How has the management of Ph + acute lymphoblastic leukemia (ALL) changed over the years.

For decades, Philadelphia-positive acute lymphoblastic leukemia (Ph+ ALL) has been considered the ALL subgroup with the worse outcome. It represents the most frequent genetic subtype of adult ALL and, in the elderly, it accounts for approximately 50% of cases. The introduction of tyrosine kinase inhibitors (TKIs) has led to obtain complete hematologic remissions (CHR) in virtually all patients, to improve disease-free survival and overall survival, and to increase the percentage of patients who can undergo an allogeneic stem cell transplant (allo-SCT). Thus, the current management of adult Ph+ ALL patients is based on the use of a TKI, with or without systemic chemotherapy, followed by an allo-SCT, which still remains the only curative option. Monitoring of minimal residual disease allowed a better stratification of patients, and also enabled to redefine the role of autologous stem cell transplant for patients who do not have a donor or are unfit for an allo-transplant. The main clinical challenges are today represented by the emergence of resistant mutations, particularly the gatekeeper T315I, for which alternative approaches, including novel TKIs and/or therapies based on the combination of TKI with immunotherapeutic strategies, are being considered.