Vinod A. Pullarkat, MD, clinical professor of Hematology & Hematopoietic Cell Transplantation, and hematologist/oncologist, City of Hope, discusses treatment strategies for patients with transplant-ineligible acute lymphoblastic leukemia (ALL).

Older patients with ALL have a historically poor prognosis, says Pullarkat. Researchers believe that moving therapies that have been approved for use in the relapsed setting into the frontline setting may improve outcomes. Older patients with Philadelphia-positive (Ph-positive) disease are a prime example, adds Pullarkat, as they have been shown to achieve deep remissions with a combined “lite chemotherapy” and TKI approach.

Furthermore, drugs such as blinatumomab (Blincyto) can be added to “lite chemotherapy” in the frontline setting to increase the tolerability of the regimen and induce more durable remissions. By re-evaluating the optimal role of these agents, investigators are beginning to show that high-intensity chemotherapy is not needed in these patients, says Pullarkat. Notably, blinatumomab is more active in the presence of minimal residual disease negativity; therefore, investigators are also evaluating the efficacy of blinatumomab following chemical debulking.

Videos

Vinod A. Pullarkat, MD, clinical professor of Hematology & Hematopoietic Cell Transplantation, and hematologist/oncologist, City of Hope, discusses treatment strategies in transplant ineligible acute lymphoblastic leukemia (ALL).

Dr. Pullarkat on Treatment Strategies in Transplant Ineligible ALL

Vinod A. Pullarkat, MD, clinical professor of Hematology & Hematopoietic Cell Transplantation, and hematologist/oncologist, discusses the importance of assessing for minimal residual disease in acute lymphoblastic leukemia.

MRD is a term applied to disease that we can detect; however, it cannot be detected via regular morphology or usual flow cytometry, says Pullarkat. In order to detect MRD, certain techniques are required, such as specialized flow cytometry and PCR-based methods, which are a little more sensitive than flow cytometry. MRD is the single most important prognostic marker in ALL, he stresses.

The earlier a patient becomes MRD-negative, the better their outcome will be. When chemotherapy is applied to frontline treatment, most experts agree that if patients do not become MRD-negative within about 3 cycles of treatment, it is unlikely they will benefit from continued therapy, explains Pullarkat.

In contrast, if a patient comes MRD-negative really quickly after induction, that patient will likely have a good outcome with continued chemotherapy, and as such, that person is not someone that would go to transplant. If a patient is persistently MRD-positive after a full cycle of consolidation therapy, then that patient would be a candidate for stem cell transplant. One unresolved question, according to Pullarkat, is whether or not something should be done to make that patient MRD-negative before transplantation.

Vinod A. Pullarkat, MD

Articles

Dr. Pullarkat on Treatment Strategies in Transplant Ineligible ALL

Dr. Pullarkat on Assessing for MRD in ALL