5 elements:
Induction
CNS directed Treatment
Consolidation
Reinduction
Maintenance phase

1. Induction Therapy:
vincristine
L- asparaginase
steroid (prednisone or dexamethasone)
ال Dexamethazone هو المفضل لان يكدر يوصل لل CNS
ممکن بالـ higher risk patient نضيف دواء من مجموعة anthracycline

2. CNS prophylaxis:

A. Intrathecal:
Cytarabine
MTX
Steroid

B. Systemic chemotherapy: Dexamethasone
high-dose methotrexate

بالاضافة الى الأشعاع
craniospinal irradiation (XRT) in selected high-risk patients (T-cell ALL)

3. Consolidation
High dose of chemotherapy

4. Reinduction
A. Interim maintenance 2 months
B. Delayed intensification for 3 months after remission
نفس ادوية ال induction نعيدها من جديد

5. Maintenance phase
oral methotrexate
6- mercaptopurine.
2-3 years with low dose

Chemotherapy:

🔸Clofarabine ➔ active in refractory acute leukemias

🔹Blinatumomab ➔ targets CD19, for Ph negative relapsed or refractory ALL

🔸Inotuzumab ozogamicin ➔ anti CD-22, used in relapsed and refractory B-ALL

🔹Tisagenlecleucel ➔ anti-CD19, used in patients with relapsed and refractory B-cell ALL

1. Induction
combination of cytarabine and daunorubicin

ممكن نضيف الـ gemtuzumab ozogamicin للـ induction therapy للمرضى كبار السن

2. Consolidation
use of 2-4 cycles of high-dose cytarabine

في حالة الـ CNS Therapy نستخدم:
● Intrathecal Cytarabine with or without MTX
● Systemic High dose Cytarabine

🔸High dose of Cytarabine
May be combined with: MECCF
Mitoxantrone, Etoposide 2-Chlorodeoxyadenosine, Clofarabine, Fludarabine

🔹Patients unable to tolerate intensive chemotherapy 👆, use low dose of Cytarabine and Azacitidine

🔸Alternative therapy:
Ventoclax combined with Decitabine or Azacitidine