FRCPath Haem Part 1 EMQs- Oncology 97

Theme: ALL Risk Stratification and Management Decisions

Options

A. Continue allocated induction and commence Imatinib from Day 15

B. Transfer to Induction C on Day 15

C. Proceed directly to Blinatumomab consolidation at Week 6

D. Proceed to Extended Induction (Hemi-1B)

E. Allocate to Standard-Risk pathway following Blinatumomab

F. Allocate to High-Risk pathway following Blinatumomab

G. Classify as Blinatumomab Failure

H. Consider allogeneic stem cell transplantation

I. Manage according to Down Syndrome pathway (Induction D)

J. Patient is not eligible for treatment under the UKALL 2025 Blinatumomab guideline

Questions

Question 1

An 11-year-old boy presents with precursor B-cell ALL. Initial WCC is 82 ×10⁹/L. CNS examination is normal and diagnostic CSF is CNS1. Cytogenetic analysis demonstrates an ABL-class fusion identified on Day 15. Day 15 MRD is 0.8%. Day 29 MRD is 0.03%. There is no evidence of testicular disease. The patient remains clinically well and achieves complete morphological remission.

Which is the single most appropriate management decision at the point the genetic result becomes available?

Question 2

A 7-year-old girl presents with precursor B-cell ALL. Initial WCC is 12 ×10⁹/L. She commences Induction A. On Day 15, FISH identifies iAMP21. Bone marrow morphology demonstrates good response and Day 15 MRD is 0.2%. There is no CNS involvement.

Which is the single most appropriate protocol-directed action?

Question 3

A 14-year-old boy with newly diagnosed BCP-ALL has a presenting WCC of 63 ×10⁹/L. Cytogenetics are unremarkable. Day 15 MRD is 0.6%. At the end of induction, MRD is reported as 7.4%. Bone marrow morphology confirms persistence of disease below the threshold of overt relapse. CNS status remains negative.

Which is the single most appropriate next treatment step?

Question 4

A 9-year-old girl with NCI standard-risk BCP-ALL has no CNS disease, no high-risk cytogenetics, and Day 15 MRD <0.01%. End-induction MRD is undetectable. Following the first cycle of Blinatumomab, both flow cytometry and molecular assays demonstrate complete MRD negativity below assay detection limits.

Which is the most appropriate post-Blinatumomab risk assignment?

Question 5

A 13-year-old boy initially presents with WCC 45 ×10⁹/L and CNS1 disease. Cytogenetics show no recognised high-risk abnormalities. Day 15 MRD is 0.2%. End-induction MRD is 0.03%, and he proceeds to Blinatumomab. Following cycle 1, bone marrow MRD is 0.12% by validated flow cytometry. Repeat testing confirms the result.

Which is the most appropriate classification under the guideline?