OnCo

Acute lymphoblastic leukaemia: lines of therapy

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11 standard-of-care settings across 5 lines and 5 biomarker subgroups. Rows come from the cancer page's standard of care; the grid places each on its line and subgroup.

LineAll comersAge groupFRαKMT2APh-positive
Early / localised·2···
Advanced, first line2···1
Second line1····
Third line and beyond··1··
Other settings21·1·

Early / localised

SubgroupSettingApproachProducts and trialsEvidence
Age groupChildren, standard risk B-ALLRisk-adapted multi-agent chemotherapy (induction, consolidation, interim maintenance, delayed intensification, 2-3 years maintenance) with two cycles of blinatumomab in consolidation (AALL1731, approved June 2024); intrathecal CNS prophylaxis; cranial radiation abandoned for most.90
Age groupChildren, high risk or MRD-positiveIntensified chemotherapy; blinatumomab for MRD persistence (AALL1331 in relapse); inotuzumab and CAR-T (tisagenlecleucel) for relapse; allogeneic transplant for very high risk or MRD persistence.85

Advanced, first line

SubgroupSettingApproachProducts and trialsEvidence
All comersFrontlineRisk-adapted chemotherapy + blinatumomab consolidation; TKI if Ph+.85
All comersMRD-positive after induction or consolidationBlinatumomab (BLAST; full approval 2018) to convert to MRD negativity, then transplant or continued blinatumomab-based therapy.85
Ph-positivePh-positive ALL, newly diagnosedPonatinib (PhALLCON) or dasatinib with reduced-intensity chemotherapy, or chemotherapy-free TKI + blinatumomab (D-ALBA); BCR::ABL1 PCR monitoring; transplant for MRD persistence or IKZF1-plus, increasingly omitted for MRD-negative patients.85

Second line

SubgroupSettingApproachProducts and trialsEvidence
All comersRelapsedCAR-T (tisagenlecleucel, obe-cel), inotuzumab, transplant.89

Third line and beyond

SubgroupSettingApproachProducts and trialsEvidence
FRαRelapsed or refractory B-ALLBlinatumomab (TOWER) or inotuzumab (INO-VATE) as salvage and bridge; CD19 CAR-T (tisagenlecleucel ≤25 years; obe-cel or brexucabtagene in adults) for second salvage or as definitive therapy; transplant for those not previously transplanted; CD22 or dual CAR-T for CD19-negative relapse in trials.93

Other settings

SubgroupSettingApproachProducts and trialsEvidence
All comersAdults 40-70, Ph-negativeHyper-CVAD or age-adapted multi-agent chemotherapy with blinatumomab interleaved in consolidation (E1910); inotuzumab-containing lower-intensity regimens (Mini-hyper-CVD + InO ± blinatumomab) for older adults; MRD-driven transplant.93
All comersT-cell ALLIntensive paediatric-type chemotherapy with nelarabine for high-risk (AALL0434); relapse: nelarabine, venetoclax combinations, CD7 CAR-T and daratumumab in trials; transplant in CR2.85
Age groupAdolescents and young adults (15-39), Ph-negativePaediatric-inspired regimens (CALGB 10403, GRAALL, UKALL) with asparaginase; blinatumomab consolidation (E1910); MRD-guided transplant.93
KMT2AInfants (<1 year), KMT2A-rearrangedInterfant-21 backbone with blinatumomab; transplant for high-risk; menin inhibitors in trials.85

Sequence and caution pairings

Regimens in the library

Lines and subgroups are parsed from the setting text of each standard-of-care row and can misclassify an unusual phrasing; the row’s own setting is always shown. Guideline chips reflect the NCCN category and ESMO-MCBS grade recorded on the cancer page, checked on its stated date. Not medical advice.