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What is Acute Lymphoblastic Leukaemia (ALL)?

Acute Lymphoblastic Leukaemia is a type of cancer of the blood and bone marrow – the spongy tissue inside the bones where the various types of blood cells are made. It develops from a type of white blood cell central to the immune system called Lymphocyte.

The term “acute” implies that the condition typically progresses rapidly and creates large numbers of immature lymphocytes called lymphoblasts. As the number of lymphoblasts increase, the number of red blood cells and platelets decreases. These lymphoblasts are less effective at fighting bacteria and viruses and they invade the blood to spread throughout the body to other organs, such as the liver, spleen, and lymph nodes.

Although rare, ALL is the most common type of childhood leukaemia, and treatment results in a god chance for a cure. ALL can also occur in adults, though the chances of a cure are greatly reduced.

What are the Symptoms of Acute Lymphoblastic Leukaemia (ALL)?

ALL usually starts slowly before rapidly becoming severe as the number of immature white blood cells in the body increases. ALL can cause a variety of symptoms – some vague and some not just specific to leukaemia. Symptoms include:

  • Fatigue
  • Fever
  • Loss of appetite or weight
  • Night sweats

Many symptoms of ALL are the result of a shortage of normal blood cells as the immature white blood cells crowd out the normal blood cells in the bone marrow.

If there are fewer red blood cells than normal, there would be symptoms of anaemia, including:

  • Fatigue or weakness
  • Dizziness
  • Feeling cold
  • Light-headedness
  • Shortness of breath

If there are fewer white blood cells than normal, the symptoms are:

  • Fevers
  • Recurring infections

If there are fewer platelets than normal, the symptoms could be:

  • Lots of bruising for no obvious reason
  • Frequent or severe nosebleeds, bleeding gums, or other unusual bleeding

And, depending upon where the leukaemia cells are present in the body, there could be other symptoms:

  • A full or swollen belly from leukaemia cells in the liver or spleen
  • Enlarged lymph nodes, such as in the neck or groin, under arms, or above the collarbone
  • Bone or joint pain
  • Headaches, trouble with balance, vomiting, seizures or blurred vision if the cancer has spread to the brain
  • Trouble breathing if the cancer spreads in the chest area

What causes Acute Lymphoblastic Leukaemia (ALL)?

It’s a mutation or a genetic change in the stem cells that causes immature white blood cells to be released into the bloodstream. A healthy cell normally stops dividing and eventually dies, but this mutation tells the cells to continue growing and dividing resulting in abnormal production of blood cells.

While, it’s not clear what cause the mutations that can lead to ALL, but doctors have found that most cases of ALL aren’t inherited. The various known risk factors include:

Previous Cancer Treatment
Children and adults who have had chemotherapy and radiation therapy for other kinds of cancer are at an increased risk of developing ALL.

Smoking
Smokers are more likely to develop ALL than non-smokers, and studies have shown that passive smoking may increase the risk of leukaemia in children

Being Obese
Studies have shown that overweight people have a slightly higher risk of developing leukaemia than those who have normal weight

Genetic Disorders
Certain genetic disorders, such as Down Syndrome, are associated with an increased risk of ALL.

THE OUTLOOK FOR CHILDREN WITH ALL IS USUALLY GOOD – ALMOST EVERY CHILD ACHIEVES REMISSION (A PERIOD WHEN THEY’RE FREE FROM SYMPTOMS), AND 85% WILL BE COMPLETELY CURED. HOWEVER, THE OUTLOOK FOR ADULTS WITH ALL IS LESS PROMISING – AROUND 40% OF PATIENTS BETWEEN 25 & 64 YEARS LIVE ON FOR FIVE YEARS OR MORE AFTER DIAGNOSIS.

How is Acute Lymphoblastic Leukaemia (ALL) Diagnosed?

The first step in the diagnosis of ALL is to check for physical signs – swollen glands, and then the doctor will take a blood sample. If the blood sample contains a high number or abnormal white blood cells, it could indicate ALL and the doctor will refer the patient to a Haematologist – a specialist doctor who specialises in treatment of blood conditions – for further tests. These include:

Bone Marrow Biopsy:
To confirm the diagnosis of ALL, the Haematologist will order a Bone Marrow Biopsy (For more information, read Bone Marrow Aspiration and Biopsy)

Cytogenetic Testing:
This test is used to identify the genetic make-up of the cancerous cells – specific genetic variations can occur during leukaemia, and the Haematologist needs to understand these variations as they might impact treatment modalities.

Immunophenotyping:
This test helps to identify the exact type of ALL as treatment may be slightly different for each type.

Lymph Node Biopsy:
A biopsy of the enlarged lymph node is carried out to check the spread of leukaemia.

CT Scans:
A Computerised Tomography (CT) Scan may be used to assess how far the leukaemia has spread and to check the health of the heart and lungs.

Lumbar Puncture:
This test is carried out if there’s a risk that ALL has spread to the body’s nervous system. In this test, a needle is inserted into the lower part of the spine to extract a small sample of the cerebrospinal fluid (the fluid that surrounds and protects the spine), and is tested for cancer cells.

How is Acute Lymphoblastic Leukaemia (ALL) Treated?

Since ALL is an aggressive condition that develops rapidly, the treatment usually begins a few days after the diagnosis and is carried out in three stages:

STAGE 1: INDUCTION – the aim of this initial stage is to kill the leukaemia cells in the bone marrow, restore the balance of cells in the blood and resolve any symptoms the patient might have.

STAGE 2: CONSOLIDATION – the aim of this stage is to kill the remaining leukaemia cells in the bone marrow and central nervous system.

STAGE 3: MAINTENANCE – this final stage involves taking regular doses of chemotherapy tablets to prevent leukaemia from returning.

STAGE 1: INDUCTION

This stage of treatment is carried out in a hospital as the patient might need regular blood transfusions since the blood doesn’t contain enough healthy blood cells. The patient is kept in a sterile environment as he/ she is more vulnerable to infections. This stage includes further treatments:

  • Chemotherapy – pills or maybe as an injection as well. In some cases, to avoid repeated injections, drugs are administered through a flexible tube that goes into a vein in the chest.
  • Steroid Therapy – administered to improve the effectiveness of chemotherapy.

STAGE 2: CONSOLIDATION

The treatment during this stage involves regular injections of chemotherapy medication on an outpatient basis. However, if the symptoms suddenly get worse or if the patient develops an infection, short overnight stays in the hospital are required. This phase of treatment lasts several months.

STAGE 3: MAINTENANCE

This phase of treatment is like an insurance against the possibility of the leukaemia returning. It involves regular chemotherapy (tablets) with regular check-ups to monitor the effectiveness of the treatment. This phase of treatment can often last for two years.

Further, in some cases, the Haematologist may opt for other treatments as well:

  • Radiotherapy – high doses of controlled radiation are used to kill cancerous cells and is used to treat ALL if it has spread to the nervous system or brain and to prepare the body for a bone marrow or a stem cell transplant.
  • Stem Cell and Bone Marrow Transplants – For more information, read Stem Cell Transplant

What are the side effects of Treatment?

Like treatment of all types of cancers, ALL treatment can also produce side effects – for most patients, the treatment side effects are temporary and go away once the therapy end, and for other patients, these side effects can be severe, sometimes requiring hospitalisation. However, many side effects go away or become less noticeable over time.

The common side effects include:

  • Mouth Ulcers called Cancer Sores
  • Diarrhoea
  • Temporary Hair Loss
  • Rashes
  • Itchy Skin
  • Nausea & Vomiting
  • Headaches
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