Malignant Hepatic Infiltration Versus Drug-Induced Liver Injury in B-Cell Acute Lymphoblastic Leukemia

B-cell acute lymphoblastic leukemia (B-ALL) is the most common subtype of lymphoid malignancy. Elevated liver enzymes in B-ALL may reflect both hepatic infiltration and chemotherapy-related drug-induced liver injury. This creates a diagnostic challenge that can be delineated with a liver biopsy, preventing delays in management and care. We present 2 patients with B-ALL who developed elevated liver enzymes during chemotherapy and underwent liver biopsy demonstrating hepatic infiltration. These biopsy-proven cases highlight the critical role of liver biopsy in distinguishing hepatic infiltration from drug-induced liver injury, guiding management decisions and allowing for continued chemotherapy without unnecessary delay.