Dasatinib-Blinatumomab for Ph-Positive Acute Lymphoblastic Leukemia in Adults

Blinatumomab added to conditioning regimen of allogeneic hematopoietic stem cell transplantation for adult MRD-positive acute lymphoblastic leukemia: a single-center case series

Allogeneic hematopoietic stem cell transplantation (Allo-HSCT) remains the mainstay of treatment for adults with high-risk acute lymphoblastic leukemia (ALL). Due to the crucial role of measurable residual disease (MRD) before Allo-HSCT in predicting relapse and the promising anti-leukemia effect of blinatumomab, we documented a short-course, low-dose conditioning regimen incorporating blinatumomab for Allo-HSCT in three ALL patients with positive MRD. Following the administration of the blinatumomab-containing conditioning regimen, all patients attained complete remission (CR) with negative MRD status, and no severe adverse events were observed. After a 2-year follow-up, 2/3 of patients remained disease-free and attained long-term survival following transplantation. These cases indicated a short-term blinatumomab conditioning regimen may effectively prolong patient survival, improve prognosis, and offer a safe and cost-effective treatment for high-risk ALL patients with positive MRD. The addition of blinatumomab to the conditioning regimen of Allo-HSCT is feasible for high-risk ALL patients with positive MRD.

TP53 mutations are associated with CD19- relapse and inferior outcomes after blinatumomab in adults with ALL

ABSTRACT

Despite the success of the CD19 × CD3 T-cell engager blinatumomab in B-cell acute lymphoblastic leukemia (B-ALL), treatment failure is common and can manifest with antigen loss and extramedullary disease (EMD) relapse. To understand the impact of leukemia genetics on outcomes, we reviewed 267 adult patients with B-ALL treated with blinatumomab and used next-generation sequencing to identify molecular alterations. Patients received blinatumomab for relapsed/refractory (R/R) disease (n = 150) and minimal residual disease (MRD; n = 88), upfront as induction (n = 10) or as consolidation in MRD-negative state (n = 19). In the overall cohort, 50 patients (19%) had Philadelphia chromosome (Ph)-positive ALL, 80 (30%) had Ph-like ALL, 35 (13%) had TP53 mutations (TP53m), 7 (3%) had KMT2A rearrangement, and 8 (3%) had PAX5 alterations. For patients treated for R/R ALL, the overall complete remission (CR)/CR with incomplete hematological recovery (CRi) rate was 59%. Only pretreatment high disease burden (P < .01) and active EMD (P < .01) were associated with inferior CR/CRi rate. Of 169 patients in CR/CRi after blinatumomab, 79 (47%) patients relapsed, including 22 (28%) with CD19- and 54 (68%) with CD19+ relapse. In multivariable analysis, TP53m was associated with an increased risk of CD19- relapse (hazard ratio [HR], 6.84; 95% confidence interval [CI], 2.68-17.45; P < .01). Post-blinatumomab allogeneic stem cell transplantation consolidation was associated with a lower risk of CD19- relapse (HR, 0.10; 95% CI, 0.03-0.37; P < .01) and EMD relapse (HR, 0.36; 95% CI, 0.18-0.73; P < .01). In conclusion, leukemia genetics may predict patterns of blinatumomab failure, with TP53m associated with CD19- relapse.

Tyrosine kinase inhibitors with blinatumomab versus chemotherapy in Philadelphia-positive acute B-lymphoblastic leukemia

Tyrosine kinase inhibitors (TKIs) and blinatumomab have improved outcomes in Philadelphia-positive B-lymphoblastic leukemia (Ph + B-ALL). However, the efficacy of TKI and blinatumomab as a standalone regimen compared to the standard chemotherapy-plus-TKI approach remains uncertain. We conducted a single-center retrospective analysis of 47 patients, including 18 treated with TKI and blinatumomab (de novo: N = 13; relapsed: N = 5) and 29 treated with chemotherapy and TKI. Patients in the blinatumomab cohort were significantly older (median age 65 years vs. 48 years), had higher rates of active central nervous system disease (27.7% vs. 0%) and were less frequently consolidated with allogeneic stem cell transplantation (33% vs. 79%, p < .05). Despite these differences, overall survival (2-year OS: 87% vs. 78%), progression-free survival (PFS: 81% vs. 54%), and non-relapse mortality (NRM: 6.3% vs. 14%) were comparable. Severe treatment-related adverse events were significantly less frequent in the TKI and blinatumomab cohort, with no difference in early molecular complete response rates. Our findings, consistent with published prospective trials, highlight the safety and efficacy of TKI and blinatumomab in managing Ph + B-ALL.

Dasatinib and CAR T-Cell Therapy in Newly Diagnosed Philadelphia Chromosome-Positive Acute Lymphoblastic Leukemia: A Nonrandomized Clinical Trial

Importance

A combination of tyrosine kinase inhibitors and chimeric antigen receptor (CAR) T cells has made a breakthrough in refractory or relapsed Philadelphia chromosome (Ph)-positive acute lymphoblastic leukemia (ALL). However, it remains unclear if this treatment in newly diagnosed Ph-positive ALL is associated with high rates of complete molecular remission (CMR) and leukemia-free survival.

Objective

To evaluate the efficacy and safety of dasatinib in combination with CAR T cells as frontline therapy in adults with newly diagnosed Ph-positive ALL.

Design, Setting, and Participants

This trial was conducted at a single center, the First Affiliated Hospital of Zhejiang University School of Medicine. Patients were enrolled in this phase 2, single-arm nonrandomized clinical trial between March 5, 2021, and April 13, 2024. The data cutoff date was February 10, 2025. The data analysis was conducted on February 11, 2025. The median duration of follow-up was 23.9 (range, 7.3-47.7) months. A total of 29 adults with newly diagnosed Ph-positive ALL and adequate organ function were screened for eligibility, and 1 patient who received a diagnosis of blast-phase chronic myeloid leukemia was excluded.

Intervention

Dasatinib was administered with a 2-week vindesine and dexamethasone regimen as induction, followed by sequential CD19 and CD22 CAR T-cell therapies and single-agent dasatinib maintenance.

Main Outcomes and Measures

The primary end point was CMR rate after CD19 CAR T-cell therapy. CMR was defined as undetectable BCR/ABL1 transcripts as measured by quantitative reverse transcription polymerase chain reaction with a sensitivity of 10-4 in the bone marrow.

Results

Twenty-eight patients (median [range] age, 48.5 [18.0-69.0] years; 10 female individuals [36%]) were enrolled, and 1 patient withdrew after induction. The CMR rate was 25% (7 of 28) after induction and increased to 85% (23 of 27) after CD19 CAR T-cell therapy. Twenty-five patients (89.3%) received sequential CD22 CAR T-cell therapy, and the CMR rate was 76% (19 of 25). Of the 52 CAR T-cell therapies, only 21 cases of grade 1 cytokine release syndrome occurred. After a median follow-up of 23.9 (range, 7.3-47.7) months, the 2-year overall survival and leukemia-free survival were 92%.

Conclusions and Relevance

The results of this nonrandomized clinical trial suggest that the combination of dasatinib and CAR T-cell therapy showed encouraging efficacy in newly diagnosed Ph-positive ALL with acceptable toxic effects. Further studies with larger cohorts and longer follow-up durations are needed.

Trial Registration

ClinicalTrials.gov Identifier: NCT04788472.

Differences in response to immunotherapy drugs including blinatumomab and inotuzumab ozogamicin in B-ALL patients

The treatment of B-cell precursor acute lymphoblastic leukemia (B-ALL) has undoubtedly transitioned into the immunotherapy era. We conducted a retrospective study on B-ALL immunotherapy, especially regimens including blinatumomab (Blina) and inotuzumab ozogamicin (InO), at our center. A total of 21 B-ALL patients were involved in this study, including 18 with newly diagnosed (ND) B-ALL and 3 with relapsed B-ALL. RNA sequencing identified a total of five new fusions (ADD1::JAK2, PVT1::IGLL5, PAX5::KANK2, ETV6::BCL2L14, and CDKN2A::TGFBR3) in five different patients. All ND patients can be divided into four groups according to treatment response. Group 1, which included patients with PAX5::KANK2 and CREBBP::ZNF384, responded best to Blina. Group 2, which included one patient with CDKN2A::TGFBR3 fusion and one who was BCR::ABL positive, showed an inferior response to Blina compared with Group 1. Group 3 initially showed no response but subsequently responded very favorably to InO and showed further improvement with Blina. Group 4, which included patients with PVT1::IGLL5 fusion, had the poorest prognosis. In conclusion, Blina and InO showed specific treatment advantages for different patient groups in our cohort that may be attributed to intrinsic genetic characteristics, such as new fusion genes.

Incorporation of immunotherapy into frontline treatment for adults with B-cell precursor acute lymphoblastic leukemia

ABSTRACT

Although complete remission rates in adults with B-cell precursor acute lymphoblastic leukemia (BCP-ALL) have improved over the last 2 decades, it is still inferior to that of the pediatric population, and once in remission, the risk of relapse is still high. Furthermore, although pediatric-inspired chemotherapy regimens have improved long-term outcomes for adolescents and young adults, these intensive chemotherapy regimens are not well tolerated in older patients and are associated with higher morbidity and mortality. Immunotherapeutic agents offer a potential opportunity to improve response and decrease relapse without increasing toxicity. The incorporation of rituximab (anti-CD20 monoclonal antibody) into chemotherapy regimens has been shown to improve outcomes. The treatment of BCP-ALL in adults has been transformed with the approval of inotuzumab ozogamicin (anti-CD22 antibody-drug conjugate), blinatumomab (CD3/CD19 bispecific antibody construct), and chimeric antigen receptor T cells for relapsed or refractory disease and of blinatumomab for measurable residual disease (MRD)-positive remission. More recently, studies of inotuzumab and blinatumomab have shown promising results when used up front either with or without multiagent chemotherapy. Blinatumomab has also been shown in a randomized trial to provide a survival benefit in patients with MRD-negative first remission when added to chemotherapy, which recently led to its additional US Food and Drug Administration approval for use in consolidation. In this review, we highlight the evolution of chemoimmunotherapy-based treatment approaches in the management of treatment-naïve BCP-ALL.

Improved post-transplant outcomes since 2000 for Ph-positive acute lymphoblastic leukemia in first remission: A study from the EBMT Acute Leukemia Working Party

Allogeneic hematopoietic cell transplantation (allo-HCT) remains a curative treatment for patients with Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) in their first complete remission (CR1). Recent results using the combination of blinatumomab and second- or third-generation tyrosine kinase inhibitors have challenged the necessity of allo-HCT in CR1. Here we assessed real-world changes over time in transplant characteristics and outcomes in adult patients with Ph+ ALL in CR1, using a large dataset from the European Society for Blood and Marrow Transplantation registry. A total of 3292 patients (45% female; median age 45 years) who underwent allo-HCT from 2001 to 2020 were included. Over four periods (2001-2005, 2006-2010, 2011-2015, and 2016-2020), the 3-year cumulative incidence of relapse decreased from 41% to 19%, and non-relapse mortality decreased from 25% to 17% (p < 0.001 for both). Correspondingly, 3-year leukemia-free survival (LFS) improved from 34% to 64%, and overall survival (OS) from 47% to 75% (p < 0.001 for both). Graft versus host disease-free and relapse-free survival also improved from 26% to 49% (p < 0.001). Factors negatively affecting LFS included older age, male gender, male donor and measurable residual disease (MRD) positivity pre-transplant, while total body conditioning (TBI) positively affected LFS. OS was positively influenced by younger age, female gender, matched sibling donor, TBI, and T cell depletion. Importantly, improvement in post-transplant outcomes over time was observed regardless of pre-transplant MRD status. In conclusion, we observed an impressive improvement over time in post-transplant outcomes of Ph+ ALL. These large-scale data can serve as a benchmark for future studies.

Post-transplant TKIs for Ph+ ALL: practices to date and clinical significance

Post-transplant tyrosine kinase inhibitors (TKIs) show promise in preventing relapse after allogeneic hematopoietic cell transplantation (allo-HCT) for Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ALL). However, their real-world use and efficacy remain unclear. A comprehensive study across seven centers included Ph+ALL patients who underwent allo-HCT between 2002 and 2022. Post-transplant TKIs were administered in 28% of patients (49 of 173 transplanted in complete remission): 7% as prophylaxis during complete molecular remission (CMR), and 21% in response to measurable residual disease (MRD) positivity. Median first post-transplant TKI duration was 13.7 months for the prophylactic group and 4.0 months for the MRD-triggered group. Prophylactic TKIs appear particularly beneficial for patients not in CMR at allo-HCT, showing a trend towards higher 5-year relapse-free survival (RFS) compared to those not receiving prophylactic TKIs (100% vs. 73%; P = 0.11). Significant RFS differences were observed between the prophylactic, non-TKI, and MRD-triggered groups. However, patients with white blood cell counts <15000/µl at diagnosis and no additional chromosomal abnormalities-an MRD-triggered high efficacy cluster-demonstrated comparable 5-year RFS regardless of TKI strategy (100% vs. 85% vs. 80%; P = 0.87). This cluster highlights the potential effectiveness of MRD-triggered TKI administration in select low-risk patients, suggesting tailored TKI strategies based on risk factors.

Integrating Blinatumomab in the Frontline Treatment in B-Cell Acute Lymphoblastic Leukemia: A New Era in Therapeutic Management

Blinatumomab, a bispecific T-cell engager (BiTE), has shown substantial efficacy in treating both relapsed/refractory (R/R) Philadelphia chromosome (Ph)-positive and Ph-negative acute lymphoblastic leukemia (ALL). With its targeted mechanism of action, favorable safety profile, and ability to induce deep molecular remissions, blinatumomab is increasingly incorporated into frontline treatment regimens for B-ALL. Recently, the Food and Drug Administration (FDA) has approved its use in the frontline setting for Ph-negative ALL. In Ph-negative ALL, combining blinatumomab with intensive chemotherapy has resulted in superior measurable residual disease (MRD) clearance and improved long-term outcomes. In Ph-positive ALL, combination therapies involving tyrosine kinase inhibitors (TKIs), particularly ponatinib and blinatumomab, are challenging the traditional approach of allogeneic hematopoietic stem cell transplantation (allo-SCT). This review explores the current evidence supporting the frontline use of blinatumomab in newly diagnosed adults with B-ALL, its impact on treatment paradigms, and potential future directions, including novel combination therapies and the role of emerging immunotherapeutic approaches.

Advances in Therapy of Adult Patients with Acute Lymphoblastic Leukemia

The landscape of adult acute lymphoblastic leukemia (ALL) is dramatically changing. With very promising results seen with novel immunotherapeutics in the setting of relapsed and refractory disease, the prospect of using these agents in first-line therapy has prompted the development of multiple clinical trials addressing this question. This review seeks to outline and expand the current standard of care, as well as new advances, in the treatment of adult patients with ALL and address future areas of research. We expect the frontline integration of immuno-oncology agents such as bispecific T-cell engagers, antibody-drug conjugates, and chimeric antigen receptor (CAR) T cells may maintain or improve outcomes in adults while also minimizing toxicity. Treatment of ALL will continue to evolve as we focus on personalized, patient-centered approaches.

Treatment-free remission in nontransplanted patients with Philadelphia chromosome-positive acute lymphoblastic leukemia

BACKGROUND

The BCR::ABL1 tyrosine kinase inhibitors (TKIs) have significantly improved the outcomes of patients with Philadelphia chromosome (Ph)-positive acute lymphoblastic leukemia (ALL). However, the optimal duration of TKI therapy in patients who achieve a complete molecular response (CMR; undetectable BCR::ABL1 transcripts) and who do not undergo allogeneic stem cell transplantation (allo-SCT) remains undefined.

METHODS

The authors conducted a retrospective analysis of patients with Ph-positive ALL in first complete remission who achieved a CMR and discontinued TKI therapy, most commonly due to treatment-related side effects.

RESULTS

In total, 14 patients were identified. The regimen of hyperfractionated cyclophosphamide, vincristine, doxorubicin, and dexamethasone alternating with high-dose methotrexate and cytarabine was the primary backbone chemotherapy and was received by 12 patients (86%) combined with either imatinib (14%), dasatinib (43%), or ponatinib (29%) during induction. Two patients received blinatumomab and ponatinib. The median duration of TKI therapy was 60 months. The median CMR duration before TKI discontinuation was 46.1 months (range, 2.7-121.3 months). After a median follow-up of 42.5 months from TKI discontinuation, three patients (21%) experienced relapse (two molecular, one morphologic), whereas 11 patients (79%) maintained treatment-free remission. The median time to relapse was 6.4 months (range, 4-16 months), and two of three relapsed patients regained CMR after resuming TKI therapy. Importantly, none of the six patients with a CMR duration >48 months before TKI discontinuation relapsed.

CONCLUSIONS

The current findings suggest that TKI discontinuation may be safe for highly selected patients with Ph-positive ALL in first complete remission who maintain CMR for at least 48 months. Larger studies are needed to confirm these findings.

Blinatumomab for the treatment of acute lymphoblastic leukemia in a real-world setting: clinical vignettes

Blinatumomab, a CD19/CD3 bispecific T-cell engager; inotuzumab ozogamicin (INO), a CD22 antibody drug conjugate; and chimeric-antigen receptor (CAR) T-cell constructs are novel immune-therapeutic options for treatment of acute lymphoblastic leukemia (ALL). The use of blinatumomab has recently expanded to multiple B-ALL treatment settings. Despite the efficacy of blinatumomab, its use can be challenging in the real-world because of limited experience with its administration and management of toxicities. Optimal use and sequencing of blinatumomab is critical to improve outcomes, reduce undesired toxicities, and decrease discontinuation rates related to such toxicities. Herein, we discuss strategies to address the unique adverse effects of blinatumomab and ways to optimize its administration and integration into the treatment backbone of B-ALL. We outline our approach to combining and sequencing blinatumomab with other immunotherapies, such as INO and CD19 CAR T-cells, and provide recommendations for the management of toxicities and dose-optimization of blinatumomab therapy in clinical practice.

Antibody-Based and Other Novel Agents in Adult B-Cell Acute Lymphoblastic Leukemia

Despite notable progress in managing B-cell acute lymphoblastic leukemia (B-ALL) over recent decades, particularly in pediatric cohorts where the 5-year overall survival (OS) reaches 90%, outcomes for the 10-15% with relapsed and refractory disease remain unfavorable. This disparity is further accentuated in adults, where individuals over the age of 40 years undergoing aggressive multiagent chemotherapy continue to have lower survival rates. While the adoption of pediatric-inspired treatment protocols has enhanced complete remission (CR) rates among younger adults, 20-30% of these patients experience relapse, resulting in a subsequent 5-year OS rate of 40-50%. For relapsed B-ALL in adults, there is no universally accepted standard salvage therapy, and the median OS is short. The cornerstone of B-ALL treatment continues to be the utilization of combined cytotoxic chemotherapy regimens to maximize early and durable disease control. In this manuscript, we go beyond the multiagent chemotherapy medications developed prior to the 1980s and focus on the incorporation of antibody-based therapy for B-ALL with an eye on existing and upcoming approved indications for blinatumomab, inotuzumab ozogamicin, other monoclonal antibodies, and chimeric antigen receptor (CAR) T cell products in frontline and relapsed/refractory settings. In addition, we discuss emerging investigational therapies that harness the therapeutic vulnerabilities of the disease through targeting apoptosis, modifying epigenetics, and inhibiting the mTOR pathway.

Tyrosine Kinase Inhibitor Post-Allogeneic Stem Cell Transplantation in Adult Philadelphia-Positive B-Acute Lymphoblastic Leukemia: State of the Art and Future Directions

In a scenario characterized by continuous improvement in outcomes, Philadelphia chromosome-positive (Ph+) ALL, once considered a biologically defined subtype with one of the poorest prognoses, now includes patients achieving long-term survival even without allogeneic stem cell transplantation. First-line therapy is increasingly adopting a chemo-free approach, combining tyrosine kinase inhibitors (TKIs) with immunotherapy-specifically blinatumomab-which has resulted in high rates of complete molecular responses and improved survival outcomes. Within this paradigm shift, the allocation to transplantation is becoming increasingly selective and genomically oriented, focusing on patients with particularly unfavorable prognostic and predictive factors. For patients undergoing transplantation, maintenance therapy with TKIs has emerged as one of the most important strategies to reduce the risk of relapse. However, there remains considerable uncertainty regarding which patients benefit most from this approach, the optimal TKI agents, dosing strategies, and the duration of maintenance therapy. In this review, we aim to consolidate the available evidence on this topic, analyzing it in the context of the most recent clinical experiences.

Metabolomic insights into pathogenesis and therapeutic potential in adult acute lymphoblastic leukemia

Acute lymphoblastic leukemia (ALL) poses challenges in adult patients, considering its heterogeneous nature and often suboptimal treatment outcomes. Here, we performed a study on 201 newly diagnosed adult ALL cases (age ≥ 15 y) to generate intracellular and dynamic serum metabolomic profiles. Our findings revealed a predominant increase in bile acid (BA) metabolites in serum, alongside metabolic rewiring that supported highly proliferative states and actively metabolic signaling, such as enriched nucleotide metabolism in leukemic blasts. By integrating intracellular metabolomics and transcriptomics, we constructed the Comprehensive Metabolic Information Dataset (CMID), which facilitated the development of a clustering system to supplement current risk stratification. Furthermore, we explored potential metabolic interventions targeting the serum BA profile and energy metabolism in blasts. The combined use of simvastatin with vincristine and dexamethasone regimen demonstrated a synergistic therapeutic effect in a murine ALL model, effectively lowering key BA levels in serum and suppressing the infiltration of leukemic blasts in the liver. In light of the enhanced intracellular redox metabolism, combining FK866 (a nicotinamide phosphoribosyltransferase inhibitor) and venetoclax significantly prolonged survival in a patient-derived xenograft ALL model. Our findings, along with the resulting resources (http://www.genetictargets.com/MALL), provide a framework for the metabolism-centered management of ALL.

Always more immunotherapy in the management of B-lineage acute lymphoblastic leukemia

In the FELIX study,1 the CAR-T product obecabtagene autoleucel (obe-cel) was investigated in relapsed/refractory adult B-cell lymphoblastic leukemia (B-ALL). The high responses associated with the low incidence of grade ≥3 side effects make obe-cel an attractive candidate for a broader use of CAR-T cells in B-ALL. Its impact will have to be weighed with the monoclonal antibody blinatumomab in the frontline treatment of B-ALL.

Final analysis of the GMALL-PH-01 trial: phase II study of standard chemotherapy in combination with dasatinib in first line treatment of Philadelphia chromosome positive acute lymphoblastic leukemia

Imatinib (IMA) plus chemotherapy followed by allogeneic hematopoietic cell transplantation (HCT) is established treatment for Philadelphia chromosome positive (Ph+) acute lymphoblastic leukemia (ALL). We investigated the use of dasatinib (DASA) combined with intensive chemotherapy in ALL (18-55 years) first-line in a prospective, multicenter phase II trial by the GMALL study group. 140 mg DASA QD was used with a pediatric-based induction and consolidation chemotherapy according to GMALL 07/2003 protocol with recommended consecutive HCT. Nineteen of 20 planned patients were enrolled in 12 centers. The hematologic CR rate after induction was 79% with an overall MRD negativity rate of 62.5%. Six patients died during induction and two discontinued therapy. This regimen achieved deep molecular responses but was associated with a higher than expected early mortality (21%) and was stopped prematurely due to toxicities. The GMALL therefore adopted a combination of low intensity chemotherapy plus IMA as its current induction regimen.

GPX3 as a Novel and Potential Therapeutic Target in the Shared Molecular Mechanisms of Traumatic Brain Injury and Parkinson's Disease

Background

Traumatic brain injury (TBI) is a prevalent neurological disorder associated with significant public health burdens and long-term risks, including neurodegenerative diseases such as Parkinson's disease (PD). Emerging evidence suggests a strong link between moderate to severe TBI and an elevated risk of PD, though the underlying mechanisms remain poorly understood.

Materials and Methods

Common differentially expressed genes (DEGs) were identified in GEO datasets of patients with traumatic brain injury (TBI) and Parkinson's disease (PD). Further analyses, including GO and KEGG pathway enrichment, protein-protein interaction (PPI) network construction, hub gene identification, as well as miRNA and transcription factor prediction and drug candidate screening, were conducted. Subsequently, the expression of hub genes was validated using additional TBI- and PD-related GEO datasets and the Comparative Toxicogenomics Database (CTD). Finally, the expression of hub genes was further validated in a mouse model of TBI induced by controlled cortical impact (CCI).

Results

Shared transcriptional signatures between TBI and PD were uncovered, highlighting overlapping molecular networks and pathways. The glutathione peroxidase 3 (GPX3) gene emerged as a pivotal hub gene, with its expression significantly altered in both TBI and PD datasets.

Conclusion

This study underscores the critical role of GPX3 in the molecular intersection of TBI and PD, suggesting it as a novel and potential therapeutic target, offering new insights into potential therapeutic strategies.

Asciminib plus dasatinib and prednisone for Philadelphia chromosome-positive acute leukemia

ABSTRACT

Dasatinib is an effective treatment for Philadelphia chromosome-positive (Ph+) acute leukemia, but some patients develop resistance. Combination treatment with dasatinib and asciminib, an allosteric inhibitor of BCR::ABL1, may deepen responses and prevent the emergence of dasatinib-resistant clones. In this phase 1 study (NCT03595017), 24 adults with Ph+ acute lymphoblastic leukemia (ALL; n = 22; p190, n = 16; p210, n = 6) and chronic myeloid leukemia in lymphoid blast crisis (n = 2) were treated with escalating daily doses of asciminib in combination with dasatinib 140 mg daily plus prednisone 60 mg/m2 daily to determine the maximum tolerated dose. After a 28-day induction, dasatinib and asciminib were continued indefinitely or until hematopoietic stem cell transplant. The median age was 64.5 years (range, 33-85; 50% aged ≥65 years). The recommended phase 2 dose of asciminib was 80 mg daily in combination with dasatinib and prednisone. The dose limiting toxicity at 160 mg daily was asymptomatic grade 3 pancreatic enzyme elevation without symptomatic pancreatitis. There were no vaso-occlusive events. Among patients with de novo ALL, the complete hematologic remission rates at days 28 and 84 were 84% and 100%, respectively. At day 84, 100% of patients achieved complete cytogenetic remission, 89% achieved measurable residual disease negativity (<0.01%) by multicolor flow cytometry, and 74% and 26% achieved BCR::ABL1 reverse transcription quantitative polymerase chain reaction <0.1% and <0.01%, respectively. Dual BCR::ABL1 inhibition with dasatinib and asciminib is safe with encouraging activity in patients with de novo Ph+ ALL. This trial was registered at www.clinicaltrials.gov as #NCT02081378.

Relapsed Philadelphia chromosome-positive B-cell acute lymphoblastic leukaemia responds well to a combination of modified hyper-CVAD, blinatumomab and tyrosine kinase inhibitor

Introduction

Adults with relapsed or refractory Philadelphia chromosome-positive B-cell precursor acute lymphoblastic leukaemia (R/R Ph+ BCP-ALL) have a dismal outcome. Blinatumomab as a single agent has shown activity in R/R Ph- BCP-ALL, and second or third-generation tyrosine kinase inhibitors (TKIs) can produce high remission rates in Ph+ leukaemias. We aimed to assess the activity of blinatumomab and TKI in combination with intensive chemotherapy in the relapsed or refractory setting.

Methods

Ten patients with R/R Ph+ BCP-ALL were treated with the combination of a modified hyper-CVAD (mHCVAD) regimen (cyclophosphamide, vincristine, adriamycin, dexamethasone), blinatumomab and TKI (mainly ponatinib).

Results

Complete remission (CR) was achieved in 10/10 patients, with deep molecular responses, and 6/10 were alive in remission after a median follow-up of 19.4 months. Three major cardiovascular events were noted.

Conclusion

These preliminary data, suggest that the mHCVAD-blinatumomab-TKI (mainly ponatinib) regimen may achieve a high rate of CR with undetectable measurable residual disease in adults with R/R Ph+ BCP-ALL and could be proposed to such patients, but cardiovascular or infectious complications should be warning, especially in older or frail patients.

Herpesvirus Infections After Chimeric Antigen Receptor T-Cell Therapy and Bispecific Antibodies: A Review

In this narrative review, we explore the burden and risk factors of various herpesvirus infections in patients receiving chimeric antigen receptor T-cell (CAR-T) therapy or bispecific antibodies (BsAb) for the treatment of hematologic malignancies. Antiviral prophylaxis for herpes simplex/varicella zoster viruses became part of the standard of care in this patient population. Breakthrough infections may rarely occur, and the optimal duration of prophylaxis as well as the timing of recombinant zoster immunization remain to be explored. Clinically significant cytomegalovirus (CMV) infections can affect up to 10% of patients after CAR-T, depending on the CAR-T product target, post-CAR-T complications such as cytokine release syndrome and the need for glucocorticoid therapy. Surveillance and prophylactic strategies for CMV need to be developed, whereas the risk factors for and the burden of CMV infections after BsAb are not yet well-defined. Human herpes virus 6 reactivation and end organ disease such as encephalitis are rarely reported after CAR-T and have not yet been reported after BsAb; additional research is needed.

Frontline immunotherapeutic combination strategies in adult B-cell acute lymphoblastic leukemia: reducing chemotherapy intensity and toxicity and harnessing efficacy

Using immunotherapeutic agents like inotuzumab ozogamicin (InO), blinatumomab, or chimeric antigen receptor T (CAR T)-cell therapy in frontline adult B-cell acute lymphoblastic leukemia (B-ALL) therapy is promising. These agents are mostly well tolerated and have different toxicity profiles than conventional chemotherapy, enabling their combination with chemotherapy. Additionally, they have often been shown to overcome the traditional adverse ALL risk features. Recently blinatumomab was approved as part of consolidation therapy in MRD negative B-ALL; however, a significant proportion of patients had progressed or relapsed before reaching the timepoint of blinatumomab administration. Including InO/blinatumomab from induction onwards could induce earlier and deeper remissions. Modifications of dosing and administration schedules, as with the fractionated InO schedule with low-intensity chemotherapy, and subcutaneous blinatumomab, appear to reduce the toxicity and improve the anti-ALL efficacy. CAR T-cell therapies like brexucabtagene autoleucel as a consolidation approach have shown positive outcomes. The feasibility of using CAR T-cells to reduce the need for long-drawn maintenance and the need for allogeneic hematopoietic stem cell transplantation (HSCT) are questions of ongoing clinical trials. Newer generation CAR T-cell products like obecabtagene autoleucel appear as effective and safer. Better disease monitoring through next generation sequencing based measurable residual disease analysis could identify patients where treatment intensification including HSCT, or deintensification, is suitable.

How I treat adult Ph+ ALL

ABSTRACT

The Philadelphia (Ph) chromosome is one of the few genetic aberrations in which a casualty has been proven and, as such, represents a success in the history of medicine. This is also evident in the setting of Ph+ acute lymphoblastic leukemia (ALL), the most frequent genetic subgroup in adult ALL, whose incidence increases with age and whose prognosis, before the advent of tyrosine kinase inhibitors (TKIs), was particularly poor. The outcome and management of patients with Ph+ ALL have greatly improved since the incorporation of first-, second-, and third-generation TKIs in the therapeutic backbone and is further changing with the more recent introduction of immunotherapy. This allows for long-term survival rates currently ranging between 75% and 80%. The clinical scenario of adult Ph+ ALL has thus changed profoundly, and new challenges are emerging. In this article, illustrative clinical cases are used to discuss the current role of systemic chemotherapy and allogeneic stem cell transplant, the difficulty in treating central nervous system relapses and, more in general, relapses in the current therapeutic era, and the possibility of stopping TKIs. Finally, the challenges related to an optimal management of these patients are discussed.

How I treat Philadelphia chromosome-like acute lymphoblastic leukemia in children, adolescents, and young adults

ABSTRACT

Philadelphia chromosome-like acute lymphoblastic leukemia (Ph-like ALL) represents a high-risk B-lineage ALL subtype characterized by adverse clinical features and poor relapse-free survival despite risk-adapted multiagent chemotherapy regimens. The advent of next-generation sequencing has unraveled the diversity of kinase-activating genetic drivers in Ph-like ALL that are potentially amenable to personalized molecularly-targeted therapies. Based upon robust preclinical data and promising case series of clinical activity of tyrosine kinase inhibitor (TKI)-based treatment in adults and children with relevant genetic Ph-like ALL subtypes, several clinical trials have investigated the efficacy of JAK- or ABL-directed TKIs in cytokine receptor-like factor 2 (CRLF2)/JAK pathway-mutant or ABL-class Ph-like ALL, respectively. The final results of these trials are pending, and standard-of-care therapeutic approaches for patients with Ph-like ALL have yet to be defined. In this How I Treat perspective, we review recent literature to guide current evidence-based treatment recommendations via illustrative clinical vignettes of children, adolescents, and young adults with newly diagnosed or relapsed/refractory Ph-like ALL, and we further highlight open and soon-to-open trials investigating immunotherapy and TKIs specifically for this high-risk patient population.

A young adult patient with Philadelphia positive acute lymphoblastic leukemia presenting with extreme hyperleukocytosis

Extreme hyperleukocytosis (Leukocyte count >200 × 109/L) in an adolescent young adult (AYA) patient with B-ALL could result in mild symptoms of leukostasis. Hyperleukocytosis requires prompt initiation of therapy with adequate hydration, cytoreduction and prevention of tumor lysis. Ph + B-ALL may present with extreme hyperleukocytosis and may be resistant to initial pre-phase therapy. In such cases, leukocytapheresis is beneficial in reducing the leukocyte count as well as controlling the symptoms.

Bispecific antibodies for the treatment of hematologic malignancies: The magic is T-cell redirection

Bispecific antibody therapy has revolutionized the treatment of hematologic malignancies. There are currently 7 FDA approved products with 4 different targets covering 5 indications in 4 diseases. Products include blinatumomab targeting B-cell ALL in MRD detectable first remission and in relapsed and/or refractory disease, elranatamab and teclistamab targeting BCMA in relapsed/refractory multiple myeloma, talquetamab targeting GPCR5D in multiple myeloma, and mosunetuzumab, epcoritamab and glofitamab which all target CD20 in follicular lymphoma, both follicular and large B cell lymphoma, or large B cell lymphoma alone, respectively. Each product utilizes the strategy of T-cell redirection by binding CD3 on the effector cell to target immune cells toward a tumor associated antigen. There are overlapping toxicities related to activation of the immune system and inflammation. The role of these agents in earlier lines of therapy and in novel combinations are under heavy investigation and their full utility and benefit in the treatment of hematologic malignancies is yet to be fully realized.

Impact of the Type of Tyrosine Kinase Inhibitor (imatinib or dasatinib) Used Before allo-HCT on Outcome of Patients with Philadelphia-Positive Acute Lymphoblastic Leukemia. A Study on Behalf of the Acute Leukemia Working Party of the EBMT

The use of tyrosine kinase inhibitors (TKIs) during induction and consolidation, followed by allogeneic hematopoietic cell transplantation (allo-HCT), is a standard of care for patients with Philadelphia (Ph)-positive acute lymphoblastic leukemia (ALL). The goal of this study was to compare results of allo-HCT according to the type of TKI used pre-transplant, either imatinib, dasatinib or both. This was a retrospective, registry-based analysis including adult patients with Ph-positive ALL treated with allo-HCT between years 2010-2022. The analysis included 606 patients pre-treated with imatinib, 163 with dasatinib and 94 with both imatinib and dasatinib. Allo-HCTs were performed in first complete remission from either unrelated (56%), matched sibling (36%) or haploidentical donors (8%). Relapse incidence at 2 years was 26% in the imatinib group and 21% in the dasatinib group and 19% in the imatinib + dasatinib group (P = .06) while non-relapse mortality was 19%, 15%, and 23%, respectively (P = .37). No significant differences were found for leukemia-free survival (55% vs. 63% vs. 58%, P = .11) and overall survival (72% vs. 76% vs. 65%, P = .32). The incidence of grade 2-4 acute graft-versus-host disease (GVHD) and chronic GVHD was comparable across study groups, while the incidence of grade 3-4 acute GVHD was significantly increased for patients pre-treated with dasatinib alone (20%) than in the imatinib group (10%) or imatinib + dasatinib group (13%) (P = .002). On multivariate analysis a chance of GVHD and relapse-free survival (GRFS) was significantly decreased while the risk of grade 3-4 acute GVHD was increased for the dasatinib compared to imatinib group (hazard ratio, HR = 1.27, P = .048 and HR = 2.26, P = .0009, respectively). This study provides no evidence for the advantage of one TKI over another in terms of LFS and OS. However, the use of dasatinib is associated with increased risk of severe acute GVHD and decreased GRFS.

The Effect of Hematopoietic Stem Cell Transplantation on Treatment Outcome in Children with Acute Lymphoblastic Leukemia

PURPOSE

Hematopoietic stem cell transplantation (HSCT) has been an important method of treatment in the advance of pediatric acute lymphoblastic leukemia (ALL). The indications for HSCT are evolving and require updated establishment. In this study, we aimed to investigate the efficacy of HSCT on the treatment outcome of pediatric ALL, considering the indications for HSCT and subgroups.

MATERIALS AND METHODS

A retrospective analysis was conducted on ALL patients diagnosed and treated at a single center. Risk groups were categorized based on age at diagnosis, initial white blood cell count, disease lineage (B/T), and cytogenetic study results. Data on the patients' disease status at HSCT and indications of HSCT were collected. Indications for HSCT were categorized as upfront HSCT at 1st complete remission, relapse, and refractory disease.

RESULTS

Among the 549 screened patients, a total of 418 patients were included in the study; B-cell ALL (n=379) and T-cell ALL (T-ALL) (n=39). HSCT was conducted on a total of 106 patients (25.4%), with a higher frequency as upfront HSCT in higher-risk groups and specific cytogenetics. The overall survival (OS) was significantly better when done upfront than in relapsed or refractory state in T-ALL patients (p=0.002). The KMT2A-rearranged ALL patients showed superior event-free survival (p=0.002) and OS (p=0.022) when HSCT was done as upfront treatment.

CONCLUSION

HSCT had a substantial positive effect in a specific subset of pediatric ALL. In particular, frontline HSCT for T-ALL and KMT2A-rearranged ALL offered a better prognosis than when HSCT was conducted in a relapsed or refractory setting.

A multiomic atlas identifies a treatment-resistant, bone marrow progenitor-like cell population in T cell acute lymphoblastic leukemia

Refractoriness to initial chemotherapy and relapse after remission are the main obstacles to curing T cell acute lymphoblastic leukemia (T-ALL). While tumor heterogeneity has been implicated in treatment failure, the cellular and genetic factors contributing to resistance and relapse remain unknown. Here we linked tumor subpopulations with clinical outcome, created an atlas of healthy pediatric hematopoiesis and applied single-cell multiomic analysis to a diverse cohort of 40 T-ALL cases. We identified a bone marrow progenitor (BMP)-like leukemia subpopulation associated with treatment failure and poor overall survival. The single-cell-derived molecular signature of BMP-like blasts predicted poor outcome across multiple subtypes of T-ALL and revealed that NOTCH1 mutations additively drive T-ALL blasts away from the BMP-like state. Through in silico and in vitro drug screenings, we identified a therapeutic vulnerability of BMP-like blasts to apoptosis-inducing agents including venetoclax. Collectively, our study establishes multiomic signatures for rapid risk stratification and targeted treatment of high-risk T-ALL.

Incidence, duration, and severity of neutropenia in adults with B-cell acute lymphoblastic leukemia receiving blinatumomab consolidation

Blinatumomab is a CD3 × CD19 antibody approved for adults with B-cell acute lymphoblastic leukemia (B-ALL). Blinatumomab is not considered myelosuppressive, but significant neutropenia has been seen in practice. We reviewed 95 patients with B-ALL who received blinatumomab at Dana-Farber Cancer Institute between 2015 and 2024. Of these, 71 patients were treated in morphologic remission with absolute neutrophil count (ANC) ≥1 × 109/L, for which 41% experienced grade ≥3 neutropenia and 13% developed ANC <0.1 × 109/L during blinatumomab. Neutropenia occurred more frequently during cycle 2 than cycle 1, and neutropenia did not necessarily portend worse neutropenia in later cycles. Multivariable analysis did not identify concurrent tyrosine kinase inhibitor use as a significant covariate for neutropenia. The nine patients who experienced ANC <0.1 × 109/L did not develop serious infections and received supportive care. Neutropenia occurs frequently and may be severe in patients with B-ALL who receive blinatumomab during remission, but complications appear manageable.

Ponatinib and prednisolone induce sustained remission in a relapsed case of mixed-phenotype acute leukemia with BCR::ABL1 fusion intolerant to dasatinib

Mixed-phenotype acute leukemia (MPAL) with BCR::ABL1 fusion is a rare leukemia subtype exhibiting both myeloid and lymphoid traits. Standard treatment involves chemotherapy with a tyrosine kinase inhibitor (TKI). However, establishing the optimal treatment strategy for elderly patients with MPAL with BCR::ABL1 fusion is challenging due to their intolerance to intensive chemotherapy. It has not yet been determined whether therapy with a TKI and prednisolone, a combination known to be effective in elderly patients with B-lymphoblastic leukemia with BCR::ABL1 fusion is also safe and effective for MPAL with BCR::ABL1 fusion. Here we report the first example of an elderly patient with MPAL with BCR::ABL1 fusion who was treated successfully with ponatinib and prednisolone. Despite achieving complete response with dasatinib plus chemotherapy, the patient suffered a relapse during the withdrawal of dasatinib and had two episodes of gastrointestinal bleeding attributed to the dasatinib therapy, necessitating therapy discontinuation. The treatment was then switched to a regimen of ponatinib and prednisolone, and the patient achieved and maintained complete molecular remission for over seven years without any serious adverse events. This case suggests that ponatinib, with or without prednisolone, could be a potential salvage option for elderly patients with MPAL with BCR::ABL1 fusion who suffer relapse or are intolerant to dasatinib.

Role of Allogeneic Hematopoietic Stem Cell Transplantation for Philadelphia Chromosome-Positive B-Cell Acute Lymphoblastic Leukemia in the Contemporary Era

The treatment of Philadelphia chromosome-positive B-cell acute lymphoblastic leukemia (Ph+ B-cell ALL) has seen substantial progress over the past two decades. The introduction of BCR::ABL1 tyrosine kinase inhibitor (TKIs) has resulted in dramatic improvements in long-term survival. Allogeneic hematopoietic stem cell transplantation (allo-HSCT), with its curative potential, has always been an integral part of the treatment algorithm of Ph+ ALL. Recently, the approval of novel therapies such as blinatumomab, inotuzumab ozogamicin and chimeric antigen receptor T-cell (CAR-T) therapy in relapse and refractory (R/R) ALL have further improved outcomes of B-cell ALL. With potent TKIs and novel targeted therapy, the treatment guidelines for Ph+ ALL are evolving rapidly. Additionally, with improved tools for detecting measurable residual disease (MRD), there has been recent interest in redefining the role of allo-HSCT for some patients. In this context, we discuss the current evidence for the utilization of allo-HSCT for Ph+ ALL, focusing on novel therapies and MRD-directed care.

Results of the Simultaneous Combination of Ponatinib and Blinatumomab in Philadelphia Chromosome-Positive ALL

Clinical trials frequently include multiple end points that mature at different times. The initial report, typically based on the primary end point, may be published when key planned co-primary or secondary analyses are not yet available. Clinical Trial Updates provide an opportunity to disseminate additional results from studies, published in JCO or elsewhere, for which the primary end point has already been reported.In this analysis, we update our experience with the chemotherapy-free regimen of blinatumomab and ponatinib in 60 patients with newly diagnosed Philadelphia chromosome (Ph)-positive ALL. At a median follow-up of 24 months, the complete molecular response rate by reverse transcriptase-polymerase chain reaction was 83% (67% at the end of course one), and the rate of measurable residual disease negativity by next-generation clono-sequencing was 98% (45% at the end of course one). Only two patients underwent hematopoietic stem cell transplantation (HSCT). Seven patients relapsed: two with systemic disease, four with isolated CNS relapse, and one with extramedullary Ph-negative, CRLF2-positive pre-B ALL. The estimated 3-year overall survival rate was 91% and event-free survival rate was 77%. Three patients discontinued blinatumomab because of adverse events (related, n = 1; unrelated, n = 2) and nine discontinued ponatinib because of cerebrovascular ischemia, coronary artery stenosis, persistent rash, elevated liver function tests with drug-induced fatty liver, atrial thrombus, severe arterial occlusive disease of lower extremities, pleuro-pericardial effusion, and debilitation. In conclusion, the simultaneous combination of ponatinib and blinatumomab is a highly effective and relatively safe nonchemotherapy regimen. This regimen also reduces the need for intensive chemotherapy and HSCT in first remission in the majority of patients.

SRC kinase drives multidrug resistance induced by KRAS-G12C inhibition

Direct targeting of the KRAS-G12C-mutant protein using covalent inhibitors (G12Ci) acts on human non-small cell lung cancer (NSCLC). However, drug resistance is an emerging concern in this approach. Here, we show that MRTX849, a covalent inhibitor targeting the KRAS-G12C mutation, leads to the reactivation of the mitogen-activated protein kinase signaling pathway in MRTX849-resistant NSCLC and pancreatic ductal adenocarcinoma. A genome-wide CRISPR screen revealed that the adenosine triphosphate binding cassette transporter ABCC1 mediates MRTX849 resistance. Functional studies demonstrated that the transcription factor JUN drives ABCC1 expression, resulting in multidrug resistance. An unbiased drug screen identified the tyrosine kinase inhibitor dasatinib that potentiates MRTX849 efficacy by inhibiting SRC-dependent JUN activation, avoiding multidrug resistance and tumor suppression in vitro as well as in suitable preclinical mouse models and patient-derived organoids. SRC inhibitors (DGY-06-116, dasatinib, and bosutinib) also exhibit synergistic effects with MRTX849 in eliminating various tumor cell lines carrying KRAS-G12C mutations. Thus, SRC inhibitors amplify the therapeutic utility of G12Ci.

Ph- ALL: immunotherapy in upfront treatment

Antibody-based and cell-based novel immunotherapies, such as bispecific T-cell engagers (BiTE), antibody-drug conjugates, or chimeric antigen receptor (CAR) T cells are currently standard treatment options for patients with relapsed or refractory (R/R) B-cell precursor acute lymphoblastic leukemia (ALL). To date, CD20-targeting monoclonal antibodies and the CD19-targeting BiTE's blinatumomab have been established elements of frontline therapy, either in patients with CD20+ ALL or in patients with measurable disease (MRD) following conventional chemotherapy. Recently, blinatumomab has also demonstrated a survival benefit in patients with MRD-negative ALL. Based on the observed high response rates and improved survival outcomes in patients with R/R ALL, antibody-based immunotherapies are being prospectively studied in the upfront setting, particularly in older adult patients, where even age-adapted conventional chemotherapies are still associated with significant rates of early death, treatment-related toxicity, and poor prognosis. In these approaches, conventional chemotherapy has been replaced or reduced and supplemented by immunotherapeutic agents, resulting in promising outcomes that form the basis for evaluating and defining new treatment standards.

Ph+ ALL: new approaches for upfront therapy

Philadelphia chromosome-positive (Ph+) ALL is the most common genetic subtype of ALL and primarily affects adults. Ph+ ALL is characterized by the constitutively active ABL1 kinase and is resistant to conventional chemotherapy. Thus, Ph+ ALL was historically associated with a dismal prognosis, particularly among patients who did not undergo allogeneic hematopoietic stem cell transplantation (alloHCT) in first complete remission (CR). Imatinib, the first tyrosine kinase inhibitor (TKI) effective against ABL1, transformed the treatment and prognosis of Ph+ ALL, allowing more patients to achieve CR and become eligible for alloHCT, thereby improving outcomes. In recent years, there has been an improved understanding of the biology of Ph+ ALL, including recognition of distinct subtypes (multilineage and lymphoblast-only Ph+ ALL). There has also been a dramatic expansion of effective therapeutic and diagnostic tools for management of Ph+ ALL, including more potent TKIs, which have activity against ABL kinase-resistance mutations; refinement of the chemotherapy and alloHCT regimens that accompany TKI therapy; introduction of immunotherapy (blinatumomab); and better assays for measurable residual disease monitoring. This article reviews recent advancements and future directions for the initial treatment of Ph+ ALL in adults.

IKZF1 in acute lymphoblastic leukemia: the rise before the fall?

Acute lymphoblastic leukemia (ALL) is the most common malignancy in children and adolescents and in recent decades, the survival rates have risen to >90% in children largely due the introduction of risk adapted therapy. Therefore, knowledge of factors influencing risk of relapse is important. The transcription factor IKAROS is a regulator of lymphocyte development and alterations of its coding gene, IKZF1, are frequent in ALL and are associated with higher relapse risk. This concise review will discuss the normal function of IKAROS together with the effect of gene alterations in ALL such as relieved energy restriction and altered response to anti-leukemic drugs. Besides the biology, the clinical impact of gene alterations in the different subtypes of ALL will be discussed. Finally, possibilities for treating ALL with IKZF1 alterations will be considered including novel therapies like cell signaling inhibitors and immunotherapy.

Impact of induction regimens intensity and allogeneic stem cell transplantation on survival of patients with Philadelphia chromosome-positive acute lymphoblastic leukemia: A multi-institutional study

Intensive chemotherapy (IC) combination with second- or third-generation TKI improves survival compared to non-IC with first-generation TKI. Allo-HCT was suggestive of improving RFS/OS after propensity score matching and multivariable analysis.

A review of immunotargeted therapy for Philadelphia chromosome positive acute lymphoblastic leukaemia: making progress in chemotherapy-free regimens

Philadelphia chromosome-positive acute lymphoblastic leukemia (PH + ALL) is the most common cytogenetic abnormality of B-ALL in adults and is associated with poor prognosis. Previously, the only curative treatment option in PH + ALL was allogeneic hematopoietic stem cell transplantation (Allo-HSCT). Since 2000, targeted therapy combined with chemotherapy, represented by the tyrosine kinase inhibitor Imatinib, has become the first-line treatment for PH + ALL. Currently, the remission rate and survival rate of Imatinib are superior to those of simple chemotherapy, and it can also improve the efficacy of transplantation. More recently, some innovative immune-targeted therapy greatly improved the prognosis of PH + ALL, such as Blinatumomab and Inotuzumab Ozogamicin. For patients with ABL1 mutations and those who have relapsed or are refractory to other treatments, targeted oral small molecule drugs, monoclonal antibodies, Bispecific T cell Engagers (BiTE), and chimeric antigen receptor (CAR) T cells immunotherapy are emerging as potential treatment options. These new therapeutic interventions are changing the treatment landscape for PH + ALL. In summary, this review discusses the current advancements in targeted therapeutic agents shift in the treatment strategy of PH + ALL towards using more tolerable chemotherapy-free induction and consolidation regimens confers better disease outcomes and might obviate the need for HSCT.

Predicting relapse in acute lymphoblastic leukemia

Outcomes in adult and pediatric patients with acute lymphoblastic leukemia (ALL) have improved over successive generations due to rigorously conducted clinical trials and incorporation of novel therapeutic agents. Despite these advances, approximately 20% of high-risk pediatric patients and 50% of adults with ALL will fail to achieve long-term remission with frontline chemotherapy protocols, mostly due to relapse. The ability to predict which patients with ALL are more likely to relapse allows for early intensification of therapy and/or incorporation of novel immunotherapies with the goal of relapse prevention. In this review, we outline the most robust clinical predictors of relapse in ALL with a focus on measurable residual disease (MRD) and genomics. We also discuss application of these prognostic tools in different clinical settings including frontline treatment, pre-/post-allogeneic stem cell transplant, and pre-/post-Chimeric Antigen Receptor T-cell therapy.

Frontline treatment of adults with newly diagnosed B-cell acute lymphoblastic leukaemia

In the past decade, there has been considerable progress in the treatment of adults with newly diagnosed B-cell acute lymphoblastic leukaemia. This evolution is the product of a more profound understanding of acute lymphoblastic leukaemia biology, innovations in measurable residual disease quantification that led to precise disease-risk stratification, adoption of contemporary paediatric-inspired regimens, inclusion of tyrosine kinase inhibitors in the treatment of Philadelphia chromosome-positive acute lymphoblastic leukaemia, and the introduction of immunotherapy in the frontline setting. Nevertheless, outcomes of acute lymphoblastic leukaemia in adults are inferior compared with those of children, with excessive rates of treatment failure, and therapy-related morbidity and mortality. Simultaneously, transplant consolidation has continued to be used frequently for high-risk adults with acute lymphoblastic leukaemia in first complete remission. Considering the rapid pace of evolution in acute lymphoblastic leukaemia management, novel trial designs are warranted to accelerate advancements and streamline approaches. Here, we summarise progress in the treatment of adults with newly diagnosed acute lymphoblastic leukaemia, which adds to previously published guidelines by focusing specifically on first-line decisions for B-cell acute lymphoblastic leukaemia and how to best personalise treatment. This Viewpoint also includes experiences with regimens and testing approaches currently available not only in Europe, but also on multiple continents with different practices and resources.

Progress on angiogenic and antiangiogenic agents in the tumor microenvironment

The development of tumors and their metastasis relies heavily on the process of angiogenesis. When the volume of a tumor expands, the resulting internal hypoxic conditions trigger the body to enhance the production of various angiogenic factors. These include vascular endothelial growth factor (VEGF), fibroblast growth factor (FGF), platelet-derived growth factor (PDGF), and transforming growth factor-α (TGF-α), all of which work together to stimulate the activation of endothelial cells and catalyze angiogenesis. Antiangiogenic therapy (AAT) aims to normalize tumor blood vessels by inhibiting these angiogenic signals. In this review, we will explore the molecular mechanisms of angiogenesis within the tumor microenvironment, discuss traditional antiangiogenic drugs along with their limitations, examine new antiangiogenic drugs and the advantages of combination therapy, and consider future research directions in the field of antiangiogenic drugs. This comprehensive overview aims to provide insights that may aid in the development of more effective anti-tumor treatments.

Clinical Insights on Brexucabtagene Autoleucel for the Treatment of Patients with Relapsed or Refractory B-Cell Acute Lymphoblastic Leukemia

Autologous chimeric antigen receptor-modified T-cell therapy (CAR-T) has revolutionized treatment paradigms across multiple lymphoid malignancies, including relapsed/refractory (R/R) B-cell acute lymphoblastic leukemia (B-ALL). The introduction of the CD19-directed CAR-T product brexucabtagene autoleucel (brexu-cel; Tecartus) in October 2021 made this treatment approach available for the first time for adults with R/R B-ALL, a historically challenging clinical entity to treat. In this review, we will discuss the pivotal clinical trial data from the ZUMA-3 study that led to the US Food and Drug Administration (FDA) approval of brexu-cel, including clinical outcomes and key toxicity data (most importantly, the incidence and severity of cytokine release syndrome and immune effector cell-associated neurotoxicity syndrome). Additionally, we will compare and contrast these data from the ZUMA-3 study with "real-world" data from examinations of patient outcomes with brexu-cel as an FDA-approved therapy in R/R B-ALL, and discuss practical considerations with brexu-cel use in the clinic, including the role of consolidative allografting for patients post-brexu-cel. We finish by discussing future directions for CAR-T use in R/R B-ALL with the anticipated introduction of a new CD19-directed CAR-T product - obecabtagene autoleucel - in the near future.

Heterogeneity of IKZF1 genomic alterations and risk of relapse in childhood B-cell precursor acute lymphoblastic leukemia

Genomic alterations of IKZF1 are common and associated with adverse clinical features in B-ALL. The relationship between the type of IKZF1 alteration, disease subtype and outcome are incompletely understood. Leukemia subtype and genomic alterations were determined using transcriptome and genomic sequencing and SNP microarray in 688 pediatric patients with B-ALL in St. Jude Total Therapy 15 and 16 studies. IKZF1 alterations were identified in 115 (16.7%) patients, most commonly in BCR::ABL1 (78%) and CRLF2-rearranged, BCR::ABL1-like B-ALL (70%). These alterations were associated with 5-year cumulative incidence of relapse (CIR) of 14.8 ± 3.3% compared to 5.0 ± 0.9% for patients without any IKZF1 alteration (P < 0.0001). IKZF1 deletions of exon 4-7 (P = 0.0002), genomic IKZF1 plus with any IKZF1 deletion (P = 0.006) or with focal IKZF1 deletion (P = 0.0007), and unfavorable genomic subtypes (P < 0.005) were independently adversely prognostic factors. Associations of genomic IKZF1 plus and exon 4-7 deletions with adverse outcomes were confirmed in an independent cohort. Genomic IKZF1 plus with any IKZF1 deletion, IKZF1 deletion of exon 4-7, and unfavorable subtype confer increased risk of relapse. The type of IKZF1 alteration, together with the subtype, are informative for risk stratification and predict response in patients with B-ALL.

Philadelphia Chromosome as a Clinically Favorable Prognostic Factor of B-cell Acute Lymphoblastic Leukemia/Lymphoblastic Lymphoma in Transplant-Ineligible Elderly Patients in the Era of Molecular-Targeted Therapy

Background and objective There is scarce data on the treatment outcomes of B-cell acute lymphoblastic leukemia/lymphoblastic lymphoma (B-ALL/LBL) in elderly patients in the era of tyrosine kinase inhibitors (TKIs), blinatumomab, and inotuzumab ozogamicin. In light of this, we aimed to address this gap in data by conducting this retrospective study. Methods Treatment outcomes were retrospectively evaluated by using data from transplant-ineligible patients aged 65 years or older with newly diagnosed B-ALL/LBL (n=29) at two hospitals in Oita, Japan between 2013 and 2023. Results The median age of the cohort was 72 (65-88) years, and 10 patients were male; 17 patients had Philadelphia chromosome (Ph)-positive ALL, and the others had Ph-negative ALL. Dasatinib combined with prednisolone was the most common induction therapy for Ph-positive ALL (88.2%). Complete response (CR) was achieved in 93.1%, and the CR rate did not differ significantly between Ph-positive ALL (100%) and Ph-negative ALL (83.3%) (p=0.16). The median observation period was 1.52 (range: 0.03-8.98) years. Overall survival (OS) and event-free survival (EFS) were significantly longer in Ph-positive ALL patients than in Ph-negative ALL patients on univariate analysis (OS: p=0.011, EFS: p=0.041). Multivariate analyses showed that the presence of Ph was significantly and independently associated with longer OS [hazard ratio (HR): 0.29, 95% confidence interval (CI): 0.10-0.87, p=0.027] and EFS (HR: 0.34, 95% CI: 0.12-0.91, p=0.03). There was no difference in relapse-free survival (RFS); 13 patients (76.5%) with Ph-positive ALL were treated with ponatinib (salvage therapy, n=7; consolidation or maintenance therapy in CR, n=6). Six of seven patients (85.7%) with ponatinib salvage therapy achieved CR, and all six patients treated with ponatinib consolidation or maintenance therapy retained CR at the last follow-up. Six patients (Ph-positive ALL: n=4; Ph-negative ALL: n=2) were treated with blinatumomab, including salvage therapy for primary refractory or relapse (n=3), and consolidation therapy due to intolerance to conventional chemotherapies (n=3). Two of three patients with blinatumomab salvage therapy achieved CR, and all three patients with blinatumomab consolidation therapy maintained CR in follow-up. Two patients (Ph-positive ALL: n=1; Ph-negative ALL: n=1) were treated with inotuzumab ozogamicin for relapsed or refractory ALL. A patient with Ph-positive ALL for the third relapse achieved CR, which was sustained for three years. The other patient with Ph-negative ALL for primary refractory achieved CR but relapsed after the fourth course of inotuzumab ozogamicin. Conclusions Elderly patients with Ph-positive ALL showed significantly longer OS and EFS than those with Ph-negative ALL in the era of molecular-targeted therapy.

Immunotherapy in first line treatment of adult acute lymphoblastic leukemia

PURPOSE OF REVIEW

The use of immunotherapy in recent years has changed the paradigm of treatment in patients with B-cell precursor acute lymphoblastic leukemia (BCP-ALL), improving outcomes in the relapsed/refractory setting. New strategies are incorporating immunotherapy into front-line regimens to reduce the toxicity of chemotherapy, prolong survival and increase the possibility of treating older patients. The aim of this review was to describe the new strategies, which have incorporated these drugs into front-line regimens for BCP-ALL patients.

RECENT FINDINGS

Recent studies have demonstrated that immunotherapy can be included in front-line induction, consolidation and/or maintenance regimens for the treatment of BCP-ALL patients by its addition to chemotherapy, by substituting some chemotherapy cycles or even including immunotherapy in chemotherapy-free strategies.

SUMMARY

The implications of these relevant findings will allow treating older patients, reducing the toxicity of chemotherapy and increasing patient outcomes. In addition, these findings have raised the possibility of avoiding the need for hematologic stem cell transplant in some selected patients.

Inotuzumab ozogamicin in adult acute lymphoblastic leukemia: Development, current status, and future directions

Inotuzumab ozogamicin (InO) is an antibody-drug conjugate approved for the treatment of relapsed/refractory B-cell acute lymphoblastic leukemia (ALL). Several clinical trials are investigating InO in combination with low-intensity chemotherapy or other anti-ALL-targeted therapies in the salvage and frontline settings, notably in older adults who often cannot tolerate intensive chemotherapy and tend to have higher-risk disease. InO is also increasingly used to bridge patients to hematopoietic stem cell transplantation (HSCT), in sequence with chimeric antigen receptor T-cell therapy, to eliminate measurable residual disease and to prevent post-HSCT relapse. Veno-occlusive disease/sinusoidal obstruction syndrome is a potential complication of InO treatment, particularly when followed by HSCT. Herein, the authors review the historical development and current status of InO, strategies for mitigating the risk of InO-related veno-occlusive disease/sinusoidal obstruction syndrome, and future directions for InO research and clinical use.

Precision Medicine for Acute Lymphoblastic Leukemia in Children: A Review

The clinical outcome for children diagnosed with acute lymphoblastic leukemia is a testimony to the success of modern medicine. Over the past few decades, survival has climbed from ∼10% to >90% for certain subgroups. Yet, the outcome for those with relapsed disease is often poor, and survivors struggle with a multitude of healthcare issues, some of which are lifelong. In recent years, the advent of the widespread sequencing of tumors has made available patients with previously unrecognized subtypes of leukemia, who have the potential to benefit from the addition of targeted therapies. Indeed, the promise of precision medicine, encompassing a person's environment, genetics and lifestyle, is likely to have profound impact on further tailoring therapies that are likely to improve outcomes, diminish toxicity and ultimately pave the pathway for a healthier population.

Efficacy of Chemotherapy-Free Regimens in the Treatment of Philadelphia Chromosome-Positive Acute Lymphoblastic Leukemia: A Systematic Review and Meta-Analysis

INTRODUCTION

The historical standard of care for Ph+ ALL is chemotherapy plus a tyrosine kinase inhibitor (TKI). Recently chemotherapy-free regimens have shown promising efficacy. We performed a meta-analysis to compare the efficacy of chemotherapy-free regimens for Ph+ ALL.

METHODS

We searched PubMed and Embase for chemotherapy-free regimens for Ph+ ALL published between January 2000 and October 2023. Of the 5,348 articles screened, 9 nonrandomized clinical trials enrolling 413 patients were included. Two trials (N = 117) included treatment with 3 agents (blinatumomab, TKI, and steroid) and 7 trials (N = 248) included treatment with 2 agents (TKI and steroids). R software was used to conduct the meta-analysis (PROSPERO registration no. CRD42023482439).

RESULTS

The pooled complete molecular response (CMR) rate of patients receiving a TKI, blinatumomab, and steroids was 81% (95%CI, 69%-89%). TKIs plus blinatumomab were nearly 6 times as likely to have CMR (odds ratio [OR], 5.98; 95%CI, 2.99-11.96) and more than 5 times as likely to be alive at 1-year (OR, 5.1; 95%CI, 1.74-14.9) as compared to TKIs alone. Patients receiving ponatinib were about twice as likely as those receiving dasatinib to achieve CMR (OR, 2.51; 95%CI, 0.72-8.72).

CONCLUSION

Adding blinatumomab to TKIs and steroids significantly improved Ph+ ALL patients' response and survival rates. Regimens with ponatinib elicited higher molecular response rates than those with other TKIs. The high response and survival rates achieved with blinatumomab plus TKIs and steroids suggest that further studies are required to assess the need for intensive treatments such as chemotherapy or stem cell transplant in these patients.

Advances in the treatment of adults with newly diagnosed B-cell acute lymphoblastic leukemia: the role of frontline immunotherapy-based regimens

Blinatumomab and inotuzumab ozogamicin (INO) are both active in relapsed/refractory B-cell acute lymphoblastic leukemia (ALL) and improve outcomes compared with conventional chemotherapy in this setting. Several prospective clinical trials have explored the use of these agents in adults with newly diagnosed B-cell ALL, with promising outcomes observed in younger and older adults and in both Philadelphia chromosome (Ph)-positive and Ph-negative ALL. These novel regimens result in high rates of deep measurable residual disease (MRD) negativity and may improve survival compared with chemotherapy-only approaches, allowing for less reliance on intensive chemotherapy and allogeneic hematopoietic stem cell transplantation (HSCT). This review discusses novel approaches to integrating INO and/or blinatumomab into frontline ALL regimens, including the potential role of chemotherapy-free regimens in some subgroups. The role of MRD monitoring is also discussed, including how this can inform decisions for consolidative allogeneic HSCT or investigational approaches with CD19 CAR T-cells.