Acute lymphoblastic leukemia (ALL) is a form of leukemia, or cancer of the white blood cells characterized by excess lymphoblasts.

Malignant, immature 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 (infiltrating) to other organs. ALL is most common in childhood with a peak incidence at 25 years of age, and another peak in old age. The overall cure rate in children is about 80%, and about 45%-60% of adults have long-term disease-free survival.[1] Acute refers to the relatively short time course of the disease (being fatal in as little as a few weeks if left untreated) to differentiate it from the very different disease of chronic lymphocytic leukemia which has a potential time course of many years. It is interchangeably referred to as Lymphocytic or Lymphoblastic. This refers to the cells that are involved, which if they were normal would be referred to as lymphocytes but are seen in this disease in a relatively immature (also termed 'blast') state. Symptoms The signs and symptoms of ALL are variable but follow from bone marrow replacement and/or organ infiltration.

Generalized weakness and fatigue Anemia Frequent or unexplained fever and infection Weight loss and/or loss of appetite Excessive and unexplained bruising Bone pain, joint pain (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 Pitting edema (swelling) in the lower limbs and/or abdomen Petechia, which are tiny red spots or lines in the skin due to low platelet levels

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. Laboratory tests which might show abnormalities include blood count tests, renal function tests, electrolyte tests and liver enzyme tests.

Pathophysiology In general, cancer is caused by damage to 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 protooncogene via juxtaposition of it to the promoter 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 radiation and chemicals in animals and humans. The association of radiation and leukemia in humans has been clearly established in studies of victims of theChernobyl nuclear reactor and atom bombs in Hiroshima and 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. Some evidence suggests that secondary leukemia can develop in individuals who are treated for other cancers with radiation and chemotherapy as a result of that treatment. [5]

The malignant cells of acute lymphoblastic leukemia (ALL) are lymphoid precursor cells (ie, lymphoblasts) that are arrested in an early stage of development. This arrest is caused by an abnormal expression of genes, often as a result of chromosomal translocations. The lymphoblasts replace the normal marrow elements, resulting in a marked decrease in the production of normal blood cells. Consequently, anemia, thrombocytopenia, and neutropenia occur to varying degrees. The lymphoblasts also proliferate in organs other than the marrow, particularly the liver, spleen, and lymph nodes.

Less is known about the etiology of acute lymphoblastic leukemia (ALL) in adults compared with acute myelogenous leukemia (AML). Most adults with ALL have no identifiable risk factors. Although most leukemias occurring after exposure to radiation are AML rather than ALL, an increased prevalence of ALL was noted in survivors of the Hiroshima atomic bomb but not in those who survived the Nagasaki atomic bomb.

Rare patients have an antecedent hematologic disorder (AHD) such asmyelodysplastic syndrome (MDS) that evolves to ALL. However, most patients with MDS that evolves to acute leukemia develop AML rather than ALL. Increasingly, cases of ALL with abnormalities of chromosome band 11q23 following treatment with topoisomerase II inhibitors for another malignancy have been described. However, most patients who develop secondary acute leukemia after chemotherapy for another cancer develop AML rather than ALL.

Epidemiology Acute lymphoblastic leukemia (ALL) is the most common type of cancer and leukemia in children in the United States. In adults, this disease is less common than acute myelogenous leukemia (AML). Approximately 1000 new cases of ALL occur in adults each year. However, due to the fact that there are more adults than children, the number of cases seen in adults is comparable to that seen in children. Worldwide, the highest incidence of ALL occurs in Italy, the United States, Switzerland, and Costa Rica, and this disease is slightly more common in men than in women.

Pathophysiology The development of ALL, like other malignancies of hematologic origin, is believed to involve a transformation event that occurs in a single progenitor cell that has the capability for indefinite clonal expansion. The leukemogenic event may occur in committed lymphoid cells of B- or T-cell lineages or in early precursors, which gives rise to the different subtypes of ALL based on the stage of lymphoid differentiation of the cell in which the event occurred.[9]About 80% of all cases of ALL express cell-surface markers indicative of a precursor B-cell lineage. Only 1% to 2% of cases express a phenotype typical of a mature B cell. T-cell ALL accounts for about 15% to 20% of cases and is commonly associated with features at diagnosis, such as older age, male predominance, high white blood cell (WBC) count, and extramedullary disease, all of which indicate the need for increased intensity of chemotherapy.[10] The identification of specific chromosomal abnormalities plays an important role in determining therapy and prognosis in certain subtypes of ALL. Some of the more common chromosomal abnormalities in ALL include the TEL-AML1 fusion gene, which by molecular techniques, can be found in 25% of cases of pre-B ALL.[10] The presence of this translocation carries a more favorable prognosis. The bcr-abl t(9,22) p180 translocation is found in only about 3% to 5% of cases of childhood ALL. The presence of this translocation is associated with a high WBC count at diagnosis and a poor response to therapy.[11] Rearrangements of the MLLgene at chromosome band 11q23 are found in 80% of cases of ALL in infants. Unfortunately, young children with this genetic abnormality have a very poor prognosis and a survival of less than 20% despite intensive therapy.[12-15] Children, with MLL gene rearrangements, > 1 year of age at

diagnosis were found to have better prognoses than those of infants with the same translocation, but far worse than age-matched patients without rearrangements of the MLL gene.

Acute lymphocytic leukemia (ALL), is a form of leukemia, or cancer of the white blood cells characterized by excesslymphoblasts. Malignant, immature 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 (metastasizing) to other organs. ALL is most common in childhood with a peak incidence at 2-5 years of age, and another peak in old age. The overall cure rate in children is about 80%, and about 45%-60% of adults have longterm disease-free survival. Acute refers to the relatively short time course of the disease (being fatal in as little as a few weeks if left untreated) to differentiate it from the very different disease of Chronic Lymphocytic Leukemia which has a potential time course of many years. It is interchangeably referred to as Lymphocytic or Lymphoblastic. This refers to the cells that are involved, which if they were normal would be referred to as lymphocytes but are seen in this disease in a relatively immature (also termed blast) state. Signs and Symptoms Back to Top 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.

Generalized weakness and fatigue Anemia Frequent or unexplained fever and infections Weight loss and/or loss of appetite Excessive and unexplained bruising Bone pain, joint pains (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 Pitting edema (swelling) in the lower limbs and/or abdomen Petechiae, which are tiny red spots or lines in the skin due to low platelet levels

Bleeding from the gums Frequent or severe nosebleeds Pale skin

Causes Back to Top ALL makes up 80% of childhood acute leukemias. Most cases occur in children ages 3 7. The disease may also occur in adults. In acute leukemia, cancerous cells multiply quickly and replace normal cells. Cancerous cells take over normal parts of the bone marrow, often causing low blood counts. Most cases of ALL have no obvious cause. However, the following may play a role in the development of leukemia: Certain chromosome problems Radiation exposure or being exposed to x-rays before birth Past treatment with chemotherapy drugs Receiving a bone marrow transplant Toxins such as benzene Persons with Down syndrome or other genetic disorders, or who have a brother or sister with leukemia are at increased risk for ALL.

Diagnosis Back to Top Diagnosing ALL begins with a medical history and physical examination, 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. Blast cells are seen on blood smear in 90% of cases. A bone marrow biopsy is conclusive proof of ALL. A lumbar puncture (also known as a spinal tap) will tell if the spinal column and brain has been invaded. Pathological examination, cytogenetics (particularly the presence of Philadelphia chromosome) and immunophenotyping, establish whether the blast cells began from the B lymphocytes or T lymphocytes. DNA testing can establish how aggressive the disease is; different mutations have been associated with shorter or longer survival. Immunohistochemical testing may reveal TdT or CALLA antigens on the surface of leukemic cells. TdT is a protein expressed early in the development of pre-T and pre-B cells

while CALLA is an antigen found in 80% of ALL cases and also in the blast crisis of CML. Medical imaging (such as ultrasound or CT scanning) can find invasion of other organs commonly the lung, liver, spleen, lymph nodes, brain, kidneys and reproductive organs. Pathogenesis/Pathophysiology Back to Top The malignant cells of acute lymphoblastic leukemia (ALL) are lymphoid precursor cells (ie, lymphoblasts) that are arrested in an early stage of development. This arrest is caused by an abnormal expression of genes, often as a result of chromosomal translocations. The lymphoblasts replace the normal marrow elements, resulting in a marked decrease in the production of normal blood cells. Consequently, anemia, thrombocytopenia, and neutropenia occur to varying degrees. The lymphoblasts also proliferate in organs other than the marrow, particularly the liver, spleen, and lymph nodes. Race and Ethnicity Back to Top All races, but usually white or Hispanic are at higher risk. Sex Back to Top Usually male. Age Back to Top ALL is the most common cancer in children 1 to 7 years old. The incidence of ALL among 1- to 4-year-old children is nearly eight times greater than the rate for young adults 20 to 24 years. Survival statistics have improved significantly over the past four decades. Most children under 19 with ALL will become five-year survivors of the disease.

Prevention Back to Top Because the cause is usually unknown, it is not possible to prevent most cases. The risk of ALL can be reduce by avoiding exposure to toxins, radiation, and chemicals. Treatment Back to Top In general, treatment for acute lymphocytic leukemia falls into separate phases: Induction therapy. The purpose of the first phase of treatment is to kill most of the leukemia cells in the blood and bone marrow. Consolidation therapy. Also called post-remission therapy, this phase of treatment is aimed at destroying the leukemia cells remaining in the brain or spinal cord. Maintenance therapy. The third phase of treatment prevents leukemia cells from regrowing. The treatments used in this stage are often given at much lower doses. Preventive treatment to the spinal cord. People with acute lymphocytic leukemia may also receive treatment to kill leukemia cells located in the central nervous system during each phase of therapy. In this type of treatment, chemotherapy drugs are injected directly into the fluid that covers the spinal cord. This kills cancer cells that cant be reached by chemotherapy drugs given by mouth or through an intravenous line. Depending on the situation, the phases of treatment for acute lymphocytic leukemia can span 2 1/2 to 3 1/2 years.

Treatments may include:

Chemotherapy. Chemotherapy, which uses drugs to kill cancer cells, is typically used as an induction therapy for children and adults with acute lymphocytic leukemia. Chemotherapy drugs can also be used in the consolidation and maintenance phases. Targeted drug therapy. Targeted drugs attack specific abnormalities present in cancer cells that help them grow and thrive. One targeted drug, imatinib (Gleevec), specifically attacks cancer cells that have a certain abnormality called the Philadelphia chromosome. The drug

dasatinib (Sprycel) works in a similar way. These drugs are approved only for people with the Philadelphia chromosome-positive form of ALL. Radiation therapy. Radiation therapy uses high-powered beams, such as X-rays, to kill cancer cells. If the cancer cells have spread to the central nervous system. Stem cell transplant. A stem cell transplant may be used as consolidation therapy in people at high risk of relapse or for treating relapse when it occurs. This procedure allows someone with leukemia to re-establish healthy stem cells by replacing leukemic bone marrow with leukemia-free marrow. A stem cell transplant begins with high doses of chemotherapy or radiation to destroy any leukemia-producing bone marrow. The marrow is then replaced by bone marrow from a compatible donor (allogeneic transplant). In some cases, adults with ALL are able to use their own bone marrow for transplantation (autologous transplant). This may be possible if the patient has gone into remission and healthy bone marrow is then harvested for a future transplant. Clinical trials. Clinical trials are experiments to test new cancer treatments and new ways of using existing treatments. While clinical trials the patient a chance to try the latest cancer treatment, treatment benefits are still being evaluated. ALL in older adults Older adults, such as those older than 65, tend to experience more complications from ALL treatments. And older adults generally have a worse prognosis than children who are treated for ALL. Patients are usually advised to discuss their options with their doctor. Based on their overall health and their goals and preferences, they may decide to undergo treatment for ALL. Some people may choose to forego treatment for the cancer, instead focusing on treatments that improve their symptoms and help them make the most of the time they have remaining. Complications Back to Top Bleeding Damage to different organs from chemotherapy Disseminated intravascular coagulation (DIC) Relapse of ALL Severe infection Spread of the cancer to other parts of the body Prognosis Back to Top

Children usually have a better outcome than adults. Almost all children go into complete remission. Without treatment, a person with ALL can expect to live for only about 3 months. The following patients tend to do better: Younger adults (especially those younger than age 50) Children between the ages of 1 and 9 Those who have a WBC count below 50,000 when first diagnosed Those who do not have a Philadelphia chromosome-positive ALL (a specific genetic change) Those who achieve complete remission (disappearance of signs and symptoms of cancer) within 4 5 weeks of starting treatment. Patients whose leukemia spreads to the brain or spinal cord tend to have a worse outcome.

Pathophysiology In normal hematopoiesis, the blast is an immature precursor of white blood cells; a normal blast will gradually mature into a mature whiteblood cell. However, inAL, a single blast accumulates genetic changeswhich "freeze" the cell in its immature state and preventdifferentiation.Such a mutation alone does not cause leukemia; however, when such a"differentiation arrest" is combined with other mutationswhich disruptgenes controlling proliferation, the result is the uncontrolled growth of animmature clone of cells, leading to the clinical entity ofAL The clinical signs and symptoms ofAL result from the fact that, as theleukemic clone of cells grows, it tends to displace or interfere with thedevelopment of normal blood cells in the bone marrow. This leads toneutropenia, anemia, and thrombocytopenia