FRCPath Haem Part 1 EMQs - Oncology 98

Theme: Management of Relapsed Acute Lymphoblastic Leukaemia (ALL)

Option List

Each option may be used once, more than once, or not at all.

A. Blinatumomab followed by HSCT

B. CAR-T cell therapy assessment

C. Standard-risk chemotherapy pathway without HSCT

D. Imatinib in addition to relapse therapy

E. Cranial radiotherapy during maintenance

F. National MDT discussion only

G. Bilateral orchidectomy

H. Second cycle of blinatumomab

I. Proceed directly to HSCT

J. Continue induction chemotherapy to Day 29

Scenario 1

A 9-year-old boy with precursor B-ALL relapses 18 months after diagnosis while still receiving maintenance therapy. Cytogenetics demonstrate an iAMP21 abnormality. Following induction, marrow MRD is undetectable after one cycle of blinatumomab.

What is the most appropriate next step?

Scenario 2

A 14-year-old girl experiences a first relapse of precursor B-ALL 4 years after completing frontline therapy. She has no adverse cytogenetic abnormalities. Bone marrow relapse responds well to induction and MRD becomes negative after blinatumomab.

Which treatment pathway is most appropriate?

Scenario 3

A 12-year-old boy with relapsed precursor B-ALL has an ABL1 fusion identified at relapse. He is commencing relapse chemotherapy.

What additional treatment should be started?

Scenario 4

A 17-year-old patient with high-risk marrow relapse receives induction and subsequently one cycle of blinatumomab. End-of-cycle MRD is 0.05%.

What is the most appropriate next treatment?

Scenario 5

A 15-year-old girl with high-risk marrow relapse has persistent marrow disease of 2% by flow cytometry at Day 29 of induction chemotherapy.

What is the most appropriate management?