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Acute lymphoblastic leukaemia (ALL)

Acute lymphoblastic leukaemia (ALL) is a type of cancer that affects white blood cells known as lymphocytes. The symptoms of ALL develop rapidly and need to be treated quickly.

The word leukaemia describes a group of cancers affecting your white blood cells and bone marrow. Leukaemia can be either acute (growing rapidly) or chronic (growing slowly). 

There are two main types of white blood cells – lymphocytes and myeloid cells. ALL is a fast growing cancer that affects your lymphocytes. If you have ALL, you produce lots of immature lymphocytes called lymphoblasts which don't work properly. They build up in your bone marrow and they stop it from producing other cells, such as red blood cells and platelets.

ALL is rare – about three in every 100,000 people get the condition worldwide. It's most common in children.

Types of acute lymphoblastic leukaemia

There are many different types of ALL, which are named depending on the type of lymphocyte that has become cancerous. The most common type in adults is called precursor B cell ALL.

Occasionally, acute leukaemia can be a mixture of ALL and acute myeloid leukaemia (AML) – this is known as mixed-phenotype acute leukaemia (MPAL).

Your doctor will tell you which type you have. For more information about the different types of ALL, see our frequently asked questions.

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How cancer develops
Cells begin to grow in an uncontrolled way

Details

  • Symptoms Symptoms of acute lymphoblastic leukaemia

    Symptoms of acute lymphoblastic leukaemia (ALL) include:

    • feeling tired, dizzy, weak and short of breath
    • feeling your heartbeat racing – these are called palpitations
    • a fever
    • getting a lot of infections that don't get better
    • unexplained bleeding, such as nosebleeds, bleeding gums and heavy periods in women
    • bruising easily
    • a rash of dark red/purple spots (called purpura)
    • losing weight for no reason you can think of
    • swollen lymph glands (glands in your neck, groin, chest and under your arms)
    • aching bones and swollen, painful joints
    • swelling in your abdomen (tummy)
    • swollen testicles in boys and men
    • headaches or feeling irritable

    Your symptoms may come on very quickly – over a matter of days or weeks. Some are similar to those for other conditions (such as the flu) so it’s easy to confuse them. If you have any of these symptoms, contact your GP.

  • Diagnosis Diagnosis of acute lymphoblastic leukaemia

    Your GP will ask about your symptoms and examine you. He or she may also ask about your medical history.

    Your GP may ask you to have a blood test to check the different levels of cells in your blood. If the results suggest you have acute lymphoblastic leukaemia (ALL), he or she will refer you to a haematologist. A haematologist is a doctor who specialises in conditions affecting your blood.

    Your haematologist will ask you to have some tests to confirm your diagnosis and investigate which type of leukaemia you have. These may include:

    • more blood tests
    • a bone marrow biopsy – your doctor uses a needle to remove a small sample of your bone marrow to be examined under a microscope
    • a chest X-ray – to see if there are leukaemia cells in your chest
    • lumbar puncture – your doctor uses a needle to remove a sample of fluid from around your spine to test if it contains leukaemia cells

    If you’re diagnosed with ALL, you may have further tests to find out exactly what type it is. This helps to make sure you get the most appropriate treatment. Further tests may include:

    • specific tests on the leukaemia cells to confirm exactly what type they are
    • tests to look at the genetic make-up of the leukaemia cells
  • Treatment Treatment of acute lymphoblastic leukaemia

    Acute lymphoblastic leukaemia (ALL) is treated in three phases. These are:

    • remission induction – to get rid of the cancer
    • consolidation treatment – to keep the cancer away
    • maintenance therapy – to prevent the cancer coming back (a relapse)

    Treatment for ALL can take two years or more. You’re likely to have some side-effects. These are the unwanted but mostly temporary effects you may get after having your treatment. Side-effects may include losing your hair, feeling weak and changes in your appetite and weight.

    Remission induction

    Chemotherapy

    The main treatment for ALL is chemotherapy, which uses medicines to destroy cancer cells in your bone marrow. In the beginning, you’ll probably need to stay in hospital for about a month while having your treatment. This is because larger doses of chemotherapy medicines are used to treat acute leukaemia than other types of cancer.

    You’re likely to be given a mixture of chemotherapy medicines because it’s thought that this works better than just one medicine on its own. You will usually have these different medicines in cycles, with rest periods in between.

    You may also be given medicines called steroids, such as prednisolone and dexamethasone, as tablets or injections. These help chemotherapy medicines to work better.

    Biological therapy

    Another treatment that's used in combination with chemotherapy is a biological medicine called imatinib. If tests show that you have an abnormal chromosome that might have caused ALL, you may be given a medicine called dasatinib. Chromosomes are structures that contain genes – you inherit these from your parents and they determine everything about you. Biological medicines block chemicals that cancer cells use to communicate with each other.

    Central nervous system (CNS)-directed therapy

    Chemotherapy medicines that travel in your blood can’t get to your brain and spinal cord – also known as your CNS. Therefore, you may have extra treatment to inject the medicines directly into the fluid that surrounds your CNS. This procedure to inject the medicine is called a lumbar puncture.

    You may have radiotherapy to your brain to get rid of any cells that are still remaining after chemotherapy. However, this treatment isn’t often used now.

    Consolidation

    Chemotherapy

    Once your leukaemia has gone into remission, you will need to have more chemotherapy to prevent it from coming back. Remission means there are no longer any leukaemia cells in your bone marrow. This will also kill any leukaemia cells that may still be in your bone marrow but can’t be detected. You may need to have different medicines to the ones that you had in the remission induction phase.

    This phase of treatment can last for several months.

    Stem cell transplantation

    Following consolidation chemotherapy you may be considered for a bone marrow (stem cell) transplant in combination with chemotherapy. This is when somebody else donates healthy bone marrow or stem cells, which are transferred into your body. This aims to keep the leukaemia from coming back so you don't need any further therapy. It can cause serious side-effects but you may be offered it if your general good health is good.

    Maintenance therapy

    Maintenance therapy aims to keep your leukaemia in long-term remission. You may need to take lower doses of chemotherapy and steroid medicines, probably as tablets, for at least two years.

    New treatments

    New treatments for ALL are often being tested in research studies called clinical trials. These include different biological therapies and chemotherapy medicines, as well as other types of stem cell transplants. You may be able to take part in a clinical trial to test one of these new treatments – ask your doctor for more information.

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  • Causes Causes of acute lymphoblastic leukaemia

    The exact reasons why you may get ALL aren't fully understood at the moment. However, doctors do know that there are a number of things that increase your risk of developing it. These include:

    • being exposed to radiation
    • smoking
    • having genetic abnormality or condition, such as Down's syndrome
    • your gender – more men and boys get ALL than girls and women
  • FAQs FAQs

    What are the different systems used to classify acute lymphoblastic leukaemia (ALL)?

    Answer

    ALL isn't just one disease – there are several different subtypes. Classifying what type of ALL you have helps to make sure you receive the right treatment.

    Explanation

    Doctors classify each subtype of ALL by using the World Health Organization (WHO) system. Less often, they classify ALL with a letter and number using the French-American-British (FAB) system.

    WHO system

    ALL affects a certain type of white blood cell called lymphocytes. T lymphocytes have two different subtypes called B cells and T cells. Using the WHO system, ALL is separated into the following categories:

    • early (precursor) B cell ALL
    • mature B cell ALL
    • early (precursor) T cell ALL
    FAB system

    The FAB system is used to classify ALL but it’s not used by doctors as often as the WHO system. It separates ALL into the following three subtypes according to the development of the lymphocytes (immature lymphocytes are called lymphoblasts).

    • L1 – the lymphoblasts look similar to healthy ones.
    • L2 – the lymphoblasts are less fully developed and look less like healthy cells.
    • L3 – the lymphoblasts aren’t well developed and look very abnormal.

    Ask your doctor for more information about classifying ALL and to explain the type you have.

    Can acute lymphoblastic leukaemia come back?

    Answer

    The leukaemia may come back (relapse) but it can be treated.

    Explanation

    How well your treatment works depends on many factors. For example, these include how old you are when you’re diagnosed, what type of leukaemia you have and what stage it is. If ALL does come back, it's usually in your bone marrow. Sometimes it can be in the fluid around your brain and spinal cord or in the testicles in men or boys.

    The treatment you receive will depend on your age and general health and the type of ALL you have, but it will probably involve chemotherapy. These may be the same or different medicines from the ones you received before. You may also be able to have a bone marrow (stem cell) transplant.

    Will I still be able to have children after treatment for acute lymphoblastic leukaemia?

    Answer

    Some people have healthy children after they’ve been treated for ALL. However, treatment for ALL will reduce your chances of being able to have children.

    Explanation

    The type and intensity of treatment that you have for ALL will determine how your fertility is affected.

    Men and teenage boys may consider storing sperm before having treatment. If you're a woman, you may be able to store fertilised eggs if you and your partner plan to have children in the future. But because ALL develops very quickly, you may need to start treatment before it’s possible to collect eggs.

    If your child is having treatment, it may affect their fertility in the future. For example, girls who have treatment as children may have an earlier menopause and in boys, sperm production may be affected.

    It’s important to speak to your doctor if treatment for ALL will affect your own or your child’s fertility. He or she can also give you more information about the possibility of storing sperm or fertilised eggs.

  • Resources Resources

    Further information

    Sources

    • Acute lymphocytic leukaemia. BMJ Best Practice. www.bestpractice.bmj.com, published 30 August 2013
    • Adult acute lymphoblastic leukemia treatment. National Cancer Institute. www.cancer.gov, published 21 October 2014
    • Leukemias. Medscape. www.emedicine.medscape.com, published 1 April 2014
    • Overview of leukemia. The Merck Manuals. www.merckmanuals.com, published July 2012
    • Acute lymphoblastic leukemia. Medscape. www.emedicine.medscape.com, published 22 August 2014
    • Types of acute lymphoblastic leukaemia. Cancer Research UK. www.cancerresearchuk.org, published 19 August 2013
    • Matutes E, Pickl WF, Van't Veer M, et al. Mixed-phenotype acute leukemia: clinical and laboratory features and outcome in 100 patients defined according to the WHO 2008 classification. Blood 2011; 117(11):3163–71. doi: 10.1182/blood-2010-10-314682
    • Acute lymphoblastic leukaemia. PatientPlus. www.patient.co.uk/patientplus.asp, published 7 June 2013
    • Leukemia – acute lymphocytic (adults). American Cancer Society. www.cancer.org, published 10 July 2013
    • Joint Formulary Committee. British National Formulary (online) London: BMJ Group and Pharmaceutical Press. www.medicinescomplete.com, accessed 29 October 2014
    • Pidala J, Djulbegovic B, Anasetti C, et al. Allogeneic hematopoietic cell transplantation for adult acute lymphoblastic leukemia (ALL) in first complete remission. Cochrane Database of Systematic Reviews 2011(10). doi: 10.1002/14651858.CD008818.pub2
    • Chronic myelogenous leukemia. Medscape. www.emedicine.medscape.com, published 22 August 2014
    • Childhood acute lymphoblastic leukemia treatment. National Cancer Institute. www.cancer.gov, published 21 October 2014
    • The effects of cancer treatment on reproductive functions. Royal College of Physicians. www.rcr.ac.uk, published November 2007
    • Long-term follow-up of survivors of childhood cancer. Scottish Intercollegiate Guidelines Network (SIGN). www.sign.ac.uk, published March 2013
    • Map of Medicine. Acute leukaemia. International View. London: Map of Medicine; 2013 (Issue 4)
    • Acute lymphoblastic leukemia staging. Medscape. www.emedicine.medscape.com, 7 August 2013
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