Acute lymphocytic leukemia (ALL)

Definition

Acute lymphocytic leukemia (ALL) is a fast-growing cancer of a type of white blood cells called lymphocytes. These cells are found in the bone marrow and other parts of the body.

See also: Leukemia

Alternative Names

ALL; Acute childhood leukemia; Cancer - acute childhood leukemia (ALL); Leukemia - acute childhood (ALL)

Causes, incidence, and risk factors

Acute lymphocytic leukemia (ALL) occurs when the the body produces a large number of immature white blood cells, called lymphocytes. The cancer cells quickly grow and replace normal cells in the bone marrow. Bone marrow is the soft tissue in the center of bones that helps form blood cells. ALL prevents healthy blood cells from being made. Life-threatening symptoms can occur.

This type of leukemia usually affects children ages 3 - 7. It is the most common childhood acute leukemia. However, the cancer may also occur in adults.

Most of the time, there is no obvious cause. However, the following may play a role in the development of leukemia in general:

• Certain chromosome problems
• Exposure to radiation, including x-rays before birth
• Past treatment with chemotherapy drugs
• Receiving a bone marrow transplant
• Toxins such as benzene

The following increase your risk for ALL:

• Down syndrome or other genetic disorders
• A brother or sister with leukemia

Symptoms

Acute lymphocytic leukemia (ALL) makes you more likely to bleed and develop infections. Symptoms include:

• Bone and joint pain
• Easy bruising and bleeding (such as bleeding gums, skin bleeding, nosebleeds, abnormal periods)
• Feeling weak or tired
• Fever
• Loss of appetite and weight loss
• Paleness
• Pain or feeling of fullness below the ribs
• Pinpoint red spots on the skin (petechiae)
• Swollen glands (lymphadenopathy) in the neck, under arms, and groin
• Night sweats

Note: These symptoms can occur with other conditions. Talk to your doctor about the meaning of your specific symptoms.

Signs and tests

A physical exam may reveal the following:

• Bruising
• Swollen liver, lymph nodes, and spleen
• Signs of bleeding (petechiae, purpura)

Blood tests may include:

• Complete blood count (CBC), including white blood cell (WBC) count
• Platelet count
• Bone marrow aspiration and biopsy
• Lumbar puncture (spinal tap) to check for leukemia cells in the spinal fluid

Tests are also done to look for chromosome changes in the cells of some leukemias. Leukemias with certain types of chromosome changes have a poor outlook, while those with other types of genes can have a very good outlook. Having certain chromosome changes may determine what kind of treatment you receive.

Treatment

The first goal of treatment is to get your blood counts back to normal. If this occurs and the bone marrow looks healthy under the microscope, the cancer is said to be in remission. After remission, you will need more treatment to be cured. This treatment can include more chemotherapy or a stem cell transplant from a donor.

Chemotherapy is the first treatment used to try and put you into remission.

• The first time you receive chemotherapy, you may need to stay in the hospital for several weeks.
• Later you may receive chemotherapy as an outpatient, meaning you come to a clinic to receive the treatment

If you have a low white blood cell count, you may need to be placed in a hospital room by yourself so you do not catch an infection from other people.

ALL may spread to the brain and spinal cord. Many chemotherapy drugs given through a vein cannot reach these areas. Therefore, you may also receive:

• Chemotherapy given directly into the space around your brain or into the spinal column
• Radiation therapy to the brain

Your health care provider will decide which treatment you receive after you've gone into remission. The treatment will depend on several factors, including:

• Your age
• Other health problems you have
• Type of lymphocyte (B-cell versus T-cell) and chromosome changes you have
• Availability of donors

If you have more chemotherapy and your ALL relapses, then you will need a stem cell transplant. 

Additional treatments depend on other symptoms. They may include:

• Transfusion of blood products, such as platelets or red blood cells
• Antibiotics to fight infection, especially if a fever occurs

Support Groups

Joining a support group where members share common experiences and problems may help ease the stress related to illness.

See: Cancer - support group

Expectations (prognosis)

Most children with ALL can be cured. Children usually have a better outcome than adults.

The following patients tend to do better:

• Younger adults (especially those younger than age 50)
• Children between the ages of 1 and 9
• Those who have a white blood cell (WBC) count below 50,000 when first diagnosed
• Those who do not have a specific genetic change called Philadelphia chromosome-positive ALL
• Those who go into remission within 4 - 5 weeks of starting treatment

Patients whose leukemia spreads to the brain or spinal cord tend to have a worse outcome.

Complications

• Bleeding
• Damage to different organs from chemotherapy
• Disseminated intravascular coagulation (DIC)
• Relapse of ALL
• Severe infection
• Spread of the cancer to other parts of the body

Calling your health care provider

Call your health care provider if:

• You develop ALL-like symptoms
• You have ALL and you have a persistent fever or other signs of infection

Prevention

You may reduce your risk of ALL by avoiding contact with certain toxins, radiation, and chemicals.

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References

Pui CH, Robison LL, Look AT. Acute lymphoblastic leukaemia. Lancet. 2008 Mar 22;371(9617):1030-43.

Pidala J, Djulbegovic B, Anasetti C, Kharfan-Dabaja M, Kumar A. Allogeneic hematopoietic cell transplantation for adult acute lymphoblastic leukemia (ALL) in first complete remission. Cochrane Database Syst Rev. 2011 Oct. 5:(10):CD008818.