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Acute lymphocytic leukemia (ALL)

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What is acute lymphocytic leukemia (ALL)?

Acute lymphocytic leukemia, also called acute lymphoblastic leukemia, is a type of cancer in which there are too many lymphocytes, the early phase of the white blood cell, in your bone marrow. Leukemia is different from other types of cancers in that it starts in the blood and bone marrow and can spread to other parts of the body. Other cancers can eventually spread to the bone marrow, but they don’t become leukemia.

A cancer that is considered acute can progress quickly and, if not treated, become fatal in just a few months. Acute leukemia differs from chronic leukemia in that with acute leukemia, the bone marrow cells don’t mature the way they’re supposed to. Immature leukemia cells continue to reproduce and build up. In chronic leukemia, the cells mature partially, but not completely, and they don’t fight infection as well as normal white blood cells do. Chronic leukemias tend to progress over time and most people can live for several years, although these kinds of leukemias are more difficult to treat.

What are the symptoms of ALL?

As with other types of leukemia, there are several symptoms that can lead to a diagnosis of ALL, but many of these signs and symptoms are also indicative of many other illnesses. Most often, ALL is detected when your doctor is testing your blood for another reason and sees the shortage of normal blood cells.

This shortage can cause the following symptoms:

  • Fatigue
  • Feeling weak, or low energy
  • Dizziness or lightheadedness
  • Shortness of breath
  • Fever
  • Inability to get rid of an infection
  • Bruises easily
  • Bleeding, as with bleeding gums and severe nosebleeds

Other symptoms that some ALL patients may experience include:

  • Weight loss
  • Fever
  • Night sweats
  • Loss of appetite

Leukemia cells can also cause an enlarged spleen, which can be detected by swelling in the abdomen; enlarged lymph nodes; and bone or joint pain. The cells sometimes – though not often – spread to other organs, and can cause more symptoms there: headaches, seizures and vomiting if the leukemia has spread to the brain or spinal cord, or difficulty breathing if it has spread to the chest cavity, for example.

How is ALL treated?

Because ALL is not a single disease – it’s actually a group of related diseases – patients with different subtypes of ALL will have different treatments and responses to those treatments.

Once you’ve been diagnosed, you and your care team will meet to decide which treatment option is best for you. The main treatment options are:

  • Chemotherapy
  • Targeted therapy—daily medication, typically given as a pill
  • Stem cell transplant

Other possible forms of treatment include surgery, radiation therapy, or monoclonal (man-made) antibodies.

Treatment for ALL typically lasts for two years. It can be an intense treatment, so it’s good to be in a center with recognized experience in treating the disease.

How is ALL diagnosed?

Many people with ALL don’t have any symptoms when it’s diagnosed – it’s typically found when a doctor orders blood tests for something completely unrelated or during a routine checkup.

Some people may be at higher risk of ALL because they have certain blood disorders, such as myelodysplastic syndrome, or inherited disorders, such as Down syndrome, or because they were treated with certain chemotherapy drugs or radiation. Doctors typically recommend these people have regular checkups.

If you have signs or symptoms of ALL, or if a physical examination indicted you may have leukemia, the doctor will need to take samples of your blood and bone marrow to have it tested to be sure. The blood will be drawn from a vein in the arm, in most cases, but the bone marrow will be extracted in two ways: through an aspiration and a biopsy.

Bone aspiration and biopsy

The bone marrow aspiration and biopsy are done at the same time. Samples are generally taken from the back of the pelvic bone (hip), or sometimes from the sternum (breastbone). These samples are sent to a lab where they examined for leukemia cells.

Lumbar puncture

ALL can sometimes spread to the brain and spinal cord, and for this reason your doctor may need to take a sample of spinal fluid for testing. The fluid will be extracted using a lumbar puncture – also known as a spinal tap. This test is used only for patients whose symptoms may be caused by the leukemia spreading to the brain and spinal cord.

Blood tests

There are several lab tests that may be used to determine whether you have ALL or how advanced the disease may be.

Complete blood count and peripheral blood smear

A complete blood count (CBC) measures the levels of the different cells in the blood: red blood cells, white blood cells, and platelets. Some of the blood is placed on a slide and examined under a microscope: most patients with AML have too many immature white blood cells and not enough red blood cells or platelets.

Blood chemistry and coagulation tests

These tests measure the amount of certain chemicals in the blood, as well as the blood’s ability to clot. These tests aren’t used to diagnose leukemia, but can detect other problems.

Chromosome testing

Normally, human cells contain 23 pairs of chromosomes, or DNA bundles. For people with leukemia, however, the cells may have some chromosome changes – sometimes there is a deletion, or a piece of the chromosome is missing.

What happens more often in ALL is that two chromosomes “share” some of their DNA – one chromosome becomes attached to part of another chromosome. This is called translocation.

Information about these and other changes can help your doctor determine your outlook and response to treatment.

Imaging tests

Imaging tests, like X-rays, computed tomography (CT) scans, magnetic resonance imaging (MRI) scans, and ultrasounds may be used to help doctors see detailed images inside your body.

What is the prognosis for ALL?

For many people with ALL, treatment may get rid of the cancer – but even after you’ve completed your treatment, your doctors will want to watch you. It’s important to keep a regular schedule of follow-up appointments, both to answer any questions you may have as well as to monitor any side effects from the treatment.

ALL risk factors

What causes ALL?

With many cancers, there are risk factors that you can control to increase or decrease your chances of getting the disease. A risk factor is something that affects your chances of getting a disease, but doesn’t necessarily mean you will get that disease.

There are just a few known risk factors for ALL:

  • Exposure to high levels of radiation
  • Exposure to certain chemicals, such as benzene and certain chemotherapy drugs
  • Certain viral infections, such as:
    • T-cell lymphoma/leukemia virus-1 (HTLV-1) in Japan and the Caribbean
    • Epstein-Barr virus in Africa
  • Inherited syndromes, such as:
    • Down syndrome
    • Klinefelter syndrome
    • Fanconi anemia
    • Bloom syndrome
    • Ataxia-telangiectasia
    • Neurofibromatosis
  • Race
    • ALL is more common in Caucasians than in African-Americans
  • Gender
    • ALL is slightly more common in men than in women

Should I get screened for ALL?

Unfortunately, there are no screening tests routinely available to detect ALL in the early stages. However, ALL is sometimes detected when certain symptoms show up in routine blood tests done for other reasons. For example, a person’s normal blood cell count may be very low, even if there are no other symptoms. That may lead to other tests in which ALL may be found.