Some patients have residual leukemia cells in their bone marrow even after they receive intensive treatment. In these cases, the disease is referred to as “refractory” (or “refractory ALL”). Other patients achieve remission but later have a return of leukemia cells in their bone marrow. This is referred to as a “relapse” of the disease (or “relapsed ALL”).

Treatment for relapsed and refractory ALL is typically more intensive than for newly diagnosed patients.

Ph-Negative ALL

For patients with relapsed or refractory Ph-negative ALL, the following are some possible treatment options:

• Blinatumomab (Blincyto®)
• Tisagenlecleucel (Kymriah®)
• Inotuzumab ozogamicin (Besponsa®)
• Combination regimens that include several chemotherapy drugs, some of which may have been given in the past
• Clinical trial

Chemotherapy regimens using different drug combinations, may also be tried. The following drugs may be part of these regimens:

• Nelarabine for patients with T-cell ALL
• Clofarabine-containing regimens (e.g., clofarabine, cyclophosphamide, etoposide)
• Fludarabine-based regimens (e.g., fludarabine, cytarabine, G-CSF, idarubicin)
• High-dose cytarabine-based regimens (e.g., high dose cytarabine, pegaspargase)
• Allogeneic stem cell transplantation

Ph-Positive ALL

Patients with relapsed or refractory Ph+ ALL may receive a different TKI than what they have taken before.

New mutations in the BCR-ABL1 gene may occur over time. Some mutations can lead to resistance to certain TKIs. Before a patient starts treatment, BCR-ABL1 mutation testing should be done to look for new mutations that may cause certain TKIs to stop working.

Other treatment options may include:

• Blinatumomab
• Tisagenlecleucel
• Inotuzumab ozogamicin, which is being studied in clinical trials
• Allogeneic stem cell transplantation

For information about the drugs listed on this page, visit Drug Listings.

Related Links

• Download or order The Leukemia & Lymphoma Society's free booklet, Acute Lymphoblastic Leukemia (ALL) in Children and Teens
• Caring for Kids and Adolescents Workbook
• About Childhood Blood Cancer