EBMT 2022 | An update on the management of Ph+ ALL

Philadelphia chromosome is traditionally considered a very high-risk feature among patients with acute lymphoblastic leukemia. It affects approximately 20% of the adult ALL population. Its frequency increases with age. Traditionally, chemotherapy was the backbone and all patients were considered for allogeneic transplant. But even with allotransplant, the results were not spectacular, they were not satisfactory with LFS rates in the range of 30%. Much lower compared to Ph-negative lymphoblastic leukemia. The situation changed dramatically with the introduction of TKIs that allow for almost a 100% CR rate which increased the proportion of patients referred for allotransplant and altogether contributed to greatly improved LFS rates at between 50 and 60% after five years.
So far imatinib is approved for first-line therapy. According to modern protocols, it is combined with low doses of chemotherapy and all patients remain candidates for allotransplant. But there are recent modern approaches that include immunotherapy like blinatumomab, in a scheme based on second or third-generation TKIs. It seems that such a treatment, which is free of chemotherapy, may allow a significant proportion of patients to achieve complete molecular remission. And these patients must not necessarily be treated with allogeneic transplant. These are Phase II studies. We need confirmation in prospective trials, but I believe that indeed, with a modern combination of second, third-generation TKIs and immunotherapy, the need for allotransplant in this setting will decrease.