Sequencing of Immunotherapeutic Agents for RR ALL in Adults – One Approach

Immunotherapy “has demonstrated superior outcomes compared to salvage chemotherapy” for relapsed or refractory (RR) B-cell acute lymphoblastic leukemia (ALL) in adults, write the authors of a review, published online in August in Leukemia & Lymphoma, of antibody and cellular immunotherapies for ALL in this population. With the caveat that no studies have yet identified the optimal sequencing of immunotherapeutic agents in this setting, authors Erik L. Kimble, MD, and Ryan D. Cassaday, MD, of the Fred Hutchinson Cancer Research Center describe their usual approach to the management of R/R B-ALL.

For persistent or re-emergent MRD following front-line chemotherapy, they typically choose blinatumomab. In a first relapse or refractory disease, they use either blinatumomab or the monoclonal antibody inotuzumab ozogamicin (InO) “unless a promising combination clinical trial is available.” They also favor blinatumomab for patients who have a relatively low disease burden or who may be at elevated risk for veno-occlusive disease, depending on whether the patient is a candidate for HSCT consolidation and on the surface expression of CD19 and CD22. In the setting of a second or greater relapse, they prefer CAR T-cell therapy; if it is unavailable, they will choose either blinatumomab or InO, depending on which of these agents the patient has received previously.

CD19-directed therapies “may be preferred,” the authors write, “if consolidative allogeneic HSCT is in doubt.” A subset of patients with excellent responses to either blinatumomab or CAR T-cell therapy “may derive durable remission without allogeneic HSCT, whereas such outcomes are rarely experienced following InO.”   

  • Kimble EL, Cassaday RD. Antibody and cellular immunotherapies for acute lymphoblastic leukemia in adults [published online ahead of print, 2021 Aug 17]. Leuk Lymphoma. 2021;1-15. doi:10.1080/10428194.2021.1964022

Tags: BiTEs, september, news brief, Sequencing, adults, agents, immunotherapeutic, one approach

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