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Acute lymphoblastic leukaemia (ALL) is a rapidly progressing type of leukaemia.
Blood cells are formed in the bone marrow, which is the spongy tissue found inside the bones. Blood-forming stem cells divide to produce either more stem cells or immature cells that become mature blood cells over time. In ALL, the process is out of control and the cells continues to divide but not mature.
A lymphoid stem cell becomes a lymphoblast cell and then one of three types of lymphocytes (white blood cells):
Acute lymphoblastic leukaemia (ALL) most commonly affects B lymphocytes. The overproduction of immature B lymphocytes means the body cannot fight infection.
Acute leukaemia progresses rapidly, but it can often be cured with standard treatments, especially in younger or fitter patients.
In most cases of ALL there is no obvious cause and it is important to understand that:
There are no specific signs or symptoms which would allow a diagnosis of ALL to be made. The most common signs and symptoms are caused by the bone marrow being unable to produce enough normal blood cells.
Other common signs and symptoms include:
Although a doctor may suspect a patient has ALL based on signs and symptoms, it can only be diagnosed by laboratory tests. The results of a simple blood count will usually indicate ALL although, rarely, a blood count may be normal. Virtually all patients with ALL will have bone marrow samples taken to confirm the diagnosis and to help to determine exactly what type of leukaemia a patient has. More specialised tests are often done at the same time.
Usually, a chest x-ray will be taken and also scans, to look for swollen lymph nodes, or other affected sites. Blood samples will be taken to test for any problems with the liver, kidneys or other organs. In ALL a sample is taken of the fluid which surrounds the brain and spinal cord – cerebrospinal fluid (CSF). This is because ALL cells can get into the nervous system, which protects them from most kinds of treatment. Some blood tests and scans will be repeated to check for the response to treatment and any complications. Other tests are usually only done at diagnosis.
Other tests which may be done include:
Blood tests, bone marrow samples and lumbar punctures will be repeated throughout treatment to monitor response.
Staging is not used for ALL, because it is spread throughout the body when first diagnosed. There is a system to classify ALL as high-risk, standard or low-risk. It is important to stress that this refers to the chance of a good response following standard treatment. If treatment is selected according to risk group, many patients with high-risk disease will do very well. It is also, unfortunately, not always true that a patient with low risk disease will do well. The risk group is only of the factors which affects the outcome of treatment.
If you are being treated for any type of leukaemia, you may be asked to consider taking part in a clinical trial. Clinical trials are scientific studies to find the best treatment; you can find out more here.
Virtually all patients with ALL will start treatment immediately. The main exception would be if a patient is very ill with other medical problems and is not fit enough to receive treatment. Acute leukaemia is very often curable with standard treatments, in younger and/or fitter patients. Older or less fit patients will usually have a good initial response to treatment but the condition will most often come back, this is known as a relapse.
The main ways in which ALL is treated are:
Chemotherapy is the use of cell-killing drugs. These kill the cancer cells and/or stop them from dividing. Chemotherapy is usually given in blocks or ‘cycles’ of treatment. One cycle of treatment will consist of a series of doses of chemotherapy followed by a break for the healthy cells to recover. After initial treatment is complete lower-dose chemotherapy is continued for 2-3 years. This is called maintenance therapy.
ALL cells may be found in the fluid around the brain and spine (called CSF) so chemotherapy for ALL includes injections into this fluid. This is called intrathecal chemotherapy.
Chemotherapy is normally given as a combination of drugs, which, for ALL, will almost always include steroids. Steroids used to treat lymphoid leukaemia are a laboratory-made version of chemicals naturally made by the body. They are very different from the type of steroids sometimes misused by body builders or sportsmen.
The details of treatment will vary depending on the specific features of the leukaemia, age and general fitness. Patients will be given a chance to discuss treatment options and detailed information on their treatment plan before it starts. The side effects of treatment vary between different types of treatment and different patients.
Targeted therapy is used in one particular form of ALL, in which there is an abnormality called the Philadelphia chromosome. This form may respond well to a type of drug called a tyrosine kinase inhibitor (TKI).
Patients will be given detailed information about any likely side effects before treatment starts.
We understand going through a blood cancer through journey can be difficult. It may help to talk to a close friend or relative about how you are feeling. Here are some questions that may be useful to ask your doctor.