Frequent infections

A fever that doesn’t go away

Feeling weak and tired all the time

Bone pain

Swollen lymph nodes (in the neck, under the arms, and groin, for example)

Paleness

Bruising or bleeding easily

Difficulty breathing

Headache

Enlarged liver or spleen during a physical examination.

Your child’s doctor will ask you questions about the symptoms your child is having to help find out the cause of the problem, called a diagnosis. This may include how long your child has been having the symptom(s) and how often.

If cancer is diagnosed, relieving symptoms and side effects remains an important part of care and treatment. This may also be called symptom management, palliative care, or supportive care. Be sure to talk with your child’s health care team about symptoms your child has, including any new symptoms or a change in symptoms.

Risk Factors

A risk factor is anything that increases a person’s chance of developing cancer. Although risk factors often influence the development of cancer, most do not directly cause cancer. Some people with several risk factors never develop cancer, while others with no known risk factors do.

Although doctors don’t know what causes the vast majority of childhood leukemia, some evidence shows that certain genetic factors play a role in ALL. Children who are born with conditions that cause an abnormal immune system, such as Down syndrome, ataxia telangiectasia, and Bloom syndrome, may have a higher risk of developing leukemia. A child with an identical twin that develops ALL before age six has an increased risk of developing leukemia. If an identical twin develops leukemia within the first few months of life, the other twin will almost always develop the same type of leukemia.

Diagnosis

Doctors use many tests to diagnose leukemia and determine if it has spread. Some tests may also determine which treatments may be the most effective. A patient history, physical examination, complete blood cell count (CBC), and bone marrow aspiration (see below) are the main procedures used to diagnose ALL or rule out other conditions.

Blood tests. A CBC provides a count of each type of cell in the blood. The blood count may also show abnormal leukemia cells. The blood count is abnormal, in some way, for nearly all children with ALL when they are diagnosed.

Bone marrow aspiration. A bone marrow aspiration is recommended if the blood test shows unusual blood counts or immature cells, or if the doctor suspects that a child may have leukemia. Bone marrow has both a solid and a liquid part. An aspiration removes a sample of fluid with a needle. The sample is then studied by a pathologist. A common site for a bone marrow aspiration is the pelvic bone, which is located in the lower back by the hip. The skin in that area is usually numbed with medication before the test, and other types of anesthesia (medication to block the awareness of pain) may be used.

From this test, the doctor can find out whether the child has leukemia and, if so, what type of leukemia it is. The doctor or nurse will collect more than one sample of bone marrow at the same time for other tests, such as chromosome and molecular genetic tests and immunophenotyping. These additional tests are important to plan the most appropriate treatments.

Lumbar puncture (spinal tap).  A lumbar puncture can determine if the leukemia has spread to the cerebral spinal fluid (CSF). CSF is the fluid that flows around the brain and the spinal cord. During a lumbar puncture, the doctor uses a needle to take a sample of the CSF to look for leukemia cells. Doctors may give an anesthetic to numb the lower back before the procedure and/or use anesthesia to block awareness of the pain. Whether or not there is leukemia in the central nervous system helps doctors choose the most appropriate treatment. There are many times when it is appropriate to give medicine to treat or prevent leukemia of the central nervous system at the same time as the lumbar puncture. 

Classification

While there is no staging system for childhood ALL compared to other types of cancer, there are a number of factors that help doctors choose the best treatment plan and predict the chance that the disease will come back after treatment. Doctors plan the child’s treatment based on these and other factors:

Age. Infants younger than 12 months and children age 10 and older need more intensive treatments.

White blood cell counts. Children with higher white blood cell counts need more intensive treatments. Commonly, white blood cell counts are labeled as higher if they are more than 50,000 per microliter (ml). 

Immunophenotyping. This test shows the types and amounts of proteins produced (called expressed) by the leukemia cells. Knowing if the cancer cells express the proteins more like those of normal white blood cells called B-cells or T-cells will help doctors plan appropriate treatment and is useful to help predict how well treatment will work.

Genetic abnormalities in the leukemia cells. Abnormal numbers of chromosomes, abnormal structural changes in a chromosome, or certain molecular genetic changes in the chromosomes of leukemia cells may affect outcome and treatment. Note that the genetic changes referred to here are changes in the genes of the leukemia cells, not the child’s cells--most children with leukemia have completely normal genes.

Response to early treatment. How well treatment works in the first one to four weeks of treatment (determined by examining the child’s blood or bone marrow) may predict the disease’s overall response to treatment. Recent studies have shown that some children may need more intense treatment to improve the chance of a cure. This includes children whose cancer is not responding well to early treatment or those who have high levels of residual leukemia cells (cells remaining after treatment) at the end of remission induction.

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