Acute Leukemias — Acute Myeloid Leukemia and Acute Lymphoblastic Leukemia

Question · easy

A 67-year-old man presents with 3 weeks of progressive fatigue and two episodes of epistaxis. Examination shows scattered petechiae on the lower extremities. Hemoglobin is 8.2 g/dL, platelet count is 18,000/μL (18 × 10⁹/L), and leukocyte count is 22,000/μL. The peripheral blood smear shows immature granulocytes containing rod-shaped cytoplasmic inclusion bodies. Which of the following is the most likely diagnosis?

Infectious mononucleosis Aplastic anemia Acute lymphoblastic leukemia Acute myeloid leukemia

Question · medium

A 42-year-old woman presents with fatigue, epistaxis, and heavy menses. Temperature is 37.8 °C. Leukocyte count is 4,800/μL, hemoglobin 9.1 g/dL, and platelet count 24,000/μL. The peripheral smear shows promyelocytes with heavy abnormal granulation. Prothrombin time and partial thromboplastin time are prolonged, fibrinogen is low, and D-dimer is markedly elevated. Cytogenetic studies are pending. Which of the following is the best next step in management?

Observe and repeat the peripheral smear after bone marrow biopsy results return Begin all-trans-retinoic acid (ATRA) immediately and support the coagulopathy with platelets and cryoprecipitate Withhold platelet transfusion until the coagulopathy is fully characterized Await molecular confirmation of PML::RARA before starting any therapy

Question · hard

The 2022 WHO 5th edition and International Consensus Classification (ICC) reorganized AML around defining genetic abnormalities rather than a fixed 20% blast threshold. According to these systems, which of the following patients can be diagnosed and treated as having AML despite a bone marrow blast percentage below 20%?

A patient with 18% blasts and multilineage dysplasia classified under the 'AML with myelodysplasia-related changes' category A patient with 15% blasts and BCR::ABL1 A patient with 16% blasts and a TP53 mutation A patient with 15% blasts and t(8;21)(q22;q22)/RUNX1::RUNX1T1

Question · medium

A 70-year-old man with newly diagnosed AML is fit for intensive therapy. Molecular testing shows a FLT3 internal tandem duplication (FLT3-ITD). He will receive standard 7+3 induction followed by cytarabine consolidation. Which FLT3-directed strategy reflects the July 2023 FDA approval based on the QuANTUM-First trial, in which adding the agent improved median overall survival to 31.9 versus 15.1 months?

Quizartinib added to 7+3 induction and cytarabine consolidation, then continued as maintenance Midostaurin given as single-agent therapy in place of chemotherapy Ivosidenib substituted for the anthracycline during induction Gilteritinib added to induction and continued as maintenance

Question · hard

A 28-year-old man with newly diagnosed BCR::ABL1-negative B-cell acute lymphoblastic leukemia achieves complete remission after induction chemotherapy, and flow cytometry shows he is measurable residual disease (MRD)-negative. Adding which agent to consolidation chemotherapy improved overall survival in the phase 3 E1910 trial (3-year overall survival 85% vs 68%) and led to FDA approval in June 2024 for this frontline consolidation setting?

Blinatumomab Inotuzumab ozogamicin CD19-directed CAR T cells Nelarabine