For patients under 40 we prefer the BFM like regimens. For those over 40 we don't have a consensus regimen for treating ALL.

Dr. Serody

Thank you for your reply. I wonder if you combine TKIs with BFM-Like regimen for patients who are Ph+.

For patients under 40 either BFM or a pediatric protocol are the preferred regimens because these regimens have L-asparaginase which has shown to improve the outcome of these patients. Unfortunately, L-asparaginase (or the peggylated form) is not well tolerated in older patients (40-60y) and Hyper-CVAD +/- rituximab (if lymphobalsts express CD20 (>20%)) or Hyper-CVAD + TKI (preferably dasatinib because of higher CNS penetration) for PH + ALL are most commonly used. For patients > 60y of age, Hyper-CVAD is very toxic and  other less toxic regimens may be used.  

Dr. Cherry,

Thank you for your reply. I think H-CVAD is more myelosuppressive than BFM-like regimens and is associated with more morbidity and mortality. We use PEG-Asparaginase with our USC ALL regimen, which is BFM-like (Dan Douer, JCO 2014), and it is well tolerated. However, I am not sure if patients who are Ph+ need that.

I prefer BFM-like protocol for adolescents and young adults under 30 years,and tolerance of Peg Aspa is better than other Aspa and tolerable for young.

For ALL ph+,we add ITk like Dasatinib

Bellow 40 yrs BFM-like protocol is more preferable but in case of Ph+cromosome patient add TKI like imatinib or dasatinib. Hyper -CVAD  is more toxic, so after 40yrs it may use but cautiously.

I wonder if anybody has experience with combining H-CVAD with PEG-Asparaginase.

Augmented hyper-CVAD based on dose-intensified vincristine, dexamethasone, and asparaginase in adult acute lymphoblastic leukemia salvage therapy. But not sure if anybody used as frontline.

You can look details here;

Clin Lymphoma Myeloma Leuk. 2011 Feb;11(1):54-9.

PMID: 21454191