asparaginase is also a core component of ALL regimens, most often given
incidence of osteonecrosis compared with the standard continuous dose during induction and consolidation for Ph-negative disease and should
of dexamethasone (9% vs. 17%; P = .0005). The difference was only be used in specialized centers. In this context, patients should also be
particularly pronounced among adolescent patients 16 years and older closely monitored in the period during and after infusion for allergic
(11% vs. 37.5%, respectively; P = .0003). This randomized trial suggested response. Four different formulations of the enzyme have been approved
that the use of intermittent (alternative week) dexamethasone during by the FDA: 1) native E. coli-derived asparaginase (E coli asparaginase);
intensification phases may reduce the risks of osteonecrosis in 2) asparaginase derived from E. coli that has been modified with a
adolescents.398 To monitor patients for risks of developing symptomatic covalent linkage to PEG; 3) asparaginase derived from a different Gram-
osteonecrosis, routine measurements for vitamin D and calcium levels negative bacteria Erwinia chrysanthemi (Erwinia asparaginase); and 4)
should be obtained, and periodic radiographic evaluation (using plain films calaspargase pegol. These formulations differ in their pharmacologic
or MRI) should be considered. In severe avascular necrosis cases, properties, and may also differ in terms of immunogenicity.410-413 In some
consider withholding steroids from therapy. regimens, asparaginase is significantly associated with potentially severe
hypersensitivity reactions (including anaphylaxis) due to anti-asparaginase
When patients are treated with inotuzumab ozogamicin, liver enzymes— antibodies and lack of efficacy in some cases. PEG seems to be
especially bilirubin—should be closely monitored because veno-occlusive associated with a lower incidence of neutralizing antibodies compared with
disease or sinusoidal obstruction syndrome may occur.403 Ursodiol may be native asparaginase.414 However, cross-reactivity between neutralizing
considered for veno-occlusive disease prophylaxis.404,405 Defibrotide may antibodies against native E. coli asparaginase and pegaspargase has
be considered for patients who develop veno-occlusive disease related to been reported.415,416 Moreover, a high anti-asparaginase antibody level
inotuzumab ozogamicin toxicity.406 If inotuzumab ozogamicin is being after initial therapy with native E. coli asparaginase was associated with
given as a bridge to allogeneic HCT, double alkylator conditioning is decreased asparaginase activity during subsequent therapy with
strongly discouraged.404,405 Patients treated with blinatumomab and pegaspargase.417 In contrast, no cross-reactivity between antibodies
tisagenlecleucel should be monitored for CRS and neurologic toxicity. For against native E. coli asparaginase and Erwinia asparaginase was
CRS (including refractory CRS), tocilizumab should be considered.407 reported,415,416 and enzyme activity of Erwinia asparaginase was not
Upon development of CRS, the panel recommends holding blinatumomab affected by the presence of anti–E coli asparaginase antibodies.417 A study
infusions with consideration for steroids and/or vasopressors for patients from the DFCI ALL Consortium showed the feasibility and activity of using

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NCCN Guidelines Version 2.2020

Acute Lymphoblastic Leukemia

Erwinia asparaginase in pediatric and adolescent patients who developed If the patient experiences grade 1 or grade 2 reactions including rash,
hypersensitivity reactions to E. coli asparaginase during frontline therapy. flushing, urticaria, and drug fever ≥38°C without bronchospasm,
Importantly, treatment with Erwinia asparaginase did not negatively impact hypotension, edema, or need for parenteral intervention, the asparaginase
EFS outcomes in these patients.418 that caused the reaction may be continued with consideration for anti-
allergy premedication (such as hydrocortisone, diphenhydramine, and
Similar to PEG, calaspargase pegol is a newer asparaginase enzyme acetaminophen). If anti-allergy medication is used prior to PEG or Erwinia
formulation with a different linker molecule that enhances its hydrolytic asparaginase administration, consideration should be given to therapeutic
stability.410 A multicenter, open-label, randomized study determined the drug monitoring using commercially available asparaginase activity
pharmacokinetic and pharmacodynamic profiles of PEG and calaspargase assays, since premedication may mask the systemic allergic reactions that
pegol to be similar in patients with high-risk ALL (n = 165; age range, 1– can indicate the development of neutralizing antibodies.420 However, if the
30.99 years), with the latter exhibiting a longer half-life.410 The DFCI ALL patient experiences anaphylaxis or other allergic reactions of grade 3 or 4
Consortium also evaluated whether calaspargase pegol could be severity (CTCAE 4.03), permanent discontinuation of the causative
administered less frequently than PEG with similar toxicity profiles and asparaginase is warranted.
serum asparaginase activity (SAA).419 In this study, patients with newly
diagnosed ALL (n = 230; age range, 1–21 years) were randomized to Asparaginase can be associated with various toxicities, including
receive an intravenous dose (2500 IU/m2) of either PEG or calaspargase pancreatitis (ranging from asymptomatic cases with amylase or lipase
pegol. The SAA was similar for both enzymes at 4, 11, and 18 days after elevation, to symptomatic cases with vomiting or severe abdominal pain),
the induction dose, but the SAA was higher for calaspargase pegol 25 hepatotoxicity (eg, increased alanine or glutamine aminotransferase), and
days after induction, suggesting the potential for this enzyme to be given coagulopathy (eg, thrombosis, hemorrhage). Detailed recommendations
less frequently than PEG.419 However, longer follow-up is needed to for the management of asparaginase toxicity in AYA and adult patients
determine the survival outcomes associated with this finding. The FDA were published,413 and have been incorporated into the NCCN Guidelines
approved calaspargase pegol in December 2018, for use as part of for ALL (see Supportive Care: Asparaginase Toxicity Management in the
multiagent chemotherapy in pediatric and AYA patients (aged ≤21 years) algorithm).
with ALL.
Pain management should be employed for patients with cancer,
Native E. coli asparaginase is no longer available; therefore, the NCCN regardless of disease stage. For discussion of the central principles of
Panel recommends the use of PEG in the treatment of patients with ALL. pain assessment and management, see the NCCN Guidelines for Adult
For patients who develop severe hypersensitivity reactions during Cancer Pain.
treatment with PEG, Erwinia asparaginase should be substituted (see
Supportive Care: Asparaginase Toxicity Management in the algorithm).
Erwinia asparaginase is currently approved by the FDA for patients with
ALL who have developed hypersensitivity to E. coli–derived asparaginase.

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Acute Lymphoblastic Leukemia

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Acute Lymphoblastic Leukemia

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NCCN Guidelines Version 2.2020

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Acute Lymphoblastic Leukemia

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https://www.ncbi.nlm.nih.gov/pubmed/16775234.

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NCCN Guidelines Version 2.2020

Acute Lymphoblastic Leukemia

150. Thomas DA, O'Brien S, Cortes J, et al. Outcome with the hyper- 157. Cohen MH, Johnson JR, Justice R, Pazdur R. FDA drug approval
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160. Schultz KR, Bowman WP, Aledo A, et al. Improved early event-free
153. Di Gion P, Kanefendt F, Lindauer A, et al. Clinical pharmacokinetics survival with imatinib in Philadelphia chromosome-positive acute
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154. Thomas DA, Faderl S, O'Brien S, et al. Chemoimmunotherapy with 161. Schultz KR, Carroll A, Heerema NA, et al. Long-term follow-up of
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https://www.ncbi.nlm.nih.gov/pubmed/15908649.

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NCCN Guidelines Version 2.2020

Acute Lymphoblastic Leukemia

label, intergroup study. Lancet Oncol 2012;13:936-945. Available at: 170. Bassan R, Rossi G, Pogliani EM, et al. Chemotherapy-phased
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leukaemia (EsPhALL2010): a prospective, intergroup, open-label, single-
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165. Hunger SP, Saha V, Devidas M, et al. CA180-372: An international leukemia. Final results of the CSTIBES02 trial. Haematologica
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http://www.bloodjournal.org/content/130/Suppl_1/98. 172. Mizuta S, Matsuo K, Yagasaki F, et al. Pre-transplant imatinib-based
therapy improves the outcome of allogeneic hematopoietic stem cell
166. Ravandi F, O'Brien S, Thomas D, et al. First report of phase 2 study transplantation for BCR-ABL-positive acute lymphoblastic leukemia.
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and promising outcome by combination of imatinib and chemotherapy for
167. Jabbour E, Short NJ, Ravandi F, et al. Combination of hyper-CVAD newly diagnosed BCR-ABL-positive acute lymphoblastic leukemia: a
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174. Kim DY, Joo YD, Lim SN, et al. Nilotinib combined with multiagent
168. de Labarthe A, Rousselot P, Huguet-Rigal F, et al. Imatinib combined chemotherapy for newly diagnosed Philadelphia-positive acute
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169. Tanguy-Schmidt A, Rousselot P, Chalandon Y, et al. Long-term adults with newly diagnosed Ph/BCR-ABL1-positive acute lymphoblastic
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155. Available at: https://www.ncbi.nlm.nih.gov/pubmed/22960387. 176. Thomas DA, Faderl S, Cortes J, et al. Treatment of Philadelphia
chromosome-positive acute lymphocytic leukemia with hyper-CVAD and

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NCCN Guidelines Version 2.2020

Acute Lymphoblastic Leukemia

imatinib mesylate. Blood 2004;103:4396-4407. Available at: Transplantation. Blood 2010;116:4439-4443. Available at:
https://www.ncbi.nlm.nih.gov/pubmed/14551133. https://www.ncbi.nlm.nih.gov/pubmed/20716774.

177. Cornelissen JJ, Carston M, Kollman C, et al. Unrelated marrow 183. Larson RA. Management of acute lymphoblastic leukemia in older
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https://www.ncbi.nlm.nih.gov/pubmed/11238093. 184. Ottmann OG, Wassmann B, Pfeifer H, et al. Imatinib compared with
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178. Esperou H, Boiron JM, Cayuela JM, et al. A potential graft-versus- chromosome-positive acute lymphoblastic leukemia (Ph+ALL). Cancer
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179. Fielding AK, Rowe JM, Richards SM, et al. Prospective outcome data results of the GRAALL AFR09 study. Leukemia 2006;20:1526-1532.
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acute lymphoblastic leukemia confirms superiority of allogeneic
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188. Chalandon Y, Thomas X, Hayette S, et al. First results of the
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retrospective study from the European Group for Blood and Marrow

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NCCN Guidelines Version 2.2020

Acute Lymphoblastic Leukemia

189. Chalandon Y, Thomas X, Hayette S, et al. Is less chemotherapy 196. Oriol A, Vives S, Hernandez-Rivas JM, et al. Outcome after relapse
detrimental in adults with Philadelphia chromosome (Ph)-positive acute of acute lymphoblastic leukemia in adult patients included in four
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197. Tavernier E, Boiron JM, Huguet F, et al. Outcome of treatment after
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198. Thomas DA, Kantarjian H, Smith TL, et al. Primary refractory and
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199. Ishida Y, Terasako K, Oshima K, et al. Dasatinib followed by second
192. Carpenter PA, Snyder DS, Flowers ME, et al. Prophylactic allogeneic hematopoietic stem cell transplantation for relapse of
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2793. Available at: https://www.ncbi.nlm.nih.gov/pubmed/17119111. https://www.ncbi.nlm.nih.gov/pubmed/20824399.

193. Chen H, Liu KY, Xu LP, et al. Administration of imatinib after 200. Millot F, Cividin M, Brizard F, et al. Successful second allogeneic
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194. Pfeifer H, Wassmann B, Bethge W, et al. Randomized comparison of 201. Collins RH, Jr., Goldstein S, Giralt S, et al. Donor leukocyte infusions
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https://www.ncbi.nlm.nih.gov/pubmed/17032921. 203. Keil F, Kalhs P, Haas OA, et al. Relapse of Philadelphia chromosome
positive acute lymphoblastic leukaemia after marrow transplantation:

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NCCN Guidelines Version 2.2020

Acute Lymphoblastic Leukemia

sustained molecular remission after early and dose-escalating infusion of Philadelphia chromosome positive acute lymphoblastic leukemia treated
donor leucocytes. Br J Haematol 1997;97:161-164. Available at: with imatinib (STI-571). Leuk Lymphoma 2004;45:695-698. Available at:
https://www.ncbi.nlm.nih.gov/pubmed/9136959. https://www.ncbi.nlm.nih.gov/pubmed/15160941.

204. Matsue K, Tabayashi T, Yamada K, Takeuchi M. Eradication of 210. Pfeifer H, Wassmann B, Hofmann WK, et al. Risk and prognosis of
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211. Takayama N, Sato N, O'Brien SG, et al. Imatinib mesylate has limited
205. Yazaki M, Andoh M, Ito T, et al. Successful prevention of activity against the central nervous system involvement of Philadelphia
hematological relapse for a patient with Philadelphia chromosome-positive chromosome-positive acute lymphoblastic leukaemia due to poor
acute lymphoblastic leukemia after allogeneic bone marrow penetration into cerebrospinal fluid. Br J Haematol 2002;119:106-108.
transplantation by donor leukocyte infusion. Bone Marrow Transplant Available at: https://www.ncbi.nlm.nih.gov/pubmed/12358909.
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https://www.ncbi.nlm.nih.gov/pubmed/9051252. 212. Branford S, Rudzki Z, Walsh S, et al. High frequency of point
mutations clustered within the adenosine triphosphate-binding region of
206. Tiribelli M, Sperotto A, Candoni A, et al. Nilotinib and donor BCR/ABL in patients with chronic myeloid leukemia or Ph-positive acute
lymphocyte infusion in the treatment of Philadelphia-positive acute lymphoblastic leukemia who develop imatinib (STI571) resistance. Blood
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transplantation and resistant to imatinib. Leuk Res 2009;33:174-177. https://www.ncbi.nlm.nih.gov/pubmed/11964322.
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213. Hu Y, Liu Y, Pelletier S, et al. Requirement of Src kinases Lyn, Hck
207. Yoshimitsu M, Fujiwara H, Ozaki A, et al. Case of a patient with and Fgr for BCR-ABL1-induced B-lymphoblastic leukemia but not chronic
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209. Leis JF, Stepan DE, Curtin PT, et al. Central nervous system failure https://www.ncbi.nlm.nih.gov/pubmed/11861307.
in patients with chronic myelogenous leukemia lymphoid blast crisis and

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NCCN Guidelines Version 2.2020

Acute Lymphoblastic Leukemia

216. Jones D, Thomas D, Yin CC, et al. Kinase domain point mutations in 2010;85:164-170. Available at:
Philadelphia chromosome-positive acute lymphoblastic leukemia emerge https://www.ncbi.nlm.nih.gov/pubmed/20131302.
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217. Hofmann WK, Komor M, Wassmann B, et al. Presence of the BCR- positive acute lymphoblastic leukemia. Leukemia 2013;27:1411-1413.
ABL mutation Glu255Lys prior to STI571 (imatinib) treatment in patients Available at: https://www.ncbi.nlm.nih.gov/pubmed/23138184.
with Ph+ acute lymphoblastic leukemia. Blood 2003;102:659-661.
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CVAD and dasatinib in patients with relapsed Philadelphia chromosome
218. Pfeifer H, Wassmann B, Pavlova A, et al. Kinase domain mutations of positive acute lymphoblastic leukemia or blast phase chronic myeloid
BCR-ABL frequently precede imatinib-based therapy and give rise to leukemia. Am J Hematol 2014;89:282-287. Available at:
relapse in patients with de novo Philadelphia-positive acute lymphoblastic https://www.ncbi.nlm.nih.gov/pubmed/24779033.
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https://www.ncbi.nlm.nih.gov/pubmed/17405907. 226. Cortes JE, Kantarjian HM, Brummendorf TH, et al. Safety and
efficacy of bosutinib (SKI-606) in chronic phase Philadelphia chromosome-
219. Redaelli S, Piazza R, Rostagno R, et al. Activity of bosutinib, positive chronic myeloid leukemia patients with resistance or intolerance to
dasatinib, and nilotinib against 18 imatinib-resistant BCR/ABL mutants. J imatinib. Blood 2011;118:4567-4576. Available at:
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227. Khoury HJ, Cortes JE, Kantarjian HM, et al. Bosutinib is active in
220. Shah NP, Tran C, Lee FY, et al. Overriding imatinib resistance with a chronic phase chronic myeloid leukemia after imatinib and dasatinib
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NCCN Guidelines Version 2.2020

Acute Lymphoblastic Leukemia

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Acute Lymphoblastic Leukemia

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NCCN Guidelines Version 2.2020

Acute Lymphoblastic Leukemia

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Acute Lymphoblastic Leukemia

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Acute Lymphoblastic Leukemia

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Acute Lymphoblastic Leukemia

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NCCN Guidelines Version 2.2020

Acute Lymphoblastic Leukemia

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NCCN Guidelines Version 2.2020

Acute Lymphoblastic Leukemia

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NCCN Guidelines Version 2.2020

Acute Lymphoblastic Leukemia

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NCCN Guidelines Version 2.2020

Acute Lymphoblastic Leukemia

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NCCN Guidelines Version 2.2020

Acute Lymphoblastic Leukemia

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NCCN Guidelines Version 2.2020

Acute Lymphoblastic Leukemia

383. Gokbuget N, Kneba M, Raff T, et al. Adult patients with acute 390. Pemmaraju N, Kantarjian H, Jorgensen JL, et al. Significance of
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Acute Lymphoblastic Leukemia

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