Transforming the Treatment of Acute Lymphoblastic Leukemia: the Role of Bispecific Antibodies, Antibody-Drug Conjugates, and CAR T-cell Therapy

B-cell acute lymphoblastic leukemia (B-ALL) is a highly aggressive hematologic malignancy, with particularly poor outcomes in relapsed or refractory cases. Relapses remain a major challenge, often resulting in short remission durations and limited survival. This review summarizes emerging therapeutic strategies for B-ALL, focusing on novel immunotherapies and targeted approaches beyond the relapsed/refractory setting.

Transformative therapies such as chimeric antigen receptor (CAR) T-cell therapy, antibody–drug conjugates (ADCs), and bispecific antibodies have shown promising efficacy. Beyond the R/R setting, both blinatumomab and inotuzumab ozogamicin demonstrated high rates of eradication of measurable residual disease (MRD) up to 97% and 80%, respectively. Furthermore, the addition of blinatumomab following chemotherapy in the frontline setting in patients with patients with Philadelphia chromosome (Ph)-negative B-ALL who achieved negative MRD was showing to improve outcomes with a 3-year overall survival rate of 85% compared to 68% with chemotherapy alone. Tisagenlecleucel, brexucabtagene autoleucel, and obecabtagene autoleucel, are chimeric antigen receptor (CAR) T-cell therapies that improved survival compared to chemotherapy alone in patients with relapsed/refractory ALL. In newly diagnosed Ph-positive ALL, chemotherapy-free regimens combining blinatumomab with TKIs resulted in high rates of MRD negativity and improved survival. The combination of blinatumomab and ponatinib led to a 98% MRD negativity rates by next-generation sequencing and a 3-year overall survival of 91% without reliance on allogeneic stem cell transplantation.

Novel immunotherapies and targeted agents offer new avenues to improve outcomes in B-ALL. Expanding the use of blinatumomab, inotuzumab ozogamicin, and CAR T-cell therapy across treatment phases, together with strategic sequencing, may help overcome relapsed/refractory disease. These approaches provide renewed hope for achieving durable remissions and extending survival in patients with B-ALL.