Acute lymphoblastic leukemia 837167 224096463 2008-07-07T08:14:03Z 59.96.20.238 {{Infobox_Disease | Name = Acute lymphoblastic leukemia | Image = acute_leukemia-ALL.jpg | Caption = | DiseasesDB = 195 | ICD10 = {{ICD10|C|91|0|c|81}} | ICD9 = {{ICD9|204.0}} | ICDO = 9821/3 | OMIM = | MedlinePlus = | eMedicineSubj = med | eMedicineTopic = 3146 | eMedicine_mult = {{eMedicine2|ped|2587}} | MeshID = D054198 | }} '''Acute lymphoblastic leukemia''' ('''ALL'''), is a form of [[leukemia]], or [[hematological malignancy|cancer of the white blood cells]]. [[Malignant]], immature [[lymphoblasts|white blood cells]] continuously multiply and are overproduced in the [[bone marrow]]. ALL causes damage and death by crowding out normal cells in the bone marrow, and by spreading ([[metastasis|metastasizing]]) to other organs. ALL is most common in childhood and young adulthood with a peak incidence at 4-5 years of age, and another peak in old age. The overall cure rate in children is 85%, and about 50% of adults have long-term disease-free survival.<ref>[http://www.accessmedicine.com/content.aspx?aID=65842 Harrison's Principles of Internal Medicine, 16th Edition,] Chapter 97. Malignancies of Lymphoid Cells. Clinical Features, Treatment, and Prognosis of Specific Lymphoid Malignancies.</ref> 'Acute' refers to the undifferentiated, immature state of the circulating lymphocytes ("blasts"), and to the rapid progression of disease, which can be fatal in weeks to months if left untreated. == Symptoms == Initial symptoms are not specific to ALL, but worsen to the point that medical help is sought. The signs and symptoms of ALL are variable but follow from bone marrow replacement and/or organ infiltration. * Generalised weakness and [[Fatigue (physical)|fatigue]] * [[Anemia]] * Frequent or unexplained [[fever]] and [[infection]]s * Weight loss and/or loss of appetite * Excessive and unexplained bruising * [[Bone pain]], [[joint pain]]s (caused by the spread of "blast" cells to the surface of the bone or into the joint from the marrow cavity) * [[Breathlessness]] * Enlarged [[lymph nodes]], [[liver]] and/or [[spleen]] The signs and [[symptoms]] of ALL result from the lack of normal and healthy blood cells because they are crowded out by malignant and immature [[leukocytes]] (white blood cells). Therefore, people with ALL experience symptoms from malfunctioning of their [[erythrocytes]] (red blood cells), leukocytes, and platelets not functioning properly. Laboratory tests which might show abnormalities include [[blood count]] tests, [[renal function]] tests, [[electrolyte]] tests and [[liver enzyme]] tests. == Diagnosis == [[Diagnosis|Diagnosing]] ALL begins with a medical history and [[physical examination]], [[Full blood count|complete blood count]], and blood smears. Because the symptoms are so general, many other diseases with similar symptoms must be excluded. Typically, the higher the white blood cell count, the worse the prognosis. <ref>{{cite book | last = Collier | first = J.A.B | == coauthors = J.M. Longmore, J.H. Harvey == | title = Oxford Handbook of Clinical Specialties, Third Edition | publisher = Oxford | date = 1991 | pages = 810 | isbn = 0-19-262116-5}}</ref> Blast cells are seen on [[blood smear]] in 90% of cases. A [[bone marrow biopsy]] is conclusive proof of ALL.<ref>[http://www.accessmedicine.com/content.aspx?aID=65842 Harrison's Principles of Internal Medicine, 16th EditioN,] Chapter 97. Malignancies of Lymphoid Cells. Clinical Features, Treatment, and Prognosis of Specific Lymphoid Malignancies.</ref> A [[lumbar puncture|spinal tap]] will tell if the spinal column and [[central nervous system|brain]] has been invaded. [[Histopathology|Pathological]] examination, [[cytogenetics]] (particularly the presence of [[Philadelphia chromosome]]) and [[immunophenotyping]], establish whether the "blast" cells began from the [[B lymphocyte]]s or [[T lymphocyte]]s. DNA testing can establish how aggressive the disease is; different mutations have been associated with shorter or longer survival. [[Medical imaging]] (such as [[medical ultrasonography|ultrasound]] or [[CT scan]]ning) can find invasion of other [[Organ (anatomy)|organs]] commonly the [[lung]], liver, spleen, lymph nodes, brain, kidneys and reproductive organs. <ref>[http://www.merck.com Merck Manual] {{Fact|date=September 2007}}</ref> == Pathophysiology == The cause of most ALL is not known. In general, cancer is caused by damage to [[Deoxyribonucleic Acid|DNA]] that leads to uncontrolled cellular growth and spread throughout the body, either by increasing chemical signals that cause growth, or interrupting chemical signals that control growth. Damage can be caused through the formation of [[fusion genes]], as well as the dysregulation of a [[proto-oncogene]] via juxtaposition of it to the promotor of another gene, e.g. the [[T-cell receptor]] gene. This damage may be caused by environmental factors such as chemicals, drugs or radiation. ALL is associated with exposure to [[ionizing radiation|radiation]] and chemicals in animals and humans. The association of radiation and leukemia in humans has been clearly established in studies of victims of the [[Chernobyl]] nuclear reactor and [[atom bombs]] in [[Hiroshima]] and [[Nagasaki, Nagasaki|Nagasaki]]. In animals, exposure to [[benzene]] and other chemicals can cause leukemia. Epidemiological studies have associated leukemia with workplace exposure to chemicals, but these studies are not as conclusive. Patients who are treated for other cancers with radiation and chemotherapy often develop leukemias as a result of that treatment.{{Fact|date=September 2007}} == Cytogenetics == Cytogenetic translocations associated with specific molecular genetic abnormalities in ALL {| class="wikitable" !Cytogenetic translocation !Molecular genetic abnormality |- |t(9;22)(q34;q11) |BCR-ABL fusion(P185) |- |t(12;21)CRYPTIC | TEL-AML1fusion |- |t(1;19)(q23;p13) |E2A-PBX fusion |- |t(4;11)(q21;q23) |MLL-AF4 fusion |- |t(8;14)(q24;q32) |IGH-MYC fusion |- |t(11;14)(p13;q11) |TCR-RBTN2 fusion |} [[Cytogenetics]], the study of characteristic large changes in the [[chromosomes]] of [[cancer cell]]s, has been increasingly recognized as an important predictor of outcome in ALL.<ref>{{cite journal |author=Moorman A, Harrison C, Buck G, Richards S, Secker-Walker L, Martineau M, Vance G, Cherry A, Higgins R, Fielding A, Foroni L, Paietta E, Tallman M, Litzow M, Wiernik P, Rowe J, Goldstone A, Dewald G |title=Karyotype is an independent prognostic factor in adult acute lymphoblastic leukemia (ALL): analysis of cytogenetic data from patients treated on the Medical Research Council (MRC) UKALLXII/Eastern Cooperative Oncology Group (ECOG) 2993 trial |journal=Blood |volume=109 |issue=8 |pages=3189–97 |year=2007 |pmid=17170120 |doi=10.1182/blood-2006-10-051912}}</ref> Some cytogenetic subtypes have a worse prognosis than others. These include: * A translocation between [[chromosome]]s 9 and 22, known as the [[Philadelphia chromosome]], occurs in about 20% of adult and 5% in pediatric cases of ALL. * A translocation between chromosomes 4 and 11 occurs in about 4% of cases and is most common in infants under 12 months. * Not all translocations of chromosomes carry a poorer prognosis. Some translocations are relatively favorable. For example, Hyperdiploidy (>50 chromosomes) is a good prognostic factor. {| class="wikitable" ! Cytogenetic change ! Risk category |- | [[Philadelphia chromosome]] | Poor prognosis |- | t(4;11)(q21;q23) | Poor prognosis |- | t(8;14)(q24.1;q32) | Poor prognosis |- | Complex [[karyotype]] (more than four abnormalities) | Poor prognosis |- | Low [[hypodiploidy]] or near [[triploidy]] | Poor prognosis |- | High [[hyperdiploidy]] | Good prognosis |- | del(9p) | Good prognosis |} == Classification == As ALL is not a solid tumour, the [[TNM|TxNxMx]] notation as used in solid cancers is of little use. ===The FAB classification=== Subtyping of the various forms of ALL used to be done according to the [[French-American-British classification|French-American-British (FAB) classification]],<ref name="urlACS :: How Is Acute Lymphocytic Leukemia Classified?">{{cite web |url=http://www.cancer.org/docroot/CRI/content/CRI_2_4_3X_How_Is_Acute_Lymphocytic_Leukemia_Classified.asp?rnav=cri |title=ACS :: How Is Acute Lymphocytic Leukemia Classified? |format= |work= |accessdate=}}</ref> which was used for all acute leukemias (including [[acute myelogenous leukemia]], AML). * ALL-L1: small uniform cells * ALL-L2: large varied cells * ALL-L3: large varied cells with [[vacuole]]s (bubble-like features) Each subtype is then further classified by determining the surface markers of the abnormal lymphocytes, called immunophenotyping. There are 2 main immunologic types: pre-B cell and pre-T cell. The mature B-cell ALL (L3) is now classified as [[Burkitt's lymphoma]]/leukemia. Subtyping helps determine the prognosis and most appropriate treatment in treating ALL. ===WHO proposed classification of acute lymphoblastic leukemia=== The recent WHO International panel on ALL recommends that the FAB classification be abandoned, since the morphological classification has no clinical or prognostic relevance. It instead advocates the use of the immunophenotypic classification mentioned below. 1- Acute lymphoblastic leukemia/lymphoma Synonyms:Former Fab L1/L2 * i. [[Precursor B acute lymphoblastic leukemia/lymphoma]]. Cytogenetic subtypes:<ref name="urlAdvances in Acute Lymphoblastic Leukemia | Clinical Laboratory Science | Find Articles at BNET.com">{{cite web |url=http://findarticles.com/p/articles/mi_qa3890/is_200410/ai_n9429273/pg_2 |title=Advances in Acute Lymphoblastic Leukemia | Clinical Laboratory Science | Find Articles at BNET.com |format= |work= |accessdate=}}</ref> ** t(12;21)(p12,q22) TEL/AML-1 ** t(1;19)(q23;p13) PBX/E2A ** t(9;22)(q34;q11) ABL/BCR ** T(V,11)(V;q23) V/MLL * ii. [[Precursor T acute lymphoblastic leukemia/lymphoma]] 2- [[Burkitt's leukemia]]/lymphoma Synonyms:Former FAB L3 3- [[Biphenotypic acute leukemia]] ===Variant Features of ALL=== * 1- Acute lymphoblastic leukemia with cytoplasmic granules * 2- Aplastic presentation of ALL * 3- Acute lymphoblastic leukemia with eosinophilia * 4- Relapse of lymphoblastic leukemia * 5- Secondary AML ===Immunophenotyping in the diagnosis and classification of ALL=== The use of a TdT assay and a panel of monoclonal antibodies (MoAbs) to T cell and B cell associated antigens will identify almost all cases of ALL. Immunophenotypic categories of acute lymphoblastic leukemia (ALL) {| class="wikitable" |- ! Types ! FAB Class ! Tdt ! T cell associate antigen ! B cell associate antigen ! c Ig ! s Ig |- | Precursor B | L1,L2 | + | - | + | -/+ | - |- | Precursor T | L1,L2 | + | + | - | - | - |- | B-cell | L3 | - | - | + | - | + |} == Treatment == The earlier acute lymphocytic leukemia is detected, the more effective the treatment. The aim is to induce a lasting [[remission]], defined as the absence of detectable cancer cells in the body (usually less than 5% blast cells on the bone marrow). Treatment for acute leukemia can include [[chemotherapy]], [[steroid]]s, [[radiation therapy]], intensive combined treatments (including [[bone marrow transplant|bone marrow]] or [[stem cell]] transplants), and growth factors. === Chemotherapy === [[Chemotherapy]] is the initial treatment of choice. Most ALL patients end up receiving a combination of different treatments. There are no surgical options, due to the body-wide distribution of the [[malignant cells]]. A newly developed study for the treatment of Acute Lymphoblastic leukemia, known as COALL 03-07 is underway. It is started in European region and has Hamburg as its center. This new study compares between the chemotherapeutic medications. Finally it shall be revealed that which chemotherapy better suits for the patients with ALL. As the [[chemotherapy regimens]] can be intensive and protracted (often about 2 years in case of the GMALL UKALL, HyperCVAD or CALGB protocols; about 3 years for males on COG protocols), many patients have an [[intravenous]] catheter inserted into a large vein (termed a [[central venous catheter]] or a [[Hickman line]]), or a [[Portacath]] (a cone-shaped port with a silicone nose that is surgically planted under the skin, usually near the collar bone, and the most effective product available, due to low infection risks and the long-term viability of a portacath). Since ALL cells sometimes penetrate the Central Nervous System ([[CNS]]), most protocols include delivery of chemotherapy into the CNS fluid. More advanced centers deliver the drug through Ommaya reservoir (a device surgically placed under the scalp and used to deliver drugs to the CNS fluid and to extract CNS fluid for various tests). More traditional centers would perform multiple lumbar punctures as needed for testing and treatment delivery. === Radiation therapy === [[Radiation therapy]] (or radiotherapy) is used on painful bony areas, in high disease burdens, or as part of the preparations for a [[bone marrow transplant]] (total body irradiation). Radiation in the form of whole brain radiation is also used for central nervous system prophylaxis, to prevent recurrence of leukemia in the brain. Whole brain prophylaxis radiation used to be a common method in treatment of children’s ALL. Recent studies showed that CNS chemotherapy provided results as favorable but with less developmental side effects. As a result, the use of whole brain radiation has been more limited. == Epidemiology == The number of annual ALL cases in the US is roughly 4000, 3000 of which inflict children. ALL accounts for approximately 80 percent of all childhood [[leukemia]] cases, making it the most common type of childhood cancer. It has a peak incident rate of 2-5 years old, decreasing in incidence with increasing age before increasing again at around 50 years old. ALL is slightly more common in males than females. There is an increased incidence in people with [[Down Syndrome]], [[Fanconi anemia]], [[Bloom syndrome]], [[Ataxia telangiectasia]], [[X-linked agammaglobulinemia]] and [[Severe combined immunodeficiency]]. == Prognosis == Advancements in medical [[Medical technology|technology]] and [[research]] over the past four decades in the treatment of ALL has improved the overall prognosis significantly from a zero to 20-75 percent survival rate, largely due to the continuous development of [[clinical trial]]s and improvements in [[bone marrow transplant]]ation (BMT) and [[stem cell transplantation]] (SCT) technology. It is worth noting that medical advances in recent years, both through matching the best treatment to the genetic characteristics of the blast cells and through the availability of new drugs, are not fully reflected in statistics that usually refer to five-year survival rates. The prognosis for ALL differs between individuals depending on a wide variety of factors: * Sex: females tend to fare better than males. * Ethnicity: [[Whites|Caucasians]] are more likely to develop acute leukemia than [[African American|African-Americans]], [[Asian American|Asians]] and [[Hispanics in the United States|Hispanics]] and tend to have a better prognosis than non-Caucasians. * Age at diagnosis: children between 1-10 years of age are most likely to develop ALL and to be cured of it. Cases in older patients are more likely to result from chromosomal abnormalities (e.g. the Philadelphia chromosome) that make treatment more difficult and prognoses poorer. * White blood cell count at diagnosis of less than 50,000/µl * Whether the cancer has spread to the [[brain]] or [[spinal cord]] * Morphological, immunological, and genetic subtypes * Response of patient to initial treatment * [[Genetic disorder]]s such as [[Down syndrome|Down's Syndrome]] '''Correlation of prognosis with bone marrow cytogenetic finding in acute lymphoblastic leukemia''' {| class="wikitable" |- ! Prognosis ! Cytogenetic findings |- | Favorable | Hyperdiploidy > 50 ; t (12;21) |- | Intermediate | Hyperdioloidy 47 -50; Normal(diploidy); del (6q); Rearrangements of 8q24 |- |Unfavorable |Hypodiploidy-near haploidy; Near tetraploidy; del (17p); t (9;22); t (11q23) |} == Additional images == <gallery> Image:ALL - Peripherial Blood - Diagnosis - 01.jpg|acute lymphoblastic leukemia (ALL), peripheral blood of a child, Pappenheim stain, magnification x100 Image:ALL-KM-2.jpg|bone marrow smear (large magnification) from a patient with acute lymphoblastic leukemia Image:ALL-KM-3.jpg|bone marrow smear from a patient with acute lymphoblastic leukemia </gallery> ==References== {{reflist|2}} ==External links== * [http://www.leukemia-lymphoma.org/all_page?item_id=7049 Information about ALL] from the [[Leukemia & Lymphoma Society]] * [http://www.cancerhelp.org.uk/help/default.asp?page=32107 Information about ALL] from [[Cancer Research UK]] * [http://spade39.ncl.ac.uk/ccw/guide2l.htm Directory of children's cancer-related resources] from Children's Cancer Web * [http://www.kids-cancer.org/all.htm Information about ALL] from the Centre for Cancer and Blood Disorders at [[Sydney Children’s Hospital]] * [http://www.leukemia-net.org/content/e58/e352/e353/ Information about ALL] from European LeukemiaNet * [http://www.acor.org/ped-onc/diseases/ALL.html Information on childhood ALL] from ACOR's Ped-Onc Resource Center, including disease details (MRD, phenotypes, molecular characterization), a layman's list of current and past clinical trials, a collection of articles on the possible causes of ALL, a bibliography of journal articles, and links to sources of support for parents of children with ALL. * [http://www.acor.org/leukemia/ Association of Cancer Online Resource (ACOR) Leukemia Links] - provides links to information on leukemia, including ALL, primarily in adults. {{Hematology}} {{Hematological malignancy histology}} [[Category:Blood disorders]] [[Category:Hematology]] [[Category:Types of cancer]] [[ar:ابيضاض الدم الليمفاوي الحاد]] [[de:Akute lymphatische Leukämie]] [[it:Leucemia acuta linfoblastica]] [[ja:急性リンパ性白血病]] [[no:Akutt lymfatisk leukemi]] [[nn:Akutt lymfatisk leukemi]] [[pl:Ostra białaczka limfoblastyczna]] [[pt:Leucemia linfóide aguda]] [[sr:Акутна лимфоцитна леукемија]] [[fi:Akuutti lymfaattinen leukemia]] [[sv:Akut lymfatisk leukemi]]