A client who was admitted with a diagnosis of acute lymphoblastic leukemia is receiving chemotherapy

Leukemia is a cancer that mostly affects white blood cells. White blood cells (also called leukocytes) fight infections.

Inhaltsverzeichnis Show

What Is Acute Lymphoblastic Leukemia?
What Are the Signs & Symptoms of Acute Lymphoblastic Leukemia?
What Causes Acute Lymphoblastic Leukemia?
How Is Acute Lymphoblastic Leukemia Diagnosed?
How Is Acute Lymphoblastic Leukemia Treated?
What Else Should I Know?
Treatment stages

Bone marrow is a spongy material inside the bones that makes white blood cells, red blood cells, and platelets. With leukemia (loo-KEE-mee-uh), the bone marrow makes white blood cells that don’t work. These abnormal cells can’t protect the body from germs. They crowd the bone marrow, enter the bloodstream, and can spread to other parts of the body, like the lymph nodes, brain, or liver.

Leukemia is the most common type of cancer in children. It can be acute (fast-growing) or chronic (slow growing). Most kids and teens treated for leukemia are cured of the disease.

What Is Acute Lymphoblastic Leukemia?

Acute lymphoblastic leukemia (ALL) happens when the body makes too many of a white blood cell called a lymphocyte. This is the most common type of leukemia in children. ALL is also called acute lymphocytic leukemia and acute lymphoid leukemia.

ALL can affect different types of lymphocytes called B-cells or T-cells. Doctors label the type of ALL based on which cells are affected. Most kids with ALL have the B-cell subtype.

Acute lymphoblastic leukemia develops and gets worse quickly, so early diagnosis is important. Most kids are cured with treatment.

What Are the Signs & Symptoms of Acute Lymphoblastic Leukemia?

Kids with ALL may get anemia, which is when the body has too few red blood cells. This happens when bone marrow stops making the usual amount of red blood cells.

Kids with anemia may:

look pale
feel very tired or weak
get short of breath while playing

When they don’t have enough platelets (PLATE-lits), kids with leukemia may bruise easily, get nosebleeds, or bleed for a long time after even a minor cut.

Other symptoms of leukemia can include:

pain in the bones or joints, sometimes causing a limp
swollen (swollen glands) in the neck, groin, or elsewhere
poor appetite and weight loss
fevers
belly pain

Because their white blood cells can't fight infections, kids with leukemia are more likely to get viral or bacterial infections.

Sometimes leukemia can spread, or metastasize (meh-TASS-tuh-size). If it spreads to the brain, symptoms may include headaches, seizures, balance problems, or vision problems. If it spreads to the lymph nodes in the chest, symptoms can include breathing problems and chest pain.

What Causes Acute Lymphoblastic Leukemia?

Doctors don't know exactly what causes leukemia. But some things can make kids more likely to get it, such as:

having a sibling with a history of leukemia
earlier radiation therapy or chemotherapy for other types of cancer
taking medicines to suppress the immune system after an organ transplant
genetic conditions such as:
- Li-Fraumeni syndrome
- Down syndrome
- neurofibromatosis
- ataxia telangectasia
- Fanconi anemia
having a non-inherited condition like myelodysplasia syndrome (a kind of pre-leukemia that stops blood cells from growing normally)

How Is Acute Lymphoblastic Leukemia Diagnosed?

Doctors use special tests to check for leukemia. These include:

Blood tests. Tests such as a complete blood count, liver function and kidney function panels, and blood chemistry tests can give important information about the number of normal blood cells in the body and how well the organs are working. The shapes and sizes of the blood cells are checked with a microscope.
Imaging studies. These may include an X-ray, CT scan, MRI, or ultrasound. Doctors use these to rule out other causes of symptoms, or look for a mass of leukemia cells in the chest that can affect breathing or blood circulation.
Bone marrow aspiration and biopsy. For this procedure, a child gets medicine to sleep and be comfortable. The doctor then puts a needle into a large bone, usually the hip, and removes a small amount of bone marrow. A lab does these tests on the bone marrow sample:
- Flow cytometry tests. Doctors carefully look at the cancer cells and figure out the type and subtype of the leukemia. This is important because treatment varies among different types of leukemia.
- Genetic tests. By looking carefully at the blood or bone marrow, doctors check for changes in the genes. This can help doctors figure out the best treatment.
- Tissue typing or HLA (human leukocyte antigen) typing. If a child needs a stem cell transplant (sometimes called a bone marrow transplant), this test helps find a suitable stem cell donor. It compares the proteins on the surface of the child's blood cells with the proteins on a potential donor's cells. The more HLA markers a child and donor share, the greater the chances that a transplant will go well.
Spinal tap (lumbar puncture). The doctor uses a hollow needle to remove a small amount of cerebrospinal fluid (the fluid surrounding the brain and spinal cord). The fluid is checked for cancer cells. This helps doctors plan treatment.

How Is Acute Lymphoblastic Leukemia Treated?

Chemotherapy

Most kids with ALL will get chemotherapy. These are special drugs that kill cancer cells. Which drugs a child gets and in what combination depends on the subtype of ALL and how fast-moving the disease is. How cancer cells respond to the first treatment helps doctors decide how to choose the next type of chemo.

Different types of chemo can be given:

into a vein (IV)
as an injection into a muscle
by mouth in pill form
with a spinal tap right into the cerebrospinal fluid

The treatment goal is remission, which is when tests don't find any cancer cells in the body. Then, maintenance chemotherapy keeps the child in remission and prevents the cancer from coming back. Kids get maintenance chemo for 2 to 3 years.

Stem Cell Transplants

Some kids who have a fast-growing type of ALL might need a stem cell transplant (sometimes called a bone marrow transplant). This treatment involves:

killing cancer cells, normal bone marrow, and immune system cells with high-dose chemotherapy and/or radiation
putting healthy donor stem cells back into the body
rebuilding a healthy blood supply and immune system with the new stem cells

Other treatments may include:

radiation therapy: high-energy X-rays that kill cancer cells
targeted therapy: specific drugs that find and attack cancer cells without hurting normal cells
immunotherapy: medicine that uses the child’s own immune system to get rid of cancer cells

Clinical Trials

Clinical trials are research studies that offer promising new treatments not yet available to the public. Doctors will decide if a child is a good candidate for a clinical trial.

What Else Should I Know?

Having a child being treated for cancer can feel overwhelming for any family. But you're not alone. To find support, talk to anyone on your child’s care team or a hospital social worker. Many resources are available to help you get through this difficult time.

You also can find information and support online at:

Acute lymphoblastic leukemia (ALL), sometimes called acute lymphocytic leukemia, is the most common form of leukemia found in children, accounting for about 30 percent of all pediatric cancer. There are about 3,000 cases of ALL in children and youth up to age 21 each year in the United States. ALL has one of the highest cure rates of all childhood cancers.

Acute lymphoblastic leukemia affects the immature forms of white blood cells, called lymphocytes. There are two basic types of lymphocytes, B-lymphocytes and T-lymphocytes, and their immature forms are the source of the two corresponding subsets of ALL, T-ALL and B- or pre-B ALL.

The job of lymphocytes is to identify and destroy foreign proteins in the body, such as bacteria and viruses. In ALL, the bone marrow makes too many immature lymphocytes (called lymphoblasts) that do not mature correctly. Immature blood cells (blasts) do not have the ability to fight infection. The lymphoblasts overproduce and crowd out normal blood-forming cells in the bone marrow.

The most common signs and symptoms of acute lymphoblastic leukemia in children are:

Anemia. Anemia occurs when normal red blood cells can't be produced because the bone marrow is overcrowded by leukemia cells. The anemic child may be more tired, take more naps, look pale, and her heart may be racing. The number of red blood cells on a blood count (expressed as "hemoglobin" or "hematocrit") will be below normal.
Bleeding and/or bruising. When the bone marrow cannot produce enough platelets, bleeding can occur, especially when the platelet numbers are less than 10-20,000/mm3. Low platelets can cause a child to bruise or bleed more easily.
Bone and joint pain. Pain in bones and joints is usually a result of the bone marrow being crowded with leukemic blasts. This is often mistaken for "growing pains."
Recurrent fevers/infections. The child with leukemia often shows non-specific symptoms of infection such as fever and fatigue. Although the blood count of a child with leukemia may show a high number of white blood cells, these cells are immature and do not normally fight infection. As a result, the child may have difficulty recovering from an ordinary childhood infection or may develop unusual infections.
Abdominal pain. Leukemia cells can collect in the kidneys, liver and spleen, causing enlargement of these organs which can cause pain in the abdomen. This pain may lead to loss of appetite and weight loss.
Swollen lymph nodes. Lymph nodes filter the blood. Leukemia cells often collect in the nodes, causing swelling. Swelling occurs in lymph nodes in the neck, under the arms, in the groin and chest. Sometimes it is difficult to distinguish the lymph nodes of leukemia from those that are a normal part of the body's response to infection or allergy.
Difficulty breathing. In leukemia, especially T-cell ALL, cells can clump together in the thymus a gland under the breastbone and around the throat. This mass of cells can cause difficulty breathing. Any wheezing, coughing and/or labored or painful breathing requires immediate medical attention.

The diagnosis of acute lymphoblastic leukemia in children is based on a complete medical history and physical examination and on the following diagnostic tests:

Complete blood count (CBC). Blood drawn through the arm or an IV is used to look at the white blood cell number, as well as platelets. Blood tests may be done to evaluate the liver and kidneys and how the blood is clotting.
Bone marrow aspirate and biopsy. Bone marrow aspirates and biopsies involve inserting a needle into a bone in the pelvis or spine and removing about 2 teaspoons of marrow for examination. Bone marrow studies require pain medicine and usually sedation or general anesthesia.
Lumbar puncture (spinal tap). Spinal taps involve inserting a needle into the lower back, between the bones of the spinal column or backbone, to remove the fluid that surrounds the brain and spinal cord. The same needle can be used to insert medicines to prevent or treat leukemia in the brain or spinal cord (intrathecal chemotherapy).
Chest X-ray. Chest X-rays are taken to see if there is a mass of cells in the thymus that may affect breathing.

Treatment for acute lymphoblastic leukemia usually begins by addressing the signs and symptoms your child has such as anemia, bleeding and/or infection. In addition, treatment for leukemia will include most of the following:

Chemotherapy. Chemotherapy refers to medicines that help fight cancer. They are given by mouth, in the vein, in the muscle or under the skin.
Intrathecal medications/chemotherapy. Intrathecal chemotherapy is chemotherapy that is injected into the spinal fluid to prevent or treat leukemia in the brain and spinal cord. Intrathecal medications/chemotherapy involves inserting medications through a needle into the fluid-filled space surrounding the spinal cord.
Blood transfusions. Blood transfusions are used for patients who have anemia who cannot make their own red blood cells. Platelets are commonly transfused when platelet counts are low. Chemotherapy causing anemia and low platelets often requires transfusions.
Antibiotics. Antibiotics are used to prevent or treat infections.
Placement of permanent line. When a central venous line is used to take blood or give medication, a plastic tube or catheter is inserted into a large vein in the chest, neck or arm. The use of a central line prevents a lot of needle sticks.
Radiation therapy. Radiation therapy uses high-energy waves such as x-rays to kill or shrink cancer cells. It is rarely used to treat leukemia in the central nervous system or other places such as the eye or the testes.
Blood and marrow transplantation. Blood and marrow transplantation consists of three steps: 1) collection of healthy stem cells from a donor without cancer or from the patient himself or herself; 2) administration of high doses of chemotherapy and possibly radiation therapy to kill any remaining leukemia cells; and 3) infusion of the healthy stem cells through an intravenous line to produce normal blood-forming cells. Bone marrow or stem cell transplantation is commonly used to treat ALL that has not responded to chemotherapy, or that was found to have very high risk of relapse.

Treatment stages

Treatment of acute lymphoblastic leukemia takes months or years and takes place in three or more stages.

Induction

Induction refers to the first month or so of treatment in which a combination of chemotherapeutic drugs is given to reduce the numbers of leukemia cells from visible to not visible under the microscope. The goal in this stage of treatment is to reduce the number of leukemia cells in the marrow to a minimum and to make room for the return of the normal red blood cells, white blood cells and platelets. When this happens, the leukemia is said to be in "remission."

Consolidation

In ALL, consolidation involves one or two months of drug treatment. During this phase, the rare remaining leukemia cells are targeted. The patient receives weekly spinal taps to prevent leukemia from going to the brain/spinal fluid.

Interim maintenance

Patients receive methotrexate in combination with other chemotherapy agents. In some protocols the methotrexate has to be given as an inpatient.

Intensification

In ALL, intensification involves repeating chemotherapy combinations similar to those used in induction and consolidation several months later. This stage is slightly more intensive and about half of patients get admitted to the hospital for fever, infection or other side effects.

Maintenance

This treatment stage involves repeated courses of less intense chemotherapy every 28 days for an additional 2 to 3 years. Monthly outpatient visits are required to determine response to treatment, detect any recurrent disease and manage any side effects of the treatment.

Some children treated for acute lymphoblastic leukemia may develop complications years later. Our Cancer Survivorship Program provides information about the potential long-term effects of the specific treatment your child received, including ways of monitoring and treating these effects.

Reviewed by Susan R. Rheingold, MD