ALL

Question 1

The malignant clone arises from hematopoietic progenitors in the bone marrow or lymphatic system – ⬆️of immature nonfunctioning leukemic cells

Answer 1

ALL

accumulation of immature lymphoblasts in the bone marrow

Question 2

Seen in ~50% of elderly B-ALL patients

Answer 2

Philadelphia chromosome-positive (Ph+ ALL, BCR/ABL)

Question 3

⬆️ALL risk in some chromosomal disorders:

Answer 3

Down syndrome: ↑ALL in childhood, ↑AML in adulthood

Question 4

Common CBC abnormalities in ALL

Answer 4

Anemia (Hb <7–8 g/dL in ~1/3 of adults)

Thrombocytopenia (critical <20 ×10⁹/L in ~20%)

Neutropenia (<0.5 ×10⁹/L in ~20%) → ↑infection risk

Question 5

Confirm leukemia, distinguish ALL vs AML, assess immunologic, cytogenetic, molecular markers

Answer 5

BONE MARROW EXAMINATION

Question 6

BMA findings in ALL

Answer 6

usually heavily packed with blasts (>90% in ~70% of cases)

normal hematopoiesis greatly reduced or absent

biopsy shows hypercellularity, replacement of fat, sometimes fibrosis

Question 7

Routine for ALL

Answer 7

LUMBAR PUNCTURE AND CNS EVALUATION

CNS leukemia if ≥5 cells/μL or blasts in CSF

either before therapy or after remission to avoid iatrogenic seeding

Question 8

Residual leukemia undetectable by microscopy

Answer 8

MINIMAL RESIDUAL DISEASE (MRD)

flow cytometry, PCR for Ig/TCR rearrangements, fusion genes (BCR-ABL, MLL-AF4)

Question 9

Strongest predictor of disease free survival (DFS) and overall survival

Answer 9

molecular complete remission (mCR)

Question 10

Most important prognostic factor

Answer 10

MRD during therapy

Question 11

Leukemic cells not detectable by light microscopy (<5% blast cells in bone marrow [BM])

Answer 11

COMPLETE hematologic
remission (CHR)

Question 12

Patient in complete remission, MRD not detectable, ≤0.01% = ≤1 leukemia cell in 10,000 BM cells

Answer 12

Complete molecular
remission/MRD negativity

Question 13

Patient in complete hematologic remission, but not in molecular complete remission >0.01%

Answer 13

Molecular failure/MRD
positivity

Question 14

Patient still in complete remission, had prior
molecular complete remission, leukemic blast cells in BM not detectable (<5%)

Answer 14

Molecular relapse/MRD
positivity

Question 15

>5% blast cells in BM/blood

Answer 15

Hematologic relapse

Question 16

Reduce tumor burden, prevent TLS, allow supportive care

Answer 16

Pre-phase therapy

Glucocorticoids (prednisone 20–60 mg/d or dexamethasone 6–16 mg/d, IV/PO) ± vincristine/cyclophosphamide, 5–7 days

Question 17

Achieve complete remission (CR) or molecular CR

Answer 17

Induction therapy

Vincristine, glucocorticoids, anthracyclines ± cyclophosphamide/cytarabine; L-asparaginase (pegylated for longer effect), dexamethasone preferred for CNS penetration

Question 18

Eliminate residual leukemia, reach sanctuary sites (CNS, testes)

Answer 18

Post-remission consolidation

6–8 cycles, often HD methotrexate (1–5 g/m²) ± HD cytarabine (1–3 g/m²)

Question 19

Prevent relapse

Answer 19

Maintenance therapy

6-mercaptopurine + methotrexate ± intrathecal therapy; duration 2–2.5 years for B-ALL/T-ALL; TKI added for Ph+ ALL

Question 20

Prevent CNS leukemia and peripheral spread

Answer 20

CNS Prophylaxis / Treatment

Intrathecal chemotherapy: methotrexate ± cytarabine ± glucocorticoids

Systemic HD therapy: HD methotrexate or cytarabine

Cranial radiation therapy (CRT): 18–24 Gy in 12 fractions

Question 21

For high-risk patients or MRD-positive in first CR; all relapsed patients

Answer 21

Stem Cell Transplantation (SCT)

Question 22

Immunotherapies

Answer 22

Rituximab CD20
Inotuzumab ozogamicin CD22
Blinatumomab CD19/CD3 bispecific
CAR-T cells CD19

Question 23

Viral infections associated with ALL

Answer 23

HTLV
EBV