Hyper-CVAD and Ponatinib in Ph-Positive and/or BCR-ABL Positive Acute Lymphoblastic Leukemia (ALL)

Inclusion Criteria:

1. Diagnosis of one of the following: a) Previously untreated Ph-positive ALL [either t(9;22) and/or bcr-abl positive] (includes patients initiated on first course of hyper-CVAD before cytogenetics known); b) Previously treated Ph-positive ALL, after 1-2 courses of chemotherapy with or without other TKIs 1) If they achieved CR, they are assessable only for event-free and overall survival, or 2) If they failed to achieve CR, they are assessable for CR, event-free, and overall survival.
2. Age >/= 18 years
3. Performance status </= 2 (ECOG Scale, Appendix E)
4. Adequate liver function as defined by the following criteria: a) Total serum bilirubin </= 1.5 x upper limit of normal (ULN), unless due to Gilbert's syndrome, b) Alanine aminotransferase (ALT) </= 2 x ULN, c) Aspartate aminotransferase (AST) </= 2.5 x ULN)
5. Adequate pancreatic function as defined by the following criteria: a) Serum lipase and amylase </= 1.5 x ULN),
6. For females of childbearing potential, a negative pregnancy test must be documented prior to randomization
7. Female and male patients who are fertile must agree to use an effective form of contraception with their sexual partners from randomization through 4 months after the end of treatment
8. Adequate cardiac function as assessed clinically by history and physical examination.
9. Signed informed consent

Exclusion Criteria:

1. Active serious infection not controlled by oral or intravenous antibiotics
2. History of acute pancreatitis within 1 year of study or history of chronic pancreatitis
3. History of alcohol abuse
4. Uncontrolled hypertriglyceridemia (triglycerides > 450mg/dL)
5. Active secondary malignancy other than skin cancer (e.g., basal cell carcinoma or squamous cell carcinoma) that in the investigator's opinion will shorten survival to less than 1 year
6. Active Grade III-V cardiac failure as defined by the New York Heart Association Criteria
7. Clinically significant, uncontrolled, or active cardiovascular disease, specifically including, but not restricted to: Any history of myocardial infarction (MI), stroke, or revascularization; Unstable angina or transient ischemic attack prior to enrollment; Congestive heart failure prior to enrollment, or left ventricular ejection fraction (LVEF) less than lower limit of normal per local institutional standards prior to enrollment; Diagnosed or suspected congenital long QT syndrome; Any history of clinically significant atrial or ventricular arrhythmias (such as atrial fibrillation, ventricular tachycardia, ventricular fibrillation, or Torsades de pointes) as determined by the treating physician; Prolonged QTc interval on pre-entry electrocardiogram (> 470 msec) unless corrected after electrolyte replacement; Any history of venous thromboembolism including deep venous thrombosis or pulmonary embolism;
8. Continued from #7: Uncontrolled hypertension (diastolic blood pressure >90mmHg; systolic >140mmHg). Patients with hypertension should be under treatment on study entry to effect blood pressure control.
9. Patients currently taking drugs that are generally accepted to have a risk of causing Torsades de Pointes (unless these can be changed to acceptable alternatives)
10. Taking any medications or herbal supplements that are known to be strong inhibitors of CYP3A4 within at least 14 days before the first dose of ponatinib
11. Prior history of treatment with ponatinib
12. Treatment with any investigational antileukemic agents or chemotherapy agents in the last 7 days before study entry, unless full recovery from side effects has occurred or patient has rapidly progressive disease judged to be life-threatening by the investigator
13. Pregnant and lactating women will not be eligible; women of childbearing potential should have a negative pregnancy test prior to entering on the study and be willing to practice methods of contraception. Women do not have childbearing potential if they have had a hysterectomy or are postmenopausal without menses for 12 months. In addition, men enrolled on this study should understand the risks to any sexual partner of childbearing potential and should practice an effective method of birth control
14. History of significant bleeding disorder unrelated to cancer, including: a) Diagnosed congenital bleeding disorders (e.g., von Willebrand's disease), b) Diagnosed acquired bleeding disorder within one year (e.g., acquired anti-factor VIII antibodies)
15. Patients with documented significant pleural or pericardial effusions unless they are thought to be secondary to their leukemia