Management of Relapse and Refractory Patients

Managing relapsed patients depends on the phase of treatment the patient was in when the relapse occurred:

Relapse through consolidation or maintenance therapy carries a poor prognosis. Reintroducing intensive treatment is usually recommended as part of an overall plan to try to achieve long-term disease control by some sort of allografting procedure. The exact protocols used will vary and depend to some extent on the initial protocols used. Other intensive schedules such as HyperCVAD could be considered. The outcome of patients who relapsed after UKALL12 is presented by Fielding et al 2007. A good account of treatment of relapsed disease is given in Frey, N.V. and Luger, S.M. (2015). "How I treat adults with relapsed or refractory Philadelphia chromosome–negative acute lymphoblastic leukemia." Blood 126: 589-96.

Treatment of high risk ALL, including relapsed ALL, is being revolutionised by use of immunotherapy, such as CART cell therapy, e.g. Tisangenlecleucel, BiTE antibody therapy, e.g. Blinatumumab and labelled antibodies, e.g. inotuzumab ozogamicin. None of these are funded in New Zealand. Some success has been achieved by applications for these agents through the NPPA scheme, as a bridge to allogeneic transplant. See:

Maude, S. L., et al (2018). "Tisagenlecleucel in Children and Young Adults with B-Cell Lymphoblastic Leukemia." New England Journal of Medicine 378(5): 439-448.
Gökbuget, N., et al (2018). "Blinatumomab for minimal residual disease in adults with B-cell precursor acute lymphoblastic leukemia." Blood 131(14): 1522-1531.
Brivio, E., et al (2021). "A phase 1 study of inotuzumab ozogamicin in pediatric relapsed/refractory acute lymphoblastic leukemia (ITCC-059 study)." Blood 137(12): 1582-1590.

If a patient relapses some years after completing maintenance treatment, the same initial treatment could be given again with longer maintenance. Alternatively a different schedule may be used.

All these decisions will be taken together with the patient by the consultant caring for the patient.


About this Canterbury DHB document (4421):
Document Owner:	Peter Ganly (see Who's Who)
Last Reviewed:	December 2021
Next Review:	December 2024
Keywords:
Note: Only the electronic version is controlled. Once printed, this is no longer a controlled document. Disclaimer The Haematology Department Protocols and Guidelines (the Red Book) are intended as a guide for registered health professionals to communicate guidelines and share best practices with supporting health professionals within New Zealand district health boards. They are not intended to be provided to or used as a reference for patients or non-registered health professionals. All health professionals must exercise their own clinical judgement and use pertinent clinical data when treating patients. The authors and editors of this publication have checked with sources believed to be reliable in their effort to provide information that is complete and in accord with the standards accepted at the time of publication. However, in view of the possibility of human error or changes in medical science, neither the authors, editors, publisher, nor any other party who has been involved in preparing or publishing this work warrants that the information contained in it is accurate or complete in every respect. They therefore have no liability (whether in tort (including negligence) or otherwise) for any loss or damage arising out of any reliance on this information. This publication has been compiled by the staff and contractors of Canterbury District Health Board (CDHB) and as such CDHB has copyright for this book. Amendments must be authorised in accordance with the documented process. No release of part of, or all of, this publication to any other party or organisation is permissible without the prior approval of the designated document owner.
Send Feedback Send Feedback	Expand All Drop-downs

Topic Code: 4421