Overview

• There are no 14 day bone marrows like in AML
• Higher rate of CNS involvement so all will get intrathecal methotrexate for CNS disease prophylaxis
  • 10% present with CNS involvement
  • 30% will relapse with CNS involvement if not given prophylaxis (10% risk with methotrexate prophylaxis
• Minimal residual disease (MRD)
  • 10^12 at diagnosis → 10^9 cancer cells with “remission”
    • More sensitive than pathology which can appear morphologically negative
  • Multicolor flow cytometer: determines cell linate and looks for abnormal leukemoid markers (can detect 100,000 vs 10,000 abnormal cells)
  • PCR send out for PH + leukemia, including P190, P210
• If Detectable minimal residual disease (MRD)
  • Blinatumomab
• If no detectable minimal residual disease
  • Consolidation
    • 6 months of CALBG 10403
    • CALBG 10102 module ABC, then repeat ABC
  • Maintenance: POMP
    • 5 days of steroids per month (prednisone)
    • Vincrinstine (Oncovin)
    • Weekly methotrexate
    • 6-MP (Mercaptopurine) daily

Treatment

• Typically 5 drug regiment: steroids (dexamethasone), anthracycline (like daunorubicin), vincristine, cyclophosphamide, +/- peg asparaginase (delayed DILI possible)
• Adult up to age 40 with Philadelphia Chromosome negative → Pediatric protocol CALGB 10403 (AKA hyper-CVAD)
• B cell with CD20 (30%): can add rituximab
• Philadelphia Chromosome + ALL
  • Steroids + vincristine + TKI → very good remission rates
  • CALGB 10701: tosatinib + steroids → stepwise with chemotherapy

• 40 with Philadelphia chromosome negative→ CALGB 10102

• Philadelphia chromosome positive → CALGB 10701