Acute Lymphocytic Leukemia
What is acute lymphocytic leukemia (ALL)?
Acute lymphocytic leukemia (ALL) is a fast-growing blood cancer that forms in immature white blood cells called lymphocytes. It starts in the bone marrow (soft, spongy tissue inside bones), which is where white blood cells form.
ALL usually spreads quickly to other areas of the body, such as the spleen, liver, lymph nodes, testicles, brain and spinal cord.
Are there different types of ALL?
There are two types of lymphocytes: B-cells and T-cells. B-cells make antibodies and help us fight infections. T-cells destroy germs and support other cells in our immune system. ALL can develop either in B-cells or T-cells.
Who is at risk of getting acute lymphocytic leukemia (ALL)?
ALL is most likely to occur in children under age 5 and adults over 50. It’s slightly more common in males than females. It also occurs more often in white races than Black.
Other risk factors may include:
- Exposure to radiation or toxic chemicals.
- Past chemotherapy.
- Some genetic conditions, including Down syndrome and neurofibromatosis type 1 (NF1).
- Viruses that lower your immune system, including human immunodeficiency virus (HIV).
How common is acute lymphocytic leukemia (ALL)?
ALL is fairly rare in the U.S. It accounts for about 1% of all cancers. Close to 6,000 people get ALL each year in this country. It’s more common in children, but deadlier in adults. Roughly 40% of cases occur in adults.
B-cell ALL is more common than T-cell ALL, accounting for about 75% to 80% of all cases.
What is the difference between acute lymphocytic leukemia and acute lymphoblastic leukemia?
Acute lymphoblastic leukemia is another name for acute lymphocytic leukemia. They are the same condition. Both names for this condition also go by the acronym: ALL.
Symptoms and Causes
What causes acute lymphocytic leukemia (ALL)?
Experts don’t know exactly what causes ALL. Many people with ALL have acquired genetic mutations (changes to genes) in the ALL cells. Changes to chromosomes, which contain genes, are also common in people with ALL. Research suggests that these changes aren’t inherited, which means parents do not pass them to children. Instead, the changes likely happen during a person’s lifetime.
What are the symptoms of acute lymphocytic leukemia (ALL)?
Symptoms of ALL include:
- Abdominal pain, swelling or fullness.
- Bleeding, such as frequent nosebleeds or heavy menstrual periods.
- Frequent infections.
- Joint pain.
- Loss of appetite.
- Night sweats.
- Pale skin.
- Shortness of breath.
- Swollen lymph nodes.
- Unexplained weight loss.
What are the complications of ALL?
If acute lymphocytic leukemia spreads to other organs, such as the brain and spine, it can lead to:
- Balance problems.
- Blurred vision.
- Facial muscle weakness or numbness.
- Nausea and vomiting.
A certain type of T-cell ALL affects the thymus, a small gland in the upper front of your chest, near your neck. It can cause the thymus gland to swell, so you may see a bulge under the skin of your chest. If the gland gets too big, it can press on your windpipe and make you cough or make breathing difficult. The thymus can also press on a large vein called the superior vena cava (SVC). This can cause SVC syndrome when blood can't pass through your vein toward your heart and backs up. This causes swelling of your face and upper extremities.
SVC syndrome is an emergency. Seek immediate medical attention if you experience these symptoms:
- Bluish-red colored skin in the head and neck area.
- Change in your mental state or confusion.
- Edema (swelling) in the face, neck, arms and upper chest.
- Blurred vision.
Diagnosis and Tests
How is acute lymphocytic leukemia (ALL) diagnosed?
Your healthcare provider evaluates your symptoms, reviews your medical history and does a physical exam. If they suspect ALL, they’ll order a complete blood count (CBC). Someone with ALL usually has:
Your healthcare provider may also do a bone marrow biopsy. They use needles to take samples of bone marrow fluid and a small piece of solid bone, usually from your hip bone. This is a small outpatient procedure usually done under local anesthesia. A pathologist examines the samples in a lab to check for ALL.
Other tests for ALL include:
- Chromosome tests usually done in the bone marrow fluids.
- Spinal tap (lumbar puncture).
- Lymph node biopsy.
Imaging tests like MRIs or CT scans can be used if your healthcare providers think that the cancer has spread to other areas of your body. ALL can also cause organs like liver and spleen to get too big.
Management and Treatment
How is acute lymphocytic leukemia (ALL) treated?
The most common treatment for ALL is long-term chemotherapy. Chemotherapy (chemo) is the use of drugs to destroy cancer cells. Immunotherapy and targeted therapy can also be combined with chemotherapy to make it more effective. Sometimes a bone marrow transplant follows chemo usually in ALL patients who are at high risk for future relapse. Since ALL doesn’t always form tumors, other common cancer treatments such as surgery and radiation therapy aren’t as effective.
How does chemotherapy treat ALL?
Chemo for ALL is usually delivered in three phases:
- Induction: You receive four to six weeks of intense chemo, usually as an inpatient (staying overnight) in the hospital, with the goal of remission (no signs or symptoms of cancer, though the cancer may still be in your body at lower amounts).
- Consolidation (intensification): If you go into remission, you receive several more months of chemo (multiple treatments each week) that gradually get more intense. Most people don’t need to stay in the hospital during this phase.
- Maintenance (post-consolidation): You receive less intensive chemo for about two years to prevent the cancer from returning.
How does a bone marrow transplant treat ALL?
High doses of chemotherapy can severely damage your bone marrow. So, some people with ALL need a bone marrow transplant to restore the bone marrow so it can produce new blood cells and give you a new immune system. You may receive bone marrow stem cells from a donor (the preferred method, usually a family member or a matched, unrelated donor identified from an international donor registry pool). Or less commonly, your provider may harvest your own stem cells, purify them and put them back into your bone marrow. This might happen if you can’t find a donor with matching DNA. Bone marrow transplant procedures are almost always covered by your insurance if medically necessary.
How does targeted therapy treat acute lymphocytic leukemia (ALL)?
Targeted therapies aim for specific parts of cancer cells. People with ALL caused by an abnormal chromosome (about 25% of adults and a very small number of children) may benefit from this treatment.
How does immunotherapy treat acute lymphocytic leukemia (ALL)?
Immunotherapy helps your body’s own immune system attack cancer cells. Immunotherapy may include:
- CAR T-cell therapy: CAR T-cell therapy removes immune cells from your body, alters them in a lab and returns them to your body where they can identify and attack leukemia cells. This type of therapy is usually reserved for ALL patients when chemo or combination of chemo and immunotherapy or targeted therapy does not work.
- Monoclonal antibodies: Synthetic (manmade) antibodies attack proteins on leukemia cells. They are usually combined with chemo or targeted therapy to make them more effective.
How can I prevent acute lymphocytic leukemia (ALL)?
There’s no way to prevent ALL. You may be able to reduce your risk by:
- Avoiding radiation exposure and toxic chemicals.
- Quitting smoking.
Outlook / Prognosis
What is the outlook for people with acute lymphocytic leukemia (ALL)?
Younger people tend to have a better outlook for ALL. The 5-year survival rate for people under 20 is 89%. This means most people live another five years after their diagnosis and many of them are cured and live normal and productive lives. The survival rate falls to 37% in people older than 20.
What should I ask my healthcare provider?
If you or your child have acute lymphocytic leukemia, you may want to ask your healthcare provider the following questions:
- Are there clinical trials I can take part in?
- Can the cancer come back after treatment?
- Is there anything I can do to make treatment more effective?
- What are the side effects of chemo?
- Am I a candidate for immunotherapy and targeted therapy?
- Will I need a stem cell transplant?
- Will CAR-T cell therapy be applicable in my case?
A note from Cleveland Clinic
Acute lymphocytic leukemia (ALL) is a type of cancer that starts in the bone marrow. It affects white blood cells called lymphocytes. It’s the most common childhood cancer, but also affects adults. ALL treatment usually involves aggressive chemotherapy and a stem cell transplant. ALL can spread very quickly if not caught early, so be sure to talk to your doctor if you experience symptoms like fever, swollen lymph nodes, frequent infections or fatigue.
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