Despite significant advancements in single-antigen targeted therapies for B-cell acute lymphoblastic leukemia (B-ALL), nonresponse and relapse persist as major challenges. Antigen escape after blinatumomab or CD19-directed chimeric antigen receptor (CAR) T cells (CD19-CAR), as CD19-negative B-ALL or lineage switch (LS) to acute myeloid leukemia, present diagnostic and treatment complexities. Given the poor outcomes for patients experiencing a postinfusion relapse, particularly those with loss of the target antigen, a strategic approach to diagnosis and treatment is imperative. In this discussion, we outline a systematic approach to managing postimmunotherapy events, categorized by CD19-positive relapse, CD19-negative relapse, and LS. We explore treatment modalities including CD19-CAR reinfusions, humanized CAR constructs, combinatorial strategies, and alternative antigen-targeted therapies, such as blinatumomab and inotuzumab. Challenges in diagnosis, particularly with antigen-escape, are addressed, highlighting the role of next-generation sequencing and multiparameter flow cytometry for myeloid marker monitoring.
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Acute Lymphoblastic Leukemia|
January 2, 2025
How I treat postimmunotherapy relapsed B-ALL
Adam J. Lamble,
Adam J. Lamble
1Department of Pediatric Hematology and Oncology, Seattle Children’s Hospital, University of Washington, Seattle, WA
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Alexandra E. Kovach,
Alexandra E. Kovach
2Hematopathology, Department of Pathology and Laboratory Medicine, Children's Hospital Los Angeles, Los Angeles, CA
3Clinical Pathology, Keck School of Medicine, University of Southern California, Los Angeles, CA
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Nirali N. Shah
Nirali N. Shah
4Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
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Blood (2025) 145 (1): 64–74.
Article history
Submitted:
May 14, 2024
Accepted:
July 12, 2024
First Edition:
July 24, 2024
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Citation
Adam J. Lamble, Alexandra E. Kovach, Nirali N. Shah; How I treat postimmunotherapy relapsed B-ALL. Blood 2025; 145 (1): 64–74. doi: https://doi.org/10.1182/blood.2024024517
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January 2 2025
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