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Updated: Dec 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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