How to Treat Ph-negative Precursor B-cell ALL and Ischemic Cardiomyopathy

Here’s how readers responded to a You Make the Call question about the management of Ph-negative ALL in a patient with ischemic cardiomyopathy.

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It is probably not possible to cure the disease or obtain longevity unless you are very lucky. Start slowly with weekly vincristine and prednisone/dexamethasone and low-dose imatinib. Avoid severe neutropenia initially to reduce issues around sepsis and the clinical/cardiac stress of tumor lysis syndrome. The ALL may be very sensitive to such therapy at the beginning. I would take the time initially to confirm that left ventricular function is optimally medically managed.

If the disease is responding hematologically and holding together clinically, you could increase treatment intensity (perhaps after about three weeks) and might switch to Part B of Hyper-CVAD.

If the patient cannot tolerate chemotherapy-induced thrombocytopenia (if he or she is fragile not just from a coronary point of view), you might switch to a monoclonal antibody.

Lothar B. Huebsch, MD
University of Ottawa
Ottawa, Canada


Anastasia Skandali, MD
Hygeia Hospital
Athens, Greece

Depends on the patient’s age and other comorbidities. If in poor condition and over age 65, I’d use steroids, vincristine, and maybe add other ALL drugs such as cyclophosphamide/methotrexate and cytarabine as tolerated.

Michael Pidcock, MBBS
Canberra Hospital
Canberra, Australia

Pediatric regimens focus on the Berlin-Frankfurt-Münster backbone of ALL therapy: glucocorticoids, vincristine, asparaginase, early and frequent central nervous system prophylaxis, and prolonged maintenance therapy.

Jesús Alcaraz Rubio, MD
Hospital Quirónsalud Murcia
Murcia, Spain