Typical Treatment of Acute Lymphocytic Leukemia (ALL)
Long-term chemotherapy (chemo) is typically the main treatment for adults with ALL (acute lymphocytic leukemia, also known as acute lymphoblastic leukemia). Other types of drugs, such as targeted drugs or immunotherapy, are sometimes part of treatment as well. For some people, a stem cell transplant might also be an option.
Treatment options for adults with ALL typically depend on several factors, including:
- Whether it is a B-cell ALL or a T-cell ALL
- If the ALL is at standard risk or high risk for coming back (based on certain prognostic factors)
- If the ALL cells have the Philadelphia chromosome (Ph+ ALL) or certain other gene or chromosome changes
- A person¡¯s age, overall health, and personal preferences
- The availability of a donor for a stem cell transplant
Note: This information is about treating acute lymphocytic leukemia (ALL) in adults. To learn about ALL in children, see Leukemia in Children.
Treatment phases for ALL
Treatment of ALL typically happens in 3 phases:
- Induction (remission induction)
- Consolidation (intensification)
- Maintenance
The total treatment usually takes about 2 years, with the maintenance phase taking up most of this time. Treatment may be more or less intense, depending on many of the factors listed above.
Central nervous system (CNS) prophylaxis
ALL sometimes spreads to the area around the brain and spinal cord. This spread is often found when leukemia cells are discovered in the cerebrospinal fluid (CSF) during a lumbar puncture (spinal tap). CSF is the liquid that surrounds your brain and spinal cord.
Even if leukemia cells aren't found in your CSF when you are diagnosed, it's possible they might spread there later.
Because of this, central nervous system (CNS) prophylaxis is an important part of treating ALL, often during all treatment phases. CNS prophylaxis lowers the risk of the leukemia spreading to the area around your brain or spinal cord. This is described in more detail below.
Induction phase
The goal of induction chemo is to get the leukemia into remission (complete remission). This means:
- Leukemia cells are no longer found in bone marrow samples (on a bone marrow biopsy)
- Normal marrow cells return
- Blood counts return to normal levels
But a remission is not necessarily a cure. Leukemia cells may still be hiding somewhere in the body.
Induction chemo usually lasts for a month or so. Treatment is typically intensive and requires frequent visits to the doctor. You may spend some or much of this time in the hospital, because serious infections or other complications can occur.
It's very important to take all your medicines as prescribed.
Sometimes, complications can be life-threatening. But these are much less common than in the past, because of recent advances in supportive care (nursing care, nutrition, antibiotics, growth factors, red blood cell and platelet transfusions as needed, etc.).
Different combinations of chemo drugs might be used to treat Ph- B-ALL. But for people who are healthy enough, this typically includes:
- Vincristine
- Dexamethasone or prednisone
- An anthracycline drug such as doxorubicin (Adriamycin) or daunorubicin
Based on your prognostic factors, your regimen might also include other drugs such as cyclophosphamide, pegylated asparaginase (pegaspargase), and/or high doses of methotrexate or cytarabine (ara-C) as part of this phase.
If the ALL cells have the CD20 protein on them (CD20-positive ALL), the immunotherapy drug rituximab might also be used, especially in younger adults.
People who are older (typically over 65) or who have other serious health conditions might not be able to tolerate an intensive induction regimen.
- In this case, reduced doses of many of these same drugs might be used.
- Other options could include treatment with the antibody-drug conjugate inotuzumab ozogamicin or a steroid drug such as dexamethasone or prednisone.
CNS treatment: ALL sometimes spreads to the area around the brain and spinal cord, so treatment aimed at this area is important as well. (See CNS treatment or prophylaxis, below).
If your ALL cells have the Philadelphia chromosome, a targeted drug called a tyrosine kinase inhibitor (TKI) is an important part of treatment. This is typically combined with either:
- Chemotherapy using many of the same drugs listed under Ph- B-ALL above, although the regimen might be less intense
- A steroid drug such as dexamethasone or prednisone
- The immunotherapy drug blinatumomab
Your treatment choices will depend on several factors, including your age and overall health.
CNS treatment: ALL sometimes spreads to the area around the brain and spinal cord, so treatment aimed at this area is important as well. (See CNS treatment or prophylaxis, below).
Different combinations of chemo drugs might be used to treat T-cell ALL. But for people who are healthy enough, this typically includes:
- Vincristine
- Dexamethasone or prednisone
- An anthracycline drug such as doxorubicin (Adriamycin) or daunorubicin
- Pegylated asparaginase (pegaspargase)
Based on your prognostic factors, your regimen might also include other drugs such as cyclophosphamide, and/or high doses of methotrexate or cytarabine (ara-C) as part of this phase.
People who are older (typically over 65) or who have other serious health conditions might not be able to tolerate an intensive induction regimen.
- In this case, reduced doses of many of the same drugs might still be used.
- Another option could be treatment with a steroid drug such as dexamethasone or prednisone.
CNS treatment: ALL sometimes spreads to the area around the brain and spinal cord, so treatment aimed at this area is important as well. (See CNS treatment or prophylaxis, below).
CNS treatment or prophylaxis during induction
ALL sometimes spreads to the central nervous system (CNS), which includes your brain and spinal cord. The CNS needs to be treated to either:
- Keep the leukemia cells from spreading to the area (CNS prophylaxis)
- Treat leukemia that has already spread to the area (CNS treatment)
This often starts during induction and continues through the other phases of treatment. It may include one or more of the following:
- Intrathecal chemotherapy (chemo injected directly into the CSF)
- High-dose IV chemo with methotrexate, cytarabine, or other drugs
- Radiation therapy to the brain and spinal cord
For intrathecal chemotherapy, the drug used most often is methotrexate. Sometimes, cytarabine or a steroid such as prednisone may be used as well. This treatment can be given during a lumbar puncture (spinal tap) or through an Ommaya reservoir (discussed in Surgery for ALL).
Consolidation (intensification) phase
The induction phase of treatment most often puts ALL into remission. But because there may still be leukemia cells somewhere in the body, you will need more treatment.
This next phase is called consolidation (intensification).
It typically consists of another relatively short course of treatment, often with many of the same drugs used for induction. This generally lasts for a few months. The drugs are usually given in high doses, so the treatment is still fairly intense.
CNS prophylaxis/treatment typically continues at this time.
If you have Ph- B-ALL, your treatment options will depend on factors such as:
- If the ALL is at high risk for coming back
- If there is still minimal/measurable residual disease (MRD, signs of remaining leukemia using very sensitive lab tests)
Your options might include:
- Continuing chemotherapy, possibly alternating with the immunotherapy drug blinatumomab
- An immunotherapy drug such as blinatumomab or inotuzumab ozogamicin alone
- Proceeding to a stem cell transplant
People with Ph+ B-ALL generally continue on the same TKI they were getting during induction, as long as it¡¯s still working and they can tolerate it. If not, they might be switched to a different TKI.
Along with the TKI, you might get:
- Chemotherapy
- An immunotherapy drug such as blinatumomab or inotuzumab ozogamicin
Other options could include:
- An immunotherapy drug alone
- Proceeding to a stem cell transplant
When choosing among these options, your cancer care team will consider several factors, including whether your ALL is at high risk of returning and if there is still minimal/measurable residual disease (MRD, signs of remaining leukemia using very sensitive lab tests).
The main options for consolidation in people with T-cell ALL include:
- Chemotherapy
- Proceeding to a stem cell transplant
The choice depends on factors such as:
- If the ALL is at high risk of returning
- If there is still minimal/measurable residual disease (MRD, signs of remaining leukemia using very sensitive lab tests)
Maintenance phase
After consolidation, most people get maintenance chemotherapy, using lower doses of drugs over a longer period of time (generally about 2 years).
CNS prophylaxis or treatment typically continues at this time.
Maintenance therapy for Ph- B-ALL usually consists of low-intensity chemotherapy with methotrexate and 6-mercaptopurine (6-MP). This is often combined with other drugs such as vincristine and prednisone. It might be alternated with the immunotherapy drug blinatumomab.
If your ALL cells have the Philadelphia chromosome, maintenance typically includes continuing on a TKI for at least 2 years. This might be combined with low-intensity chemotherapy, such as that used for Ph- B-ALL.
Maintenance therapy for T-cell ALL typically consists of chemotherapy with several different drugs, in lower doses than during induction and consolidation. The chemo drug nelarabine might be added at this time as well.
Response rates to ALL treatment
In general, about 80% to 90% of adults will have their ALL go into complete remission at some point during treatment. This means leukemia cells can no longer be seen in their bone marrow.
In about half of these people, the ALL will come back (relapse) at some point and need to be treated again (see below).
These rates can vary a lot, depending on the subtype of ALL and other prognostic factors. For example, cure rates tend to be higher in younger patients.
If the ALL doesn¡¯t respond or returns after treatment
ALL can be harder to treat if it comes back or doesn¡¯t respond to initial treatment. But it might still be possible to get it into remission with other treatments. If this can be done, a stem cell transplant is often recommended (if a person is eligible).
Treating refractory ALL
If leukemia doesn¡¯t go away with the first treatment, it is referred to as refractory ALL. This happens in about 10% to 20% of people with ALL.
- Newer or more intensive doses of chemo drugs may be tried at this point.
- Immunotherapy (monoclonal antibodies or CAR T-cell therapy) may be an option for people with B-cell ALL.
- A stem cell transplant may be tried if the leukemia can be put into at least partial remission.
- Clinical trials of new treatment approaches may also be considered.
Treating relapsed/recurrent ALL
If leukemia goes into remission with the first treatment but then comes back (relapses or recurs), it most often does so in the bone marrow and blood. Occasionally, it recurs first in the brain or spinal fluid.
It is sometimes possible to put the leukemia into remission again with more chemotherapy (chemo), although this remission tends to be shorter than the first one.
The way the ALL is treated at this point may depend on how soon it returned after the initial treatment.
- If the relapse happens after a long time, the same or similar treatment may be used to try for a second remission.
- If the time-to-relapse is shorter, more aggressive treatment with other drugs may be needed.
Aside from chemotherapy, other treatment options might depend on the type and subtype of ALL. For example:
- Immunotherapy with a monoclonal antibody or CAR T-cell therapy might be an option for some people with B-cell ALL.
- People with B-cell ALL with the Philadelphia chromosome and who were taking a TKI are often switched to a different TKI.
- If the leukemia cells have a KMT2A gene mutation, treatment with a targeted drug called a menin inhibitor, such as revumenib (Revuforj), might be an option.
- For people with T-cell ALL, the chemo drug nelarabine (Arranon) may be helpful.
If the leukemia can be put into a second remission, most doctors will advise some type of stem cell transplant if possible.
If a stem cell transplant isn¡¯t possible, a clinical trial testing newer treatments might still be an option for some people.
Treating ALL relapse after a stem cell transplant
If the leukemia relapses after a stem cell transplant, a donor lymphocyte infusion (DLI) is sometimes helpful. In this treatment, you get an infusion of T lymphocytes (T cells) from the person who donated the stem cells for the initial transplant.
Supportive or palliative treatment
No matter where you are in your treatment for ALL, it¡¯s important to get help with your symptoms. This includes any side effects caused by treatment or any symptoms from the leukemia.
Treatment aimed at your symptoms rather than at the leukemia itself is known as palliative treatment or supportive care. This is an important part of your overall treatment plan. In some cases, it can even help treatment aimed at the leukemia work better.
Examples of supportive care you may get during treatment for ALL include:
- Medicines to help prevent or treat nausea or vomiting from chemotherapy
- Medicines to help prevent or treat infections from having a weakened immune system
- Medicines to help lower your risk of allergic reactions to certain drugs
- Pain medicines or radiation therapy if the leukemia is causing bone pain
- Red blood cell or platelet transfusions if you are having symptoms from low blood cell counts (such as fatigue or bleeding)
Regardless of where you are in your treatment, it¡¯s important to tell your cancer care team about any symptoms, so they can help you manage them.
- Written by
- References
Developed by the ÁñÁ«ÊÓƵ medical and editorial content team with medical review and contribution by the American Society of Clinical Oncology (ASCO).
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Last Revised: August 13, 2025
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