Beyond Standard Protocols: Real-world Challenges and Innovative Solutions in Pediatric Leukemia Management - “Experience from a Tertiary Oncology Center Integrating MRD-guided Therapy and Novel Agents”

Background: Pediatric acute leukemias represent a heterogeneous group of malignancies with variable prognoses. Although survival rates have improved significantly with risk-adapted protocols and advances in supportive care, management becomes complicated in the presence of comorbidity, age-related challenges, or rare molecular subtypes. Objective: To present three pediatric cases—infantile AML, ALL in a child with Down syndrome, and APML with differentiation syndrome—demonstrating diagnostic dilemmas, therapeutic challenges, and the potential of modified regimens. Methods: Retrospective descriptive case series at a tertiary pediatric oncology unit, examining clinical profiles, treatment adaptations, and outcomes. Results: All patients achieved remission. Two required significant modifications due to toxicity or preexisting conditions. Integration of MRD-guided strategies, novel therapeutic agents like azacitidine and venetoclax, and aggressive management of complications led to favorable outcomes. Conclusion: Personalized protocols, vigilant monitoring, and early recognition of complications are essential in pediatric leukemia care. Incorporation of newer agents may rescue patients where traditional therapies fail or are poorly tolerated.