Clinical Commander

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heme.acute-leukemia.core.v1

Acute Leukemia (AML / ALL / APL)

oncologyacuteadultacuteinpatient
Start encounter →Print handoutPRODUCTION

STEP 3 deepened 2026-05-16: replaced placeholder evidence ("Pending guideline review" + non-leukemia PMIDs 29766750 POINT / 23900119 REDUCE) with WebSearch-VERIFIED provenance — ELN 2022 AML 35797463, VIALE-A 32786187, APL0406 23841729 + final JCO 27400939, ELIANA 29385370. Co-located _research-bundle.md authored (§5.5 item 2; design brief already present). §5.5.1 effect sizes wired: VIALE-A median OS 14.7 vs 9.6 mo (HR ~0.66), CR+CRi ~66% vs 28%; APL0406 EFS 97.3% vs 80% / relapse 1.9% vs 13.9% / OS 99.2% vs 92.6% (chemo-free ATRA+ATO non-high-risk APL); ELIANA 81% remission all MRD-neg. §5.5.2 APL load-bearing pivot (coagulopathy + Auer/faggot + t(15;17)/PML-RARA → STAT ATRA before genetic confirmation), leukostasis + TLS routing. All 5 evidence PMIDs re-verified live 2026-05-22. 2026-05-22 RxCUI remediation (RxNav reverse-lookup): daunorubicin 4054(invalid)->3109, azacitidine 46051(invalid)->1251, imatinib 40048(=carboplatin)->282388. Confirmed correct: tretinoin 10753, arsenic trioxide 18330, prednisone 8640, idarubicin 5650, cytarabine 3041, midostaurin 1919083, gemtuzumab ozogamicin 1294580, venetoclax 1747556, dasatinib 475342, rasburicase 283821, allopurinol 519. last_reconciled 2026-05-22.

Entry points (4)

  • lab_abnormality
    Leukocytosis with circulating blasts on smear
    leukocytosis_with_blasts
  • lab_abnormality
    Pancytopenia + blasts
    pancytopenia
  • symptom
    Bleeding / DIC (concern for APL)
    bleeding_dic
  • lab_abnormality
    Hyperleukocytosis (WBC >100k) — leukostasis emergency
    hyperleukocytosis

Required inputs (7)

  • agerequired
    demographic • used at CONTEXT
    Fit vs unfit determines 7+3 vs venetoclax+aza (VIALE-A)
  • cbc_with_diffrequired
    lab • used at ENTRY
    WBC + blast %; hyperleukocytosis triggers leukapheresis decision
  • peripheral_smearrequired
    lab • used at INITIAL_WORKUP
    Auer rods → AML; faggot cells → APL; lymphoblasts → ALL
  • coag_panelrequired
    lab • used at INITIAL_WORKUP
    DIC concern in APL — fibrinogen + D-dimer + PT
  • tls_panelrequired
    lab • used at INITIAL_WORKUP
    Uric acid + K + Phos + Ca for TLS risk
  • flow_cytometry
    lab • used at BRANCHING_WORKUP
    Lineage assignment AML/ALL + immunophenotype
  • cytogenetics_fish
    lab • used at BRANCHING_WORKUP
    t(15;17) APL → STAT ATRA; t(9;22) Ph+ ALL → TKI; risk strat for AML

12-phase flow (12)

  1. 1FRAME
    Suspect acute leukemia from blasts on smear; APL recognition is the time-critical priority
    inputs: cbc_with_diff, peripheral_smear
    advance: Acute leukemia suspected
  2. 2ENTRY
    Triage by hyperleukocytosis, DIC, leukostasis, infection
    inputs: cbc_with_diff
    advance: Acuity assigned
  3. 3CONTEXT
    Capture comorbidities, performance status, prior chemo/radiation, MDS history
    inputs: age
    advance: Performance + history captured
  4. 4RED_FLAGS
    APL load-bearing pivot — coagulopathy/DIC + faggot cells/Auer rods + promyelocytic morphology (± t(15;17)/PML-RARA pending) → START ATRA IMMEDIATELY at first suspicion, BEFORE genetic confirmation (early DIC-hemorrhagic death is the dominant APL induction-mortality driver; ATRA reverses coagulopathy). Leukostasis (blasts typically >100K + CNS/pulmonary symptoms → cytoreduction); TLS (→ workup.tls); severe sepsis in neutropenia; spinal cord compression
    inputs: coag_panel, tls_panel
    actions: workup.tls
    advance: Emergencies stabilized
  5. 5INITIAL_WORKUP
    CBC + diff + smear; coag panel; TLS labs; LDH; LFT; CMP; HLA typing; baseline echo (anthracycline)
    inputs: peripheral_smear, coag_panel, tls_panel
    actions: panel.cbc, panel.coag, workup.acute_leukemia
    advance: Baseline labs sent + heme/onc consulted
  6. 6BRANCHING_WORKUP
    BM aspirate + biopsy + flow + cytogenetics + FISH + molecular (FLT3, NPM1, IDH1/2, BCR-ABL); CSF if CNS sx or ALL
    inputs: flow_cytometry, cytogenetics_fish
    advance: Subtype + risk class assigned
  7. 7DIFFERENTIAL
    AML / ALL / APL t(15;17) / mixed-phenotype / blast crisis CML / lymphoma leukemic phase
    advance: Diagnosis confirmed
  8. 8RISK_STRATIFICATION
    AML ELN 2022 favorable/intermediate/adverse; ALL Ph+/Ph-like; APL Sanz score
    advance: Risk class set
  9. 9TREATMENT
    APL non-high-risk: chemo-free ATRA + arsenic trioxide — APL0406 (Lo-Coco NEJM 2013 PMID 23841729; final JCO 2016 PMID 27400939): EFS 97.3% vs 80%, relapse 1.9% vs 13.9%, OS 99.2% vs 92.6% vs ATRA+chemo. AML fit: 7+3 (cytarabine + anthracycline) ± targeted (FLT3/IDH per ELN 2022 PMID 35797463). AML unfit: azacitidine + venetoclax — VIALE-A (DiNardo NEJM 2020 PMID 32786187): median OS 14.7 vs 9.6 mo (HR ~0.66), CR+CRi ~66% vs 28%. ALL: multi-agent + Ph TKI (HyperCVAD/CALGB). Refractory B-ALL: tisagenlecleucel CAR-T — ELIANA (Maude NEJM 2018 PMID 29385370): 81% remission, all MRD-negative; allo-HSCT.
    advance: Induction regimen started
  10. 10DISPOSITION
    Heme/onc inpatient; ICU if leukostasis/DIC/sepsis; transplant referral early for adverse-risk AML and Ph- ALL
    advance: Transfer to specialty service
  11. 11MONITORING
    Daily CBC + coag (APL DIC) + TLS labs; differentiation syndrome monitoring on ATRA; mucositis + neutropenic fever; QTc on arsenic
    inputs: cbc_with_diff, tls_panel
    actions: panel.cbc, panel.coag
    advance: Monitoring schedule documented
  12. 12FOLLOWUP
    Consolidation + maintenance per protocol; MRD assessment; survivorship + late-effect screening
    advance: Long-term plan documented