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heme.acute-leukemia.core.v1PRODUCTION
heme.acute-leukemia.core.v1

Acute Leukemia (AML / ALL / APL)

oncologyacuteadult
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Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Suspect acute leukemia from blasts on smear; APL recognition is the time-critical priority

Inputs
2
Actions
0
Advance rule
Set
Advance when

Acute leukemia suspected

Patient inputs (7)

Fit vs unfit determines 7+3 vs venetoclax+aza (VIALE-A)

WBC + blast %; hyperleukocytosis triggers leukapheresis decision

Auer rods → AML; faggot cells → APL; lymphoblasts → ALL

DIC concern in APL — fibrinogen + D-dimer + PT

Uric acid + K + Phos + Ca for TLS risk

Lineage assignment AML/ALL + immunophenotype

t(15;17) APL → STAT ATRA; t(9;22) Ph+ ALL → TKI; risk strat for AML

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (8)

8 need judgement
  • informationallife_threateningAPL DIC pattern (NCCN 2024 APL)
    Promyelocytes + DIC (low fibrinogen + high D-dimer + bleeding) (NCCN 2024 APL)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningleukostasis (NCCN 2024 AML)
    WBC >100k + CNS / pulmonary / cardiac symptoms (NCCN 2024 AML)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningspinal cord compression (NCCN 2024)
    Back pain + neurologic deficit in leukemia patient (NCCN 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningDIC severe (NCCN 2024 APL)
    Fibrinogen <150 + bleeding + APL/sepsis context (NCCN 2024 APL)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereTLS high risk (Cairo-Bishop; NCCN 2024)
    WBC >50k OR uric acid >8 OR LDH >2x ULN OR Burkitt-like (Cairo-Bishop 2004; NCCN 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverefebrile neutropenia (IDSA 2010; NCCN 2024)
    Fever ≥38.3 OR ≥38.0 sustained + ANC <500 (IDSA 2010)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveredifferentiation syndrome (NCCN 2024 APL)
    On ATRA/ATO + dyspnea + fever + edema + hypotension (NCCN 2024 APL)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereCNS leukemia (NCCN 2024 ALL)
    CNS symptoms or positive CSF cytology (NCCN 2024 ALL)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

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Recommended regimen

Subtype-driven induction (ELN 2022 AML / NCCN ALL / NCCN APL)
axis: leukemia_subtype_inductionstep apl - APL t(15;17) — STAT ATRA + arsenic at suspicion
Selected step "APL t(15;17) — STAT ATRA + arsenic at suspicion" — Suspicion of APL (DIC + faggot cells + promyelocytes + low/intermediate WBC)
  • all_trans_retinoic_acid
    first line
    differentiating_agent
    45 mg/m²/day PO divided BID • PO • BID
    triggers: apl_suspected
    Lo-Coco NEJM 2013; do NOT wait for confirmation; differentiation syndrome prophylaxis with steroid
    rxcui 10753
  • arsenic_trioxide
    first line
    demethylating_agent
    0.15 mg/kg/day IV • IV • daily until remission then consolidation
    triggers: apl_confirmed_low_intermediate_risk
    Lo-Coco NEJM 2013 — chemo-free for low/intermediate; QTc monitoring
    rxcui 18330
  • prednisone
    add on
    corticosteroid
    0.5 mg/kg PO daily • PO • daily
    triggers: differentiation_syndrome_prophylaxis
    Prevent dyspnea/fever/edema syndrome
    rxcui 8640
  • idarubicin
    add on
    anthracycline
    12 mg/m²/d × 4 days • IV • days 2,4,6,8
    triggers: high_risk_apl, WBC>10k
    High-risk APL adds anthracycline
    rxcui 5650

ed playbook — drug actions (6)

  1. 1. all-trans retinoic acid (ATRA)
    45 mg/m²/day PO BID • PO • BID
    trigger: APL suspected (DIC + faggot cells + promyelocytes)
    Lo-Coco NEJM 2013 — do not wait for confirmation
  2. 2. rasburicase
    0.2 mg/kg IV • IV • single dose
    trigger: High TLS risk (WBC >50k or uric acid >8)
    TLS prophylaxis/rescue; check G6PD if applicable
  3. 3. allopurinol
    300 mg PO daily • PO • daily
    trigger: Low/intermediate TLS risk
    TLS prophylaxis
  4. 4. IV fluids hyperhydration
    3 L/m²/day NS or LR • IV • continuous
    trigger: TLS prophylaxis
    Maintain UOP >100 mL/m²/h
  5. 5. cefepime or pip-tazo
    Cefepime 2 g IV q8h OR pip-tazo 4.5 g IV q6h • IV • q6-8h
    trigger: Febrile neutropenia (fever + ANC <500)
    IDSA — treat as sepsis
  6. 6. platelet transfusion
    1 unit apheresis • IV • as needed
    trigger: Plt <10k OR <50k + bleeding/procedure OR DIC
    Bleeding prevention

Auto-drafted A&P note

ed

Subjective

- Possible entry pathways: Leukocytosis with circulating blasts on smear; Pancytopenia + blasts; Bleeding / DIC (concern for APL).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Acute Leukemia (AML / ALL / APL)** (heme.acute-leukemia.core.v1).
Phenotype framing: AML / ALL / APL t(15;17) / mixed-phenotype / blast crisis CML / lymphoma leukemic phase
Scope: Suspect acute leukemia from blasts on smear; APL recognition is the time-critical priority

No severity triggers fired against current inputs.

Plan

Regimen axis: **Subtype-driven induction (ELN 2022 AML / NCCN ALL / NCCN APL)** — step "APL t(15;17) — STAT ATRA + arsenic at suspicion".
1. all_trans_retinoic_acid 45 mg/m²/day PO divided BID PO BID (differentiating_agent, first line) — Lo-Coco NEJM 2013; do NOT wait for confirmation; differentiation syndrome prophylaxis with steroid
2. arsenic_trioxide 0.15 mg/kg/day IV IV daily until remission then consolidation (demethylating_agent, first line) — Lo-Coco NEJM 2013 — chemo-free for low/intermediate; QTc monitoring
3. prednisone 0.5 mg/kg PO daily PO daily (corticosteroid, add on) — Prevent dyspnea/fever/edema syndrome
4. idarubicin 12 mg/m²/d × 4 days IV days 2,4,6,8 (anthracycline, add on) — High-risk APL adds anthracycline

Setting playbook (ed) — Recognize leukemia, identify life-threatening complications (DIC/leukostasis/TLS/sepsis), expedite to heme/onc
5. all-trans retinoic acid (ATRA) 45 mg/m²/day PO BID PO BID — APL suspected (DIC + faggot cells + promyelocytes) (Lo-Coco NEJM 2013 — do not wait for confirmation)
6. rasburicase 0.2 mg/kg IV IV single dose — High TLS risk (WBC >50k or uric acid >8) (TLS prophylaxis/rescue; check G6PD if applicable)
7. allopurinol 300 mg PO daily PO daily — Low/intermediate TLS risk (TLS prophylaxis)
8. IV fluids hyperhydration 3 L/m²/day NS or LR IV continuous — TLS prophylaxis (Maintain UOP >100 mL/m²/h)
9. cefepime or pip-tazo Cefepime 2 g IV q8h OR pip-tazo 4.5 g IV q6h IV q6-8h — Febrile neutropenia (fever + ANC <500) (IDSA — treat as sepsis)
10. platelet transfusion 1 unit apheresis IV as needed — Plt <10k OR <50k + bleeding/procedure OR DIC (Bleeding prevention)

Non-pharmacologic actions:
- Leukapheresis if leukostasis (WBC >100k + symptoms)
- STAT heme/onc consult
- Reverse isolation if neutropenic
- IV access (large-bore × 2; avoid central if DIC)

AVOID / contraindication checks:
- ATRA differentiation syndrome prophylaxis with prednisone (NCCN 2024 APL)
- Arsenic QTc monitor q1w (NCCN 2024 APL; Lo Coco NEJM 2013)
- Venetoclax TLS ramp up and prophylaxis (NCCN 2024 AML; VIALE A DiNardo NEJM 2020)
- Rasburicase G6PD screen (NCCN 2024 AML/ALL)
- Anthracycline cumulative dose limit (NCCN 2024 AML)
- Cytarabine conjunctivitis prophylaxis with steroid eye drops (NCCN 2024 AML)

Monitoring

Regimen monitoring:
- Daily CBC + differential (NCCN 2024 AML/ALL)
- Daily coags + fibrinogen if APL (NCCN 2024 APL)
- Daily TLS labs (K, Phos, Ca, uric acid, LDH, Cr) (NCCN 2024 AML/ALL)
- QTc q1w on arsenic (NCCN 2024 APL; Lo-Coco NEJM 2013)
- LFTs q1w (NCCN 2024 AML)
- Echo before each anthracycline cycle (NCCN 2024 AML)
- Surveillance cultures + chest CT for pulmonary infiltrates (NCCN 2024 AML/ALL)

Setting (ed) monitoring:
- Continuous cardiac telemetry (NCCN 2024 AML/ALL)
- Q4-6h TLS labs (NCCN 2024)
- Hourly UOP (NCCN 2024)
- Coag q4-6h if DIC (NCCN 2024 APL)

Follow-up plan: Consolidation + maintenance per protocol; MRD assessment; survivorship + late-effect screening
- Close-out criterion: Long-term plan documented

Monitoring phase: Daily CBC + coag (APL DIC) + TLS labs; differentiation syndrome monitoring on ATRA; mucositis + neutropenic fever; QTc on arsenic

Disposition

Current setting: ed — Recognize leukemia, identify life-threatening complications (DIC/leukostasis/TLS/sepsis), expedite to heme/onc

Disposition criteria:
- Admit heme/onc inpatient for induction (NCCN 2024 AML/ALL)
- Admit ICU if leukostasis, DIC, septic shock (NCCN 2024)

Escalation triggers (move to higher acuity):
- Leukostasis with CNS/pulm symptoms → ICU + leukapheresis (NCCN 2024 AML)
- Severe DIC with bleeding → ICU + cryoprecipitate + FFP (NCCN 2024 APL)
- Septic shock → ICU + pressors (NCCN 2024)
- Spinal cord compression → STAT MRI + radiation/dex (NCCN 2024)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Promyelocytes + DIC (low fibrinogen + high D-dimer + bleeding) (NCCN 2024 APL)
- [LIFE_THREATENING] WBC >100k + CNS / pulmonary / cardiac symptoms (NCCN 2024 AML)
- [LIFE_THREATENING] Back pain + neurologic deficit in leukemia patient (NCCN 2024)

Citations

- ELN 2022 AML Recommendations (Döhner et al, Blood 2022) + 2024 ELN less-intensive-therapy risk refinement; APL0406 ATRA+arsenic (Lo-Coco NEJM 2013, final JCO 2016); VIALE-A azacitidine+venetoclax (DiNardo NEJM 2020); ELIANA tisagenlecleucel CAR-T (Maude NEJM 2018); NCCN AML/ALL/APL [PMID:35797463](https://pubmed.ncbi.nlm.nih.gov/35797463/)
- Cited evidence (PMID 32786187) [PMID:32786187](https://pubmed.ncbi.nlm.nih.gov/32786187/)
- Cited evidence (PMID 23841729) [PMID:23841729](https://pubmed.ncbi.nlm.nih.gov/23841729/)
- Cited evidence (PMID 27400939) [PMID:27400939](https://pubmed.ncbi.nlm.nih.gov/27400939/)
- Cited evidence (PMID 29385370) [PMID:29385370](https://pubmed.ncbi.nlm.nih.gov/29385370/)

Last reconciled with current guidelines: 2026-05-22.
References
  • ELN 2022 AML Recommendations (Döhner et al, Blood 2022) + 2024 ELN less-intensive-therapy risk refinement; APL0406 ATRA+arsenic (Lo-Coco NEJM 2013, final JCO 2016); VIALE-A azacitidine+venetoclax (DiNardo NEJM 2020); ELIANA tisagenlecleucel CAR-T (Maude NEJM 2018); NCCN AML/ALL/APL — PMID:35797463
  • Cited evidence (PMID 32786187) — PMID:32786187
  • Cited evidence (PMID 23841729) — PMID:23841729
  • Cited evidence (PMID 27400939) — PMID:27400939
  • Cited evidence (PMID 29385370) — PMID:29385370