ASH Clinical News ACN_4.14_Full Issue_web | Page 101

TRAINING and EDUCATION You Make the Call Each month in “You Make the Call,” we pick a challenging clinical question submitted through the Consult a Colleague pro- gram and post the expert’s response, but we also want to know what you would do. Send in your response to next month’s clinical dilemma and see how your answer matches up to the expert’s in the next print issue. This month, Anjali S. Advani, MD, discusses the management of Ph-negative ALL in a patient with ischemic cardiomyopathy. Clinical Dilemma: What induction regimen would you choose for a patient with Philadelphia chromosome–negative (Ph–) precursor B-cell acute lymphocytic leukemia (ALL) and ischemic cardiomyopathy with a left ventricular ejection fraction of 35 percent? Expert Opinion Anjali S. Advani, MD Director, Inpatient Leukemia Unit Cleveland Clinic Taussig Cancer Institute Professor of Medicine, Cleveland Clinic Lerner College of Medicine Standard induction regimens for patients with Ph– B-cell ALL include an anthracycline. However, administration of an anthracycline may not be safe in a patient with an ejection fraction of 35 percent. One treatment option in this setting would be CVP (cyclophosphamide, vincristine, prednisone) and the addition of rituximab if the patient’s leukemia is CD20-positive. Intrathecal therapy would also be used for central nervous system (CNS) prophylaxis. CVP is used as part of the backbone of most ALL regimens, but would be less intensive and have a lower chance of achieving complete remission (CR) and minimal residual disease (MRD) negativity. If the patient had persistent morphologic disease or MRD positivity, the bispecific T-cell engaging antibody blinatumomab would then be an excellent option. Alternative options could include a high-dose cytarabine- based regimen, FLA (fludarabine, cytarabine, granulocyte colony stimulating factor), or MOAD (methotrexate, vin- cristine, PEG-asparaginase, dexamethasone). These latter regimens have been used in the setting of relapsed/ refractory ALL with reasonable response rates. In this patient’s case, I would favor the first approach (CVP with or without rituximab) with intrathecal chemotherapy as CNS prophylaxis followed by blinatumomab if the patient remains refractory or is MRD positive. Unfortunately, there are no data with a curative ALL treatment regimen omitting an anthracycline and not proceeding with allogeneic hematopoietic cell transplantation (alloHCT). However, the toxicity and response rates with CVP, rituximab, and blinatumomab are the best of the various options listed. In the setting of MRD-positive disease, blinatumomab has also led to durable remissions in the absence of alloHCT. A recent clinical trial in older patients with Ph– B-cell ALL (SWOG 1318) evaluated blinatumomab for induction and post-remission therapy followed by POMP (prednisone, vincristine, 6-mercaptopurine, methotrexate) maintenance. This trial recently completed accrual and should address the outcomes of patients who are not candidates for intensive chemotherapy. ASHClinicalNews.org ASH Clinical News 99