Leukemia
Acute Lymphocytic Leukemia
search
Acute Lymphocytic Leukemia
, Acute Lymphoblastic Leukemia, ALL
History
Success story of Twentieth Century Oncology
Previously ALL was 100% fatal in 3 months
Current
Chemotherapy
regimens hold >50% cure
Epidemiology
Disease of children and young adults
Onset is at under age 20 years old in more than half of patients
Highest
Incidence
is between ages 2-3 years
Most common childhood (25% of cancers diagnosed under age 15 years)
Incidence
: 35-40 cases per 1 Million
Annual
Incidence
: 2900 children and adolescents per year in U.S
Ethnicity
Highest
Incidence
in hispanic and white children
Lowest rate among black children
Risk Factors
Prenatal Radiation Exposure
Genetic Syndrome
s
Down Syndrome
Neurofibromatosis
Ataxia Telangiectasia
Shwachman syndrome
Bloom syndrome
Symptoms
See
Acute Leukemia
Fever
Lethargy
Bleeding or
Bruising
Musculoskeletal pain
Gastrointestinal symptoms from
Hepatosplenomegaly
Nausea
Abdominal fullness
Early Satiety
Signs
See
Acute Leukemia
Hepatomegaly
or
Splenomegaly
(50% to 75%)
Lymphadenopathy
Testicular involvement may occur
Anterior
Mediastinal Mass
(
T-Cell
Variant)
CNS Involvement in 5-8% of adults with Acute Lymphoblastic Leukemia
Labs
Pathology
Immature
Lymphoblast
s (blast cells)
Round or convoluted nuclei
Express Common ALL
Antigen
(CALLA) in 60% of cases
Contrast with
Acute Myelogenous Leukemia
Smaller blast cells with ALL
No Auer rods in ALL
Contain deoxynucleotidyl transferase in 90% of cases (rare in AML)
Lymphocyte
Cell Types
T-Cell
Type (20% of cases)
B-Cell Type (5%)
Null Cell Type (15%)
Diagnosis
Sources
Peripheral Blood Smear
Bone Marrow Biopsy
Studies to distinguish between AML and ALL
Flow cytometry with immunophenotyping
Sorts and counts cells by cell surface markers
Cytogenetic testing
Chromosome
evaluation (karyotype or fluorescence in situ hybridization analysis)
Management
Acute
Remission-Induction
Chemotherapy
Vincristine
Prednisone
Daunorubicin or L-asparaginase
CNS Prophylaxis (prevents Leukemic
Meningitis
)
Whole Brain Radiation (18 to 24-Gy)
Intrathecal
Methotrexate
Maintenance
Chemotherapy
for 2-3 years
6-Mercaptopurine
Methotrexate
Management
Surveillance of survivors treated with
Chemotherapy
and radiation
Initial surveillance
Year 1
Monthly Physical Exam and
Complete Blood Count
(CBC)
Every 2 month
Liver Function Test
s until normal
Bone Marrow Aspirate
or
Lumbar Puncture
as indicated
Echocardiogram
as indicated
Year 2
Every 3 month physical exam (with testicular exam) and
Complete Blood Count
Year 3 (and after)
Every 6 month physical exam (with testicular exam) and
Complete Blood Count
Routine periodic exams
Eye Examination
Dental care
Annual lab testing
Complete Blood Count
with differential
Obtain for up to 10 years following last treatment
Comprehensive metabolic panel
Includes serum
Electrolyte
s,
Serum Creatinine
,
Blood Urea Nitrogen
,
Serum Calcium
and
Liver Function Test
s
Serum Phosphorus
Serum Magnesium
Thyroid Stimulating Hormone
Urinalysis
Hepatitis testing (one time screening)
Hepatitis C Antibody
testing (if treated before 1993)
Hepatitis B Surface Antigen
(if treated before 1972)
Other tests as indicated
Respiratory symptoms
Chest XRay
Pulmonary Function Test
ing
Hearing changes
Audiometry
Cardiac symptoms (e.g. CHF)
Repeat testing every 3-5 years if pretreatment cardiac testing was abnormal
Echocardiogram
Electrocardiogram
Management
Surveillance of survivors miscellaneous
Treated with cranial or craniospinal radiation
Neuroimaging is indicated for neurologic symptoms
Treated with
Hematopoietic Stem Cell Transplant
ation
See
Hematopoietic Stem Cell Transplant
for protocol
Prognosis
Child: Probable cure in >50%
Age under 50 years: Five-year survival 75%
Adult: Long term survival <30%
Age over 50 years: Five-year survival 25%
Complications
See
Acute Leukemia
Leukemic
Meningitis
in relapse
Headache
and
Nausea
Cranial Nerve
palsy
Seizure
s
Altered Level of Consciousness
Gene
ral
Chemotherapy
complications
Lymphocytopenia
Immunodeficiency
(predominantly
T-Cell
s)
Pneumocystis carinii Pneumonia
Growth retardation (most attain normal growth)
Sterility (most resolves)
Joint osteonecrosis (hips,
Shoulder
s and knees)
Cummulative 20 year
Incidence
2.8% in adolescents treated for ALL
Cyclophosphamide related
Bladder Cancer
Anthracycline (doxorubicin or daunorubicin) related
Cardiomyopathy
Cranial
Radiotherapy
related
CNS tumor
Papillary
Thyroid Carcinoma
Acute monocytic
Leukemia
Cognitive decline
Osteoporosis
Obesity
Periodontal Disease
Cataract
s
Resources
National Cancer Institute
http://www.cancer.gov/cancertopics/pdq/treatment/childALL/HealthProfessional
References
Davis (2014) Am Fam Physician 89(9): 731-8 [PubMed]
Wilbur (2014) Am Fam Physician 91(1):29-36 [PubMed]
Type your search phrase here