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

Acute lymphocytic leukemia (ALL) is a fast-growing cancer in which the body produces a large number of immature white blood cells (lymphocytes). These cells are found in the blood, bone marrow, lymph nodes, spleen, and other organs.

Review Date: 3/2/2010

Reviewed By: David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc., and Yi-Bin Chen, MD, Leukemia/Bone Marrow Transplant Program, Massachusetts General Hospital.

ALL makes up 80% of childhood acute leukemias. Most cases occur in children ages 3 - 7. The disease may also occur in adults.

In acute leukemia, cancerous cells multiply quickly and replace normal cells. Cancerous cells take over normal parts of the bone marrow, often causing low blood counts .

Most cases of ALL have no obvious cause. However, the following may play a role in the development of leukemia:

• Certain chromosome problems
• Radiation exposure or being exposed to x-rays before birth
• Past treatment with chemotherapy drugs
• Receiving a bone marrow transplant
• Toxins such as benzene

Persons with Down syndrome or other genetic disorders, or who have a brother or sister with leukemia are at increased risk for ALL.

A person with ALL is more likely to bleed and have infections because there are fewer normal blood cells and platelets. Life-threatening symptoms may develop.

• Bone and joint pain or tenderness
• Easy bruising and bleeding (bleeding gums, skin bleeding, nosebleeds, menstrual irregularities)
• 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.

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

The goal of treatment is to get the blood counts and the bone marrow back to normal. If this occurs and the bone marrow looks healthy under the microscope, the cancer is said to be in remission.

If you have ALL, you will need chemotherapy. For the first round of chemotherapy (called induction), you may need to stay in the hospital for 3 - 6 weeks.

Later you may get chemotherapy on an outpatient basis (living at home and going to a clinic to receive your treatments). If you have a low white blood cell count, you may need to be placed in a room by yourself so you do not catch an infection.

Many chemotherapy drugs given into the veins do not reach the brain and spinal cord tissue. Therefore, many patients will also receive radiation therapy to the brain or chemotherapy drugs injected into the space around the brain and spinal column to prevent later spread to these sites.

If you go into remission, you may receive additional chemotherapy or radiation therapy to kill any cancer cells that are in the spinal fluid. You may also receive chemotherapy from time to time to prevent relapse. A bone marrow or stem cell transplant may also be recommended, especially if one of your siblings is proven to be a full match.

If your leukemia returns or does not respond to other treatments, a bone marrow or stem cell transplant is usually recommended.

Additional treatments depend on other symptoms. They may include:

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

Because the cause is usually unknown, it is not possible to prevent most cases. You may reduce your risk of ALL by avoiding exposure to toxins, radiation, and chemicals.

Children usually have a better outcome than adults. Almost all children go into complete remission. Without treatment, a person with ALL can expect to live for only about 3 months.

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 WBC count below 50,000 when first diagnosed
• Those who do not have a Philadelphia chromosome-positive ALL (a specific genetic change)
• Those who achieve complete remission (disappearance of signs and symptoms of cancer) within 4 - 5 weeks of starting treatment

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

• 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

A physical exam may reveal the following:

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

Blood tests may show the following:

• Abnormal white blood cell (WBC) count
• Low red blood cell count (anemia)
• Low platelet count (thrombocytopenia)

A bone marrow aspiration will show abnormal levels of certain cells. The bone marrow is usually taken from the back of one of the hip bones, but can be taken from other bones. Tests are done on the bone marrow cells to identify the type of leukemia.

A lumbar puncture or spinal tap is usually done to both detect if leukemia cells are in the spinal fluid and to give chemotherapy to prevent spread to the spinal fluid.

Doctors look for chromosome changes in the cells of some leukemias. This helps aid in diagnosis and prognosis. Leukemias with certain types of chromosome changes have a poor outlook, while those with other types of genes can have a very good outlook. This may determine what kind of therapy is used to treat the ALL.