What are the treatment options for relapsed T-ALL in a patient who was nonadherent with AALL and hyper-CVAD regimens?

Regimens to consider with data for R/R T-ALL include:

• Nelarabine +/- chemotherapy. There are retrospective data to support adding nelarabine to a chemo backbone (Shimony et al., PMID 36508268 and Shimony et al., PMID 37389830).
• HMA + venetoclax (Pinton et al., PMID 37889114 and Cao et al., Blood 2023)
• Doing molecular testing to assess for the presence of IDH or FLT3 mutation and potentially using a targeted therapy approach (Madero-Marroquin et al., PMID 38073116).

One could consider mini-CVD + Venetoclax as well but I would be less enthused given the exposure to hyper-CVAD already. Given that nelarabine is the only FDA-approved therapy for R/R T-ALL, I think a nelarabine +/- chemotherapy option may be considered if the patient is fit/well ...