Early T-precursor acute lymphoblastic leukemia (ETP-ALL) is a unique subtype of immature T-ALL that was initially associated with a dramatically inferior prognosis as compared to non-ETP T-ALL (Not-ETP) when it was first described in 2009. Analyses of larger patient cohorts treated with more contemporary regimens, however, have shown minimal survival differences between ETP and Not-ETP. In this manuscript we utilize representative cases to explore therapeutic advances and address common clinical questions regarding management of children, adolescents, and young adults with ETP-ALL. We describe our recommended treatment approach for a child or adolescent with newly diagnosed ETP-ALL, with an emphasis on the prognostic significance of induction failure and detectable minimal residual disease and the role for hematopoietic stem cell transplant in first remission. We discuss the interplay between the ETP immunophenotype and genomic markers of immaturity in T-ALL. Finally, we review novel therapeutic approaches that should be considered when managing relapsed or refractory ETP-ALL.-