FRCPath Haem Part 1 EMQ-Oncology 74 and 74 AML

Theme: Acute Myeloid Leukaemia (AML)

Options

A. DA 3+7 plus Gemtuzumab Ozogamicin (GO)

B. DA 3+10 plus Midostaurin

C. CPX-351 (Vyxeos)

D. FLAG-IDA

E. ATRA + Arsenic Trioxide

F. ATRA + Idarubicin (AIDA)

G. Allogeneic stem cell transplantation in CR1

H. Gilteritinib

I. Quizartinib

J. Azacitidine + Donor Lymphocyte Infusion (DLI)

K. HiDAC consolidation alone

L. Hydroxycarbamide cytoreduction followed by induction

M. Supportive/palliative management

N. Enasidenib

O. Ivosidenib

Questions

Question 1

A 34-year-old man presents with fatigue, gum hypertrophy, and easy bruising. Blood tests show Hb 72 g/L, WBC 42 ×109/L, platelets 28 ×109/L. Bone marrow confirms AML with t(8;21). Flow cytometry demonstrates strong CD33 expression. FLT3 mutation testing is negative and NPM1 is wild type. After induction chemotherapy, MRD assessment demonstrates a >3-log reduction in RUNX1-RUNX1T1 transcript level.

What is the SINGLE most appropriate initial management strategy?

Question 2

A 51-year-old woman presents with fever, mucosal bleeding, and pancytopenia. Blood film shows abnormal promyelocytes with Auer rods. Coagulation profile demonstrates disseminated intravascular coagulation. WBC is 4 ×109/L. FISH confirms t(15;17).

What is the SINGLE best treatment approach?

Question 3

A 63-year-old man with previous MDS treated conservatively develops worsening cytopenias and circulating blasts. Bone marrow demonstrates AML with multilineage dysplasia. Cytogenetics reveal monosomy 7 and del(5q). He is fit for intensive treatment.

What is the SINGLE most appropriate induction regimen?

Question 4

A 46-year-old woman is diagnosed with AML. Molecular analysis reveals FLT3-ITD mutation with high allelic ratio and NPM1 wild type disease. She achieves CR after induction therapy.

What is the SINGLE most appropriate additional treatment consideration to improve long-term survival?

Question 5

A 58-year-old patient with AML receives two cycles of intensive induction chemotherapy. Repeat marrow demonstrates persistent 18% blasts with minimal reduction from baseline disease burden. Cytogenetics demonstrate complex karyotype with TP53 mutation.

What is the SINGLE most appropriate next management option?

Question 6

A 39-year-old woman with low-risk APML treated with ATRA and arsenic trioxide develops dyspnoea, pulmonary infiltrates, fever, rapid weight gain, hypotension, and acute kidney injury during induction.

What is the MOST likely complication?

Question 7

A 49-year-old man previously treated for FLT3-ITD AML relapses 10 months after achieving remission. He is fit for salvage therapy and has no major comorbidities. Molecular testing again confirms FLT3-ITD positivity.

What is the SINGLE best salvage treatment option?

Question 8

A 66-year-old woman relapses 18 months after allogeneic stem cell transplantation for AML. Bone marrow shows 12% blasts. Donor chimerism is declining. She is unfit for intensive chemotherapy but has good performance status.

What is the SINGLE most appropriate management option?

Question 9

A 29-year-old man with AML has NPM1 mutation and low allelic ratio FLT3-ITD. Following two induction cycles, RT-qPCR demonstrates less than 3-log reduction in NPM1 MRD transcript.

What is the SINGLE most appropriate next management strategy?

Question 10

A 72-year-old frail man presents with AML evolving from CMML. He has severe COPD, poor functional status, recurrent infections, and significant cardiac impairment. Cytogenetics show complex abnormalities and TP53 mutation.

What is the SINGLE most appropriate management strategy?