# Transplant-free Ph-positive ALL for MRD-negative adults

Source: https://onco.cc/ideas/idea-transplant-free-ph-all/  
OnCo record `idea-transplant-free-ph-all` (Idea). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

If a pill plus immunotherapy makes the leukaemia undetectable, can most adults safely skip a bone-marrow transplant?

## Summary

If a tyrosine kinase inhibitor plus blinatumomab renders Philadelphia chromosome-positive acute lymphoblastic leukaemia undetectable, this idea asks whether most adults can safely forgo allogeneic transplant in first remission. The hypothesis is that patients in complete molecular remission have equivalent overall survival with TKI maintenance and MRD surveillance as with transplant. The rationale is that deaths caused by the transplant itself may exceed the relapse risk it prevents, and that blinatumomab and ponatinib rescue many relapses; in D-ALBA (GIMEMA LAL2116) around half of patients were not transplanted and did well. A trial would randomise MRD-negative patients to transplant or to TKI maintenance with BCR::ABL1 PCR and pre-emptive blinatumomab; it is being tested at scale.

## Fields

- Kind: Idea
- Last checked: 2026-09-07
- Hypothesis: Adults with Ph+ ALL who achieve complete molecular remission after TKI + blinatumomab have equivalent OS with TKI maintenance and MRD surveillance versus allogeneic transplant in CR1.
- Rationale: Transplant mortality (10-20%) may exceed the relapse risk it prevents in molecularly negative patients; blinatumomab and ponatinib rescue many relapses.
- Proposed test: A trial would randomise MRD-negative patients after induction/consolidation to transplant vs TKI maintenance with monthly BCR::ABL1 PCR and pre-emptive blinatumomab; primary endpoint OS at 3 years.
- Maturity: being-tested-at-scale

## Sources

- ClinicalTrials.gov NCT02744768: D-ALBA (GIMEMA LAL2116): https://clinicaltrials.gov/study/NCT02744768

## Connected records

- cancers: [Acute lymphoblastic leukaemia](https://onco.cc/cancers/all-leukemia/), [Philadelphia chromosome-positive acute lymphoblastic leukaemia in children (Ph-positive ALL)](https://onco.cc/cancers/all-paediatric-ph-positive/)
- technologies: [Allogeneic stem cell transplantation](https://onco.cc/technologies/allogeneic-hsct/), [NGS-based MRD (clonoSEQ and molecular MRD)](https://onco.cc/technologies/ngs-mrd-clonoseq/)
- drugs: [Blinatumomab](https://onco.cc/drugs/blinatumomab/), [Dasatinib](https://onco.cc/drugs/dasatinib/), [Ponatinib](https://onco.cc/drugs/ponatinib/)
- terms: [MRD-negative complete remission](https://onco.cc/terms/mrd-negative-cr/), [Ph-positive ALL](https://onco.cc/terms/ph-positive-all/)
- trials: [D-ALBA (GIMEMA LAL2116)](https://onco.cc/trials/d-alba/)
- key papers: [Blinatumomab versus Chemotherapy for Advanced Acute Lymphoblastic Leukemia](https://onco.cc/key-papers/paper-blinatumomab-all-leukemia-n-engl-j-med-2017/), [PACE: ponatinib in Philadelphia chromosome-positive leukaemias resistant to earlier tyrosine kinase inhibitors](https://onco.cc/key-papers/paper-pace-ponatinib-nejm-2013/), [Safety and activity of blinatumomab for adult patients with relapsed or refractory B-precursor acute lymphoblastic leukaemia: a multicentre, single-arm, phase 2 study](https://onco.cc/key-papers/paper-blinatumomab-all-leukemia-lancet-oncol-2015/)

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