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Acute Lymphocytic Leukemia (ALL)

by Michael E. Rytting, MD

Acute lymphocytic (lymphoblastic) leukemia is a life-threatening disease in which the cells that normally develop into lymphocytes become cancerous and rapidly replace normal cells in the bone marrow.

  • People may have symptoms, such as fever, weakness, and paleness, because they have too few normal blood cells.

  • Blood tests and a bone marrow evaluation are usually done.

  • Chemotherapy is given and is often effective.

Acute lymphocytic leukemia (ALL) occurs in people of all ages but is the most common cancer in children, accounting for 25% of all cancers in children younger than 15 years. ALL most often affects young children between the ages of 2 and 5 years. Among adults, it is somewhat more common in people older than 45.

In ALL, very immature leukemia cells accumulate in the bone marrow, destroying and replacing cells that produce normal blood cells. The leukemia cells are carried in the bloodstream to the liver, spleen, lymph nodes, brain, and testes, where they may continue to grow and divide. However, ALL cells can accumulate anywhere in the body. They can irritate the layers of tissue covering the brain and spinal cord, causing inflammation (meningitis), and can cause anemia, liver and kidney failure, and other organ damage.

Symptoms

Early symptoms result from the inability of the bone marrow to produce enough normal blood cells. Fever and excessive sweating may indicate infection. A high risk of infection results from too few normal white blood cells. Weakness, fatigue, and paleness, which indicate anemia, result from too few red blood cells. Easy bruising and bleeding, sometimes in the form of nosebleeds or bleeding gums, result from too few platelets. Leukemia cells in the brain may cause headaches, vomiting, and irritability. Leukemia cells in the bone marrow may cause bone and joint pain. A sense of fullness in the abdomen and sometimes pain can result when leukemia cells enlarge the liver and spleen. Some people may have a rapid heart rate or chest pain.

Did You Know...

  • About 80% of children with acute lymphocytic leukemia are cured.

Diagnosis

Blood tests, such as a complete blood count (see Complete blood count), can provide the first evidence of ALL. The total number of white blood cells may be decreased, normal, or increased, but the number of red blood cells and platelets is almost always decreased. In addition, very immature white blood cells (blasts) are often present in blood samples examined under a microscope.

A bone marrow examination (see Bone Marrow Examination) is almost always done to confirm the diagnosis and to distinguish ALL from other types of leukemia.

Tests of blood and urine may also be done to detect other abnormalities related to ALL. Imaging tests may also be needed. Computed tomography (CT) or magnetic resonance imaging (MRI) is done if the the person has symptoms that suggest leukemia cells in the brain. Chest x-ray may be done to check for leukemia cells in the area around the lungs. CT, MRI, or ultrasonography of the abdomen may be done when internal organs are enlarged.

Prognosis

Before treatment was available, most people who had ALL died within 4 months of the diagnosis. Now, nearly 80% of children and 30 to 40% of adults with ALL are cured. For most people, the first course of chemotherapy brings the disease under control (complete remission). Children between the ages of 3 and 9 have the best prognosis. Infants and older adults fare least well. The white blood cell count and particular chromosome abnormalities in the leukemia cells also influence outcome.

Treatment

Chemotherapy is highly effective and is administered in phases:

  • Induction

  • Consolidation with preventive treatment of the brain

  • Intensification

  • Maintenance

Induction chemotherapy is the initial phase of treatment. The goal of induction chemotherapy is to achieve remission by destroying leukemia cells so that normal cells can once again grow in the bone marrow. People may need to stay in the hospital for a few days or weeks, depending on how quickly the bone marrow recovers. Blood and platelet transfusions may be necessary to treat anemia and to prevent bleeding, and antibiotics may be needed to treat bacterial infections. Intravenous fluids and therapy with a drug called allopurinol may also be used to help rid the body of harmful substances, such as uric acid, that are released when leukemia cells are destroyed.

One of several combinations of drugs is used, and doses are repeated for several days or weeks. The specific combination depends on results of the diagnostic tests. One combination consists of prednisone (a corticosteroid) taken by mouth and weekly doses of vincristine (a chemotherapy drug) given with an anthracycline drug (usually daunorubicin), asparaginase, and sometimes cyclophosphamide, given intravenously. New drugs are being investigated.

The consolidation phase continues to treat bone marrow disease, but because ALL is likely to spread to the brain, it also concentrates on treating leukemia that has spread to the brain or on preventing the spread of leukemia cells to the brain. For treatment of leukemia cells in the layers of tissue covering the brain and spinal cord (the meninges), methotrexate, cytarabine, corticosteroids, or a combination are usually injected directly into the cerebrospinal fluid. This chemotherapy may be given in combination with radiation therapy to the brain.

During intensification (also called delayed intensification or interim maintenance), other blocks of intensive treatment are given to destroy any remaining leukemia cells. Additional chemotherapy drugs, or the same drugs as were used during the induction phase, may be used a few times over a period of several weeks. For some people who are at high risk of relapse because of particular chromosomal changes found in their cells, stem cell transplantation (see Stem Cell Transplantation) during the first remission is often recommended.

Further maintenance chemotherapy, which usually consists of fewer drugs, sometimes at lower doses, usually continues for 2 to 3 years.

Relapse

Leukemia cells may begin to appear again (a condition termed relapse), often in the blood, bone marrow, brain, or testes. Early reappearance in the bone marrow is particularly serious. Chemotherapy is given again, and although many people respond to this repeat treatment, the disease has a strong tendency to come back, especially in infants and in adults. When leukemia cells reappear in the brain, chemotherapy drugs are injected into the cerebrospinal fluid 1 or 2 times a week. When leukemia cells reappear in the testes, radiation therapy is given along with chemotherapy.

For people who have relapsed, high doses of chemotherapy drugs along with allogeneic stem cell transplantation offers the best chance of cure. But transplantation can be done only if stem cells can be obtained from a person who has a compatible tissue type (HLA-matched). The donor is usually a sibling, but cells from matched, unrelated donors (or occasionally partially matched cells from family members or unrelated donors, as well as umbilical stem cells) are sometimes used. Stem cell transplantation is rarely used for people older than 65, because it is much less likely to be successful and side effects are much more likely to be fatal.

After relapse, additional treatment for people who are unable to undergo stem cell transplantation is often poorly tolerated and ineffective, frequently causing people to feel much sicker. However, remissions can occur. End-of-life care should be considered for people who do not respond to treatment (see Introduction to Death and Dying).

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Drugs Mentioned In This Article

  • Generic Name
    Select Brand Names
  • ZYLOPRIM
  • CYTOXAN (LYOPHILIZED)
  • OTREXUP
  • RAYOS
  • MARQIBO KIT
  • ELSPAR