Acute lymphocytic leukaemia

Last reviewed: June 2018

Last updated: November 2017

Summary

Diagnosis of acute lymphocytic leukaemia involves taking a clinical history, including signs and symptoms that reflect bone marrow dysfunction. They include fatigue, dyspnoea, dizziness, bleeding, easy bruising, and recurrent infections. The symptoms are often non-specific.

Physical examination may reveal pallor, ecchymoses, lymphadenopathy, or hepatosplenomegaly. There may also be evidence of tissue infiltration such as bone pain, testicular enlargement, and cranial nerve palsies.

Definitive diagnosis requires a bone marrow biopsy. Presence of blast cells in greater than 20% of the bone marrow cells confirms the diagnosis of acute lymphocytic leukaemia (ALL). Initial peripheral blood smear may show leukaemic lymphoblasts.

Treatment uses multi-agent dose-intense chemotherapy regimens in induction, consolidation, and maintenance phases. Early stem cell transplantation is considered in selected patients.

Despite the aggressive management methods, less than 30% of adults with ALL can be cured. Long-term adverse effects of treatment include heart failure, sterility, secondary malignancies, and neurotoxicity.

Definition

Acute lymphocytic leukaemia (ALL) is a malignant clonal disease that develops when a lymphoid progenitor cell becomes genetically altered through somatic changes and undergoes uncontrolled proliferation. This progressive clonal expansion eventually leads to ALL, characterised by early lymphoid precursors replacing the normal haematopoietic cells of the bone marrow and further infiltrating various body organs. [1] [2] [3]

History and exam

Key diagnostic factors

presence of risk factors
lymphadenopathy
hepatosplenomegaly
pallor, ecchymoses, or petechiae
fever
fatigue, dizziness, palpitations, and dyspnoea
epistaxis, menorrhagia

Full details

Other diagnostic factors

papilloedema, nuchal rigidity, and meningismus
focal neurological signs
painless unilateral testicular enlargement
renal enlargement
bony pain
abdominal pain
mediastinal or abdominal mass
pleural effusion
skin infiltrations

Full details

Risk factors

children less than 6 years of age
age in mid to late 30s
age in mid 80s
genetic factors
family history of ALL
viruses
environmental factors
history of malignancy
treatment with chemotherapy
male sex
white population

Full details

Diagnostic investigations

1st investigations to order

FBC with differential
peripheral blood smear
serum electrolytes
renal function
liver function
lactic dehydrogenase
coagulation profile
bone marrow biopsy or aspiration
immunophenotyping (on bone marrow, or peripheral blood if cell count is raised)
thiopurine methyltransferase (TPMT) phenotype
cytogenetics
molecular studies

Full details

Investigations to consider

HLA-typing
CXR
lumbar puncture
pleural tap
CT/MRI brain
CT thorax or a full CT thorax, abdomen, and pelvis
minimal residual disease (MRD) molecular samples

Full details

Treatment algorithm

ACUTE

newly diagnosed: no CNS disease

newly diagnosed: CNS disease

ONGOING

complete remission

relapse, refractory, or residual disease

Contributors

Authors VIEW ALL 

Melissa Ooi, MB BCh, BAO, MRCP(I), FRCPath, PhD

Consultant

Department of Haematology-Oncology

National University Cancer Institute

Singapore

Disclosures

MO declares that she has no competing interests.

Michelle Poon, MBBS, MRCP, FRCPath

Senior Consultant

Department of Haematology-Oncology

National University Cancer Institute

Singapore

Disclosures

None declared.

Esther Chan, MD

Consultant

Department of Haematology-Oncology

National University Cancer Institute

Singapore

Disclosures

EC declares that she has no competing interests.

Chin Hin Ng, MD, MRCP, FRCPath

Consultant

Department of Haematology-Oncology

National University Cancer Institute

Singapore

Disclosures

CHN declares that he has no competing interests.

Acknowledgements

Dr Melissa Ooi, Dr Michelle Poon, Dr Esther Chan, and Dr Chin Hin Ng would like to gratefully acknowledge Dr Arati V. Rao, Dr Matthew Smith, Dr Samer Bleibel, and Dr Robert Leonard, previous contributors to this monograph. AVR, MS, SB, and RL declare that they have no competing interests.

Peer reviewers VIEW ALL 

Olga Kozyreva, MD

Staff Physician

Department of Hematology and Oncology

New England Medical Center

Tufts University

Boston

Disclosures

OK declares that she has no competing interests.

Shankaranarayanan Paneesha, MD, MRCP, FRCPath

Consultant Haematologist

Department of Haematology and Stem Cell Transplantation

Heartlands Hospital

Birmingham

Disclosures

SP declares that he has no competing interests.

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Acute lymphocytic leukaemia

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Treatment algorithm

newly diagnosed: no CNS disease

newly diagnosed: CNS disease

complete remission

relapse, refractory, or residual disease

Contributors

Authors VIEW ALL 

Melissa Ooi, MB BCh, BAO, MRCP(I), FRCPath, PhD

Disclosures

Michelle Poon, MBBS, MRCP, FRCPath

Disclosures

Esther Chan, MD

Disclosures

Chin Hin Ng, MD, MRCP, FRCPath

Disclosures

Acknowledgements

Peer reviewers VIEW ALL 

Olga Kozyreva, MD

Disclosures

Shankaranarayanan Paneesha, MD, MRCP, FRCPath

Disclosures

Differentials

Guidelines

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