Updated: 12/27/2021

Acute Lymphoblastic Leukemia (ALL)

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  • Snapshot
    • A 7-year-old boy presents with low-grade fever and fatigue. He is notably pale. On physical exam, he has bilateral cervical lymphadenopathy and a mediastinal mass. Blood smear shows increased lymphoblasts. He is referred for a bone marrow biopsy.
  • Introduction
    • Acute leukemia of lymphoid precursor cells that occurs in children
    • Subtypes
      • B-cell ALL – 85% of all ALL
        • t(12;21) most common in children
        • t(9;22) most common in adults
          • same translocation seen in CML
        • CD10+ and CD19/20+
        • TdT+ (marker of precursor T- and B-cells)
      • T-cell ALL
        • presents in teenagers
        • CD2-8+ (especially CD3+)
        • TdT+ (marker of precursor T- and B-cells)
        • most common presentation is mediastinal mass
          • infiltration of thymus
  • Epidemiology
    • < 15 years
    • Most common type of cancer and leukemia in children
    • Most cases with no identifiable risk factor
  • etiology
    • Associated conditions
      • Down syndrome in children > 5 years
        • leukemia in Down syndrome children < 5 years = AML
  • Presentation
    • Symptoms
      • most common symptom is fever
      • acute onset
        • recurrent infections
        • bleeding
        • fatigue
    • Physical exam
      • mediastinal mass from infiltration of thymus
      • hepatosplenomegaly
      • lymphadenopathy
  • Evaluation
    • Best initial test - peripheral blood smear
      • lymphoblasts
    • Most accurate test
      • bone marrow biopsy with cytogenetics
        • ↑ lymphoblasts (> 25%)
        • TdT+, a marker of pre-T and pre-B cells
        • T-cell ALL
          • CD3+
        • B-cell ALL
          • CD10+
          • CD19+
        • negative MPO (myeloperoxidase)
    • CBC reflects bone marrow crowding by neoplasm
      • anemia
      • thrombocytopenia
      • ↓ mature WBCs
  • Differential Diagnosis
    • AML
    • B-cell lymphoma
    • Non-Hodgkin lymphoma
  • Treatment
    • Chemotherapy
    • Prophylaxis to CNS (standard chemotherapy does not penetrate blood-brain barrier)
      • intrathecal chemotherapy
  • Complications
    • Likes to spread to CNS and testes
    • DIC
    • Tumor lysis syndrome
      • rapid breakdown and turnover of lysed cells causes
        • hyperuricemia
        • hyperkalemia
        • hypocalcemia (most common electrolyte abnormality)
  • Prognosis
    • Very responsive to therapy
    • Good prognosis in t(12;21)
    • Worse prognosis in t(9;22)
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(M2.ON.15.4679) A 7-year-old boy is brought to his pediatrician by his mother for recent fatigue and intermittent fevers over the past month. She also reports that her son has appeared much paler recently. Vital signs at today's visit are within normal limits. Physical examination is significant for pallor, petechiae, lymphadenopathy, and hepatosplenomegaly. A complete blood count reveals anemia, thrombocytopenia, and neutropenia. A peripheral blood smear is shown in Figure A. Bone marrow aspiration reveals 47% lymphoblasts. Which of the following is associated with this patient's presenting condition?

QID: 107285
FIGURES:

Klinefelter syndrome

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(1/21)

Turner syndrome

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Down syndrome

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(19/21)

Edwards syndrome

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(0/21)

Patau syndrome

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(0/21)

M 6 D

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(M2.OMB.4870) A 5-year-old boy presents to his primary care physician for recurrent colds, fatigue, and fussiness. Over the past several weeks, the child has been more fatigued and his parents state that “he always seems to be sick.” He otherwise is healthy and up to date on his vaccinations. They state that sometimes he complains about his bones hurting and they note that he is less playful. His temperature is 102°F (38.9°C), blood pressure is 92/60 mmHg, pulse is 115/min, respirations are 23/min, and oxygen saturation is 99% on room air. Physical exam is notable for diffuse non-tender lymphadenopathy. Abdominal exam reveals hepatosplenomegaly. Laboratory studies are ordered as seen below.

Hemoglobin: 8.0 g/dL
Hematocrit: 23%
Leukocyte count: 27,500/mm^3 with 35% lymphoblasts
Platelet count: 49,000/mm^3

Serum:
Na+: 139 mEq/L
Cl-: 101 mEq/L
K+: 4.0 Eq/L
HCO3-: 24 mEq/L
BUN: 16 mg/dL
Glucose: 100 mg/dL
Creatinine: 0.7 mg/dL

Which of the following is the most likely diagnosis?

QID: 216615

Acute lymphoblastic leukemia

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Acute myelogenous leukemia

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Chronic myelogenous leukemia

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Leukemoid reaction

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Parvovirus B19 infection

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M 10

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