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
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