Adult Acute Lymphocytic Leukemia (ALL)

What is adult acute lymphocytic leukemia (ALL)?

Acute lymphocytic leukemia (ALL) is a fast-growing cancer of the blood and bone marrow. It affects a type of white blood cells called lymphocytes. The cancer causes large numbers of abnormal white cells to form, crowding out normal blood cells.

Another name for this type of leukemia is acute lymphoblastic leukemia.

How does it occur?

The cancer starts in the bone marrow. The bone marrow makes blood stem cells, which become the different types of blood cells, including lymphocytes, the other type of white blood cells called leukocytes or granulocytes, red blood cells, and platelets.

Blood cells grow in the bone marrow and are supposed to be fully grown when they enter the bloodstream. In acute lymphocytic leukemia too many lymphocytes form and they lose their ability to fully mature. When the cancerous marrow produces too many abnormal lymphocytes, the abnormal cells crowd out other, normal blood cells needed by the body. The abnormal white blood cells cannot fight infections like normal lymphocytes. In addition, you become anemic as your red blood cell count decreases. And as the number of platelets decreases, you will start having blood clotting problems and will bleed easily.

The cancer can spread to the blood, lymph nodes, spleen, liver, central nervous system, and other organs.

It is not known why the bone marrow becomes cancerous, but there are some known risk factors for developing ALL. You are more likely to get ALL if:

• You are male.
• You are Caucasian.
• You are 70 years old or older.
• You have had chemotherapy or radiation therapy
• You have been exposed to atomic radiation.
• You have a genetic condition that increases your risk, such as Down syndrome.

What are the symptoms?

The symptoms of ALL are often subtle. Symptoms may include:

• tiredness
• weakness
• fever
• easy bruising or bleeding
• loss of appetite
• weight loss
• bone pain
• full feeling below the ribs, especially on the left
• swollen lymph nodes in the neck, underarms, and groin.

How is it diagnosed?

Your healthcare provider will ask about your medical history, including symptoms and possible risk factors, and you will have a physical exam.

Diagnostic tests include:

• A CBC blood test (complete blood count) to count the cells in your blood and to see if they are normal.
• A bone marrow biopsy, which uses a needle to get a sample of bone marrow from the breast bone or the hip bone (after local anesthesia). The sample is examined in the lab for abnormal cells.
• A blood test to look at your genes (genetic analysis) if your provider thinks you may have a genetic condition that might be linked to ALL.

When the blood and bone marrow tests confirm a diagnosis of ALL, more tests are done before you start treatment to see if the cancer has spread beyond the blood and bone marrow. This is called staging. Tests that may be done include:

• chest X-ray to look at the lung and chest cavity
• lumbar puncture (also called a spinal tap) to look for a spread of cancer to the brain and spinal cord
• ultrasound scan of the abdomen
• CT scan of the abdomen.

The ultrasound and CT scans look for spread to the abdominal organs, including lymph nodes in the abdomen.

The specific treatment depends on whether the disease has spread, but in general there are 2 phases of treatment:

• Phase 1: Kill tumor cells in the blood and bone marrow and put the cancer in remission, which means that the cancer becomes inactive.
• Phase 2: Prevent new tumor cells from becoming active.

Possible treatments include chemotherapy (anticancer drugs), radiation therapy, and stem cell therapy.

• Chemotherapy uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping the cells from dividing. Chemotherapy is usually given by vein, but because the cancer sometimes spreads to the brain and spinal cord, chemotherapy medicines may be injected into the area around the spinal cord.
• Radiation therapy is usually used when there is spread of the cancer to the brain and spinal cord.
• Stem cell therapy or bone marrow transplant may be used, especially if the first treatments are not working as well as hoped. This involves taking your own bone marrow, or marrow from a donor, and freezing and storing it. You are then given chemotherapy to kill the cancerous cells in the marrow and blood. The chemotherapy usually causes the blood counts to become very low--low enough to be life-threatening. Then the marrow is given back to you so that new, healthy cells can begin to replace the cells that were killed by the chemotherapy.

Newer therapies are available and continue to be studied. Examples of new treatments you may want to ask your healthcare provider about are tyrosine kinase inhibitors and immunotherapy (which is also called biotherapy or biologic therapy).

You may want to think about participating in a clinical trial. Clinical trials are research studies to find the most effective cancer treatments. They usually compare existing treatments with new, experimental treatments. This is a way you may be able to have treatment with the latest drugs. Ask your healthcare provider about clinical trials that might be available to you. It's always your choice whether you consider them or not.

How long will the effects last?

Treatment for newly diagnosed ALL results in a remission 80 to 85% of the time. When the cancer is in remission, you will need to have regular follow-up visits with your healthcare provider to keep checking your blood counts and overall health. In some cases you may have treatment during remission to try to keep the cancer in remission. The cancer may return in weeks, months, or years. When the cancer comes back, it is called a recurrence. Recurrences can be treated.

How can I take care of myself?

• It is very important to have a good relationship with your cancer doctor, so that you feel comfortable asking questions and getting answers. Take a family member or friend with you to your appointments to help you remember what you were going to ask and what was said.
• Follow your provider's treatment recommendations carefully.
• Read all of the information you are given about your medicines, radiation therapy, and any other treatments. Feel free to ask questions at any time.
• Eat a healthy diet and be as active as is comfortable and recommended. Ask your provider if you need to avoid some activities or be careful about what you eat.
• Take precautions during your treatment to avoid infections. Avoid crowds and anyone who is sick. Avoid small children, especially children who attend day care (they often have colds and other infections). When you are around people, including family, wash your hands often. Do not share towels. If you have to go out, wear a surgical mask so that you are less likely to breathe in germs.
• If you lose your appetite and begin to lose weight, ask your provider about medicine that can help you have a better appetite.
• Do not smoke.
• Ask your provider if you need to avoid drinking alcohol. It may interfere with medicines you are taking. Alcohol can also make it harder for white blood cells to fight infections well.
• Learn about your illness.
• Join a support group to learn from other cancer survivors and to share what has helped you.

How can I help prevent ALL?

Because we don't know what causes ALL, there's no way to prevent it.