Patient Basics: Acute Lymphocytic Leukemia (ALL) in Adults

Originally published by Harvard Health.

What Is It?

Acute lymphocytic leukemia (ALL) is a type of leukemia. Leukemia is a cancer of the blood or bone marrow. ALL is also known as acute lymphoblastic leukemia and acute lymphoid leukemia.

ALL is a cancer of the body’s blood-making system. Blood cells are produced in the bone marrow, the soft, inner part of bones.

The word “acute” in acute lymphocytic leukemia refers to the fact that the disease can progress quickly. The word “lymphocytic” means that the cancer develops from lymphocytes, a type of white blood cell.

The body produces three types of infection-fighting lymphocytes:

• B lymphocytes, which make antibodies to help protect the body from germs.
• T lymphocytes, which can destroy virus-infected cells, foreign cells, and cancer cells.
• Natural killer cells, which also can kill cancer cells and viruses.

In ALL, the body produces too many immature lymphocytes (lymphoblasts). These cells cannot fight infection as well as normal cells.

In addition, as these lymphocytes quickly multiply, they crowd out healthy white blood cells, red blood cells, and platelets in the blood and bone marrow. This may lead to infection, anemia, and easy bleeding.

Certain genetic changes are also associated with ALL.

Acute lymphocytic leukemia typically invades the blood quickly. It can involve other parts of the body, such as the lymph nodes, liver, spleen, brain and spinal cord (central nervous system), and testes.

Symptoms

Among the possible signs and symptoms of ALL are:

• Unexplained and persistent fever
• Marked fatigue and weakness
• Unexpected weight loss with poor appetite
• Easy bruising or bleeding

Leukemia cells that spread to the brain and spinal cord can cause:

• Severe and persistent headache
• Seizures
• Trouble with balance

ALL is not a common disease. So most often the above symptoms are caused by some other medical condition.

Most often the above symptoms are caused by some other condition, not ALL. However, you should always contact your doctor if you experience any of them.

Diagnosis

The first step in diagnosis is usually a physical examination and medical history. Your doctor will check for signs of disease. He or she will ask about your health habits and past illnesses and treatments.

To determine whether you have ALL, your doctor will also need to examine your blood and bone marrow, and possibly other cells and tissues. The following tests and procedures may be used:

• Blood cell count and other blood tests – Blood will be drawn from your arm to check for the numbers and appearance of blood cells.
• Bone marrow aspiration and biopsy – A small sample of bone and liquid bone marrow is taken from the hipbone or breastbone with a long needle. A specially trained doctor checks for abnormal cells.
• Cytogenetic analysis – This test looks for specific changes in the genetic material of ALL cells.
• Flow cytometry (immunophenotyping) – This examines the characteristics of a patient’s cells. In ALL, it can help determine whether cancerous cells began from B lymphocytes or T lymphocytes.

These and other lab tests will help your doctor determine your subtype of ALL and your prognosis.

Once you have been diagnosed with ALL, you may need several additional tests and procedures. These will help determine whether the cancer has spread beyond the blood and bone marrow. The results will also help to plan a course of treatment. These additional tests are likely to include:

• Imaging tests, such as chest X-ray, computed tomography (CT) scan and ultrasound.
• Lumbar puncture/spinal tap, which uses a needle to collect some fluid from the spinal column.

If you are diagnosed with leukemia, you may be referred to a hematologist/oncologist, a doctor who specializes in treating cancers and blood diseases.

Expected Duration

Acute lymphocytic leukemia usually gets worse quickly if not treated.

Prevention

There are no known ways to prevent ALL.

A few factors may increase a person’s risk of developing ALL, but most are not avoidable. These include:

• Being male.
• Being white.
• Exposure to high levels of radiation, such as that from an atomic bomb.
• Exposure to certain chemicals, including past treatment with some chemotherapy drugs.
• Certain inherited disorders, such as Down syndrome or Fanconi anemia.

Having one or more of these risk factors does not mean you will develop ALL. Many people with the disease do not have any risk factors.

Treatment

ALL is classified as:

• Untreated. Untreated ALL is newly diagnosed.
• In remission. ALL that is in remission has been treated. The patient does not currently have any signs or symptoms of leukemia.
• Recurrent. Recurrent ALL has been treated. It has come back after going into remission.

There are usually two phases of treatment for adult ALL. The goal of the first treatment phase is to kill as many leukemia cells in the blood and bone marrow as possible. This puts the disease into remission. The goal of the second phase is to kill any remaining leukemia cells that may not be active but which could begin to regrow and cause a relapse. The total treatment can take two or three years.

During these phases, patients also receive therapy to prevent or treat leukemia in the brain and spinal cord.

The major standard therapy for ALL is chemotherapy. Chemotherapy for ALL is usually given as combination chemotherapy. This means that more than one anticancer drug is used. Other treatments may be used under different circumstances.

Following are some of the commonly used treatments for ALL:

• Chemotherapy uses drugs to stop the growth of cancer cells by killing them or keeping them from dividing. Chemotherapy drugs may be taken by mouth or injected into a vein or muscle. They travel through the bloodstream and body. Chemotherapy that goes directly into the spinal column may be used to treat ALL that has, or may, spread to the brain and spinal cord.
• Radiation therapy uses high-energy radiation to kill cancer cells or stop them from growing. The radiation can be delivered from a machine outside the body (external radiation therapy). Or, it can come from a radioactive substance placed in or near a local collection of cancer cells.
• Tyrosine kinase inhibitor therapy blocks an enzyme that causes the development of too many white blood cells in the body. Imatinib (Gleevec) and dasatinib (Sprycel) are two examples of these drugs.

The cancer drug, vincristine, has been the main chemotherapy used for ALL in adults. A new form of vincristine allows more of the drug to be administered. It’s prescribed for people with certain types of ALL that have had an incomplete response to other therapies.

A more recent treatment for ALL is a stem cell transplant. A stem cell transplant replaces a person’s blood-forming cells. Stem cell transplants can use stem cells from your own body or from a donor. Donor stem cell transplant may be necessary if the patient’s own stem cells are abnormal or have been destroyed by cancer treatment.

Stem cells (immature blood cells) are removed from the blood or bone marrow of a patient or donor. Once removed, they are examined under a microscope and the cell number is counted. The stem cells are stored for future use.

The patient then undergoes high-dose chemotherapy to eradicate the leukemic cells that populate the bone marrow. The stored stem cells are then infused into the patient’s bloodstream. They migrate into the bone marrow space. Because these are stem cells, they are able to regenerate and grow into the many different cells that normally populate the bone marrow.

Stem cell transplants require very high dose chemotherapy to rid the body of all the leukemia. In the process, the patient cannot make any blood cells until the stem cells have had time to mature. This puts the patient at high risk of infection and bleeding. In addition to the short term risks, there are also long term side effects. Stem cell transplants should be undertaken only in specialized centers.

Patients who have finished treatment should continue to see their doctors regularly for checkups. Some of the tests done to diagnose ALL may be repeated during and after treatment to see how well the therapy is working and/or whether your condition has changed.

Side Effects

Some people receiving ALL treatment may experience no side effects. Others may face short-term or long-lasting side effects. Among the possible side effects of treatment are:

• anemia
• infection
• easy bleeding
• nausea and vomiting
• mouth sores
• nerve damage causing pins and needles sensations in the feet and hands
• diarrhea
• hair loss.

There are many ways to manage these side effects. For example, regular hand washing can help lower the risk of infection.

When considering a treatment option, it’s important to ask your doctor about the expected benefits and risks of a particular therapy. How will this treatment affect my prognosis? What will my quality of life be during and after treatment?

When To Call a Professional

Contact your doctor or healthcare provider if you experience any symptoms of ALL, such as:

• Unexplained and persistent fever
• Marked fatigue and weakness
• Unexpected weight loss with poor appetite
• Easy bruising or bleeding

Prognosis

The outlook for a person with ALL depends on several factors, including:

• Patient’s age
• White blood cell count at time of diagnosis
• The subtype of ALL
• Whether the leukemia has spread to the brain or spinal cord
• The presence of a specific change in the patient’s genetic material
• How well the patient responds to chemotherapy
• Whether the disease has come back

Additional Information

National Cancer Institute (NCI)
NCI Public Inquiries Office
6116 Executive Boulevard
Room 3036A
Bethesda, MD 20892-8322
1-800-4-CANCER (1-800-422-6237) — Cancer Information Service (English or Spanish)
TTY: 1-800-332-8615
http://www.cancer.gov/

American Cancer Society (ACS)
P.O. Box 56566
Atlanta, GA 30343
Toll-Free: 1-800-ACS-2345 (1-800-227-2345)
TTY: 1-866-228-4327
http://www.cancer.org/

Leukemia & Lymphoma Society
1311 Mamaroneck Ave.
White Plains, NY 10605
(914) 949-5213; Toll-Free: 1-800-955-4572
http://www.leukemia-lymphoma.org