Philadelphia chromosome-like acute lymphoblastic leukaemia: the decisions you may face
4 treatment settings, 3 with more than one named option. Each section lays out the options the standard of care names, what each is for, the trials behind them with their recorded results, the side effects and cautions on record, and questions to ask. Built from the cancer page's standard-of-care rows; nothing here is advice for your case.
Diagnosis
Screen every B-ALL without BCR::ABL1 for the Ph-like signature and identify the kinase lesion; treat as high risk with MRD monitoring.
Sequencing hundreds of cancer genes at once from a biopsy to find the mutations a drug can target.
- One test, all actionable alterations
- Trial matching
Flow cytometry MRD counts leukaemia cells in the bone marrow one at a time by their surface proteins, down to one in ten thousand.
- Broadly applicable, fast (same day)
- Works without a molecular marker
Sequencing the unique genetic barcode of a patient's leukaemia to find one cancer cell in a million.
- 10^-5 to 10^-6 sensitivity
- Blood-based monitoring in many settings
No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.
- Tissue quantity
- VUS interpretation
- 2-3 week turnaround
- Operator and lab dependent
- Sensitivity below molecular methods; immunophenotype shift after therapy
- Requires a baseline sample to identify the clone
- Persisting pre-leukaemic clones (CHIP) confound AML MRD
- Between Comprehensive genomic profiling, Multiparameter flow cytometry MRD and NGS-based MRD (clonoSEQ and molecular MRD), which do you recommend for me, and what about my case would make you choose differently?Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
- What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?Why: The aim shapes how much side effect and disruption is worth accepting.
- What happens if I delay, or decline this step for now? Is the decision reversible?Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
- Does your recommendation follow the current guideline (NCI PDQ: Childhood Acute Lymphoblastic Leukemia Treatment (health professional version)), and if it departs from it, why?Why: Departures from guidelines are sometimes right for an individual; they should be explained.
- For my situation (diagnosis), which of the standard options do you recommend and why?Why: Guideline options include: Screen every B-ALL without BCR::ABL1 for the Ph-like signature and identify the kinase lesion; treat as high risk with MRD monitoring.
Add these to your appointment list, or take the full question set for this cancer.
ABL-class fusions
Dasatinib or imatinib added to high-risk chemotherapy from induction, as for Ph-positive ALL.
Dasatinib is a second-generation BCR::ABL1 pill that, combined with the immunotherapy blinatumomab, can put Ph-positive ALL into deep remission with no chemotherapy at all.
The drug that started the targeted therapy era in 2001, turning chronic myeloid leukaemia into a manageable condition with near-normal life expectancy.
No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.
| Side effect | Any grade | Grade 3+ |
|---|---|---|
| Pleural effusion · CML long-term data | 28% | - |
- Known QT prolongation. Avoid other QT-prolonging drugs where possible; check ECG and correct potassium and magnesium before and during treatment.
Rates from the label or pivotal trial as recorded on the product page; each grade 3+ figure links to its source.
- Take with a meal and a large glass of water.
- Between Dasatinib and Imatinib, which do you recommend for me, and what about my case would make you choose differently?Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
- What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?Why: The aim shapes how much side effect and disruption is worth accepting.
- Which side effects of Dasatinib are most likely for me, which are reversible, and which would make us stop?Why: The recorded rates below come from labels and trials; your own risk depends on dose, other medicines and your health.
- What happens if I delay, or decline this step for now? Is the decision reversible?Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
- Does your recommendation follow the current guideline (NCI PDQ: Childhood Acute Lymphoblastic Leukemia Treatment (health professional version)), and if it departs from it, why?Why: Departures from guidelines are sometimes right for an individual; they should be explained.
- For my situation (abl-class fusions), which of the standard options do you recommend and why?Why: Guideline options include: Dasatinib or imatinib added to high-risk chemotherapy from induction, as for Ph-positive ALL.
- Am I a candidate for Dasatinib, Imatinib, and what side effects should I expect?Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
Add these to your appointment list, or take the full question set for this cancer.
CRLF2, JAK2 or EPOR lesions
High-risk chemotherapy; ruxolitinib added in trials (AALL1521).
Ruxolitinib was the first JAK inhibitor: it shrinks the spleen and relieves symptoms in myelofibrosis and controls blood counts in polycythaemia vera, without eliminating the disease clone.
No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.
- Reduce dose for CrCl below 60 with platelets under 150; dialysis dosing after each session.
- Is Ruxolitinib the only reasonable path for me, or is there a trial, a different sequence or a wait-and-see option?Why: A single standard does not mean a single choice; timing and trials are decisions too.
- What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?Why: The aim shapes how much side effect and disruption is worth accepting.
- What happens if I delay, or decline this step for now? Is the decision reversible?Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
- Does your recommendation follow the current guideline (NCI PDQ: Childhood Acute Lymphoblastic Leukemia Treatment (health professional version)), and if it departs from it, why?Why: Departures from guidelines are sometimes right for an individual; they should be explained.
- For my situation (crlf2, jak2 or epor lesions), which of the standard options do you recommend and why?Why: Guideline options include: High-risk chemotherapy; ruxolitinib added in trials (AALL1521).
- Am I a candidate for Ruxolitinib, and what side effects should I expect?Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
Add these to your appointment list, or take the full question set for this cancer.
Persistent residual disease
Blinatumomab or CD19 CAR T-cells to clear residual disease, then allogeneic transplant.
Blinatumomab was the first T-cell engager (2014), and is now given to children and adults with leukaemia even when in remission, because it improves survival.
Tisagenlecleucel was the first CAR-T therapy ever approved (2017), for children and young adults whose leukaemia had come back after everything else.
Allogeneic stem cell transplantation replaces a patient's blood system with a donor's after conditioning chemotherapy, so donor immune cells hunt down leukaemia left behind. It remains the only cure for adverse-risk acute myeloid leukaemia, high-risk acute lymphoblastic leukaemia and Richter transformation, at the price of graft-versus-host disease.
- Curative for otherwise incurable leukaemia
- Graft-versus-leukaemia is an antigen-agnostic immune therapy
No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.
| Side effect | Any grade | Grade 3+ |
|---|---|---|
| Febrile neutropenia · Relapsed/refractory adult ALL | 31% | 28% |
| Infections · Relapsed/refractory adult ALL | 28% | 15% |
| Neurological toxicities · Relapsed/refractory adult ALL | 65% | 13% |
| Pyrexia · Relapsed/refractory adult ALL | 55% | 6% |
Rates from the label or pivotal trial as recorded on the product page; each grade 3+ figure links to its source.
| Side effect | Any grade | Grade 3+ |
|---|---|---|
| Cytokine release syndrome · ELIANA, Penn grading | 77% | 46% |
Rates from the label or pivotal trial as recorded on the product page; each grade 3+ figure links to its source.
- Treatment-related mortality 10-20%
- Chronic GVHD
- Relapse remains the main cause of failure
- Between Blinatumomab, Tisagenlecleucel and Allogeneic stem cell transplantation, which do you recommend for me, and what about my case would make you choose differently?Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
- What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?Why: The aim shapes how much side effect and disruption is worth accepting.
- Which side effects of Blinatumomab or Tisagenlecleucel are most likely for me, which are reversible, and which would make us stop?Why: The recorded rates below come from labels and trials; your own risk depends on dose, other medicines and your health.
- What happens if I delay, or decline this step for now? Is the decision reversible?Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
- Does your recommendation follow the current guideline (NCI PDQ: Childhood Acute Lymphoblastic Leukemia Treatment (health professional version)), and if it departs from it, why?Why: Departures from guidelines are sometimes right for an individual; they should be explained.
- For my situation (persistent residual disease), which of the standard options do you recommend and why?Why: Guideline options include: Blinatumomab or CD19 CAR T-cells to clear residual disease, then allogeneic transplant.
- Am I a candidate for Blinatumomab, Tisagenlecleucel, and what side effects should I expect?Why: Knowing the expected toxicities helps you plan work, family, and supportive care.
Add these to your appointment list, or take the full question set for this cancer.