Acute lymphoblastic leukaemia (ALL)

About acute lymphoblastic leukaemia

The term leukaemia refers to a group of cancers of the white blood cells and bone marrow. Bone marrow produces white blood cells and there are two types – lymphocytes and myeloid cells. Usually these divide in a controlled way and help your body to get rid of infections. If you have leukaemia, your white blood cells start to divide and grow in an uncontrolled way, and don’t develop properly.

Leukaemia can be described as either acute (growing rapidly) or chronic (growing slowly). Acute leukaemia is divided into two main types – ALL and acute myeloid leukaemia (AML). This factsheet focuses on ALL.

In ALL, your bone marrow produces abnormal lymphocytes, which can’t function properly. They also build up in your bone marrow, meaning it can’t make enough of other types of blood cells. Immature lymphocytes are called lymphoblasts – these are the cells that don’t develop properly in ALL.

ALL is the most common type of leukaemia to affect children under 14. About 400 children are diagnosed each year in the UK, and it’s slightly more common in boys than girls. The condition affects about the same number of adults a year, most commonly those under 25 or over 75. The symptoms develop rapidly and need to be treated quickly.

Types of acute lymphoblastic leukaemia

There are several different forms or subtypes of ALL. Your doctor will tell you which type you have. Occasionally, acute leukaemia appears to be a mixture of ALL and AML – this is known as acute biphenotypic leukaemia.

Symptoms of acute lymphoblastic leukaemia

Symptoms of ALL include:

  • feeling tired, weak and breathless
  • repeated 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)
  • fever
  • weight loss

Your symptoms may come on very quickly – over a matter of days or weeks. Some of these symptoms are similar to those for other conditions so it’s easy to confuse them.

Less common symptoms of ALL include:

  • swollen lymph glands (glands in your neck, groin, chest and under your arms)
  • aching bones
  • swollen, painful joints
  • swelling in your abdomen (tummy)
  • swollen testicles in boys and men
  • headaches or problems with your sight (if your nervous system has been affected)

These symptoms aren’t always caused by ALL but if you have them, see your GP.

Causes of acute lymphoblastic leukaemia

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

  • exposure to radiation
  • smoking – this includes passive smoking
  • having genetic conditions, such as Down's syndrome
  • viruses – a virus called human T cell leukaemia virus (HTLV-1) can cause a rare form of leukaemia in adults
  • being overweight or obese – if you have a body mass index (BMI) of 30 or above
  • being male
  • not being exposed to common infections from birth

Diagnosis of acute lymphoblastic leukaemia

Your GP will ask about your symptoms and examine you. If he or she thinks you may have leukaemia, you will be asked to have a blood test. You may then be referred to a haematologist (a doctor who specialises in conditions of the blood).

You will then have some tests to confirm the 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 (there are two ways in which a biopsy may be done)
  • a chest X-ray – to see if there are leukaemia cells in your chest
  • lumbar puncture – your doctor uses a needle to remove a small sample of the fluid from around your spine, which can be tested to see if it contains leukaemia cells

If you’re diagnosed with leukaemia, you may have further tests to find out what type it is. This can help to determine the most appropriate treatment for you. Further tests that you may have 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 of acute lymphoblastic leukaemia

You may hear your doctor referring to your treatment 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 as a result of treatment, such as hair loss, 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. Initially, you will probably need to stay in hospital for about a month 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 using a combination works better than just one medicine on its own. You will usually have these different medicines in cycles, with rest periods in between.

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

Biological therapy

If your leukaemia has a genetic fault involving the Philadelphia chromosome, you may be given a medicine called imatinib. This blocks chemicals that cancer cells use to communicate with each other. Research has shown that the medicine is more effective when it’s given in the first phase of treatment.

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 central nervous system (CNS). Therefore, you may have additional treatment to inject the medicines directly into the fluid that surrounds your CNS.

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

Consolidation

Chemotherapy

Once your leukaemia has gone into remission (this is when there are no longer any leukaemia cells in your bone marrow) you will need to have more chemotherapy to prevent it from coming back. 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 were used 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 if you’re in general good health. This is when somebody else (preferably a brother or sister) donates healthy bone marrow or stem cells, which are transferred into your body. This aims to keep the leukaemia from coming back in the long term without the need for further therapy.

Maintenance therapy

Maintenance therapy aims to keep your leukaemia in long-term remission. You will need to take lower doses of chemotherapy and steroid medicines, probably in tablet form, for up to three years.

New treatments

Many possible new treatments for ALL are being tested in clinical trials all the time. 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 – speak to your doctor for more information.

 

Produced by Polly Kerr, Bupa Health Information Team, February 2013.

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