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What is Leukemia - Acute Lymphocytic (ALL) in Adults?
Leukemia is a cancer of the blood. Leukemia begins when normal blood cells change and grow uncontrollably. Acute lymphocytic leukemia (ALL) is a cancer of the lymphocytes, a type of white blood cell involved in the body's immune system. ALL is also called acute lymphoid leukemia or acute lymphoblastic leukemia. Acute means that the disease begins and gets worse quickly; patients with ALL usually need immediate treatment. ALL is most common in young children and adults older than 50, but people of any age can develop ALL.
Lymphocytes are made in the bone marrow, the spongy, red tissue in the inner part of the large bones. Lymphocytes are found in the blood, lymph nodes, and spleen. Healthy lymphocytes fight bacterial and viral infections. In people with ALL, new lymphocytes do not develop into mature cells, but stay as immature cells called lymphoblasts. There are three different types of lymphocytes: T cells, B cells, and natural killer (NK) cells. Generally, T cells fight infections by activating other cells in the immune system and by destroying infected cells, B cells make antibodies, and NK cells fight microbes and cancer cells. About 85% of people with ALL have the B-cell subtype and about 15% have the T-cell type. The NK-cell subtype is quite rare.
In people with ALL, the abnormal cells crowd other types of cells in the bone marrow, preventing the production of red blood cells (which carry oxygen), other types of white blood cells, and platelets (parts of the blood needed for clotting). This means that people with ALL may be anemic (because they do not have enough red blood cells), more likely to get infections (because they do not have enough of the type of white blood cells called neutrophils that fight bacteria), and bruise or bleed easily (because of a low level of platelets). Lymphoblasts may also collect in a person's lymphatic system and cause swelling of the lymph nodes. Some cells may invade other organs, including the brain, liver, spleen, or the testicles in men. Unlike other types of cancer, the spread of ALL to other parts of the body does not mean the cancer is in an advanced stage because acute leukemia is usually found throughout the body when it is diagnosed.
People with ALL may experience the following symptoms or signs. Sometimes, people with ALL do not show any of these symptoms. Or, these symptoms may be caused by a medical condition that is not cancer. If you are concerned about a symptom or sign on this list, please talk with your doctor.
Your doctor will ask you questions about the symptoms you are experiencing to help find out the cause of the problem, called a diagnosis. This may include how long you've been experiencing the symptom(s) and how often.
If leukemia 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 health care team about symptoms you experience, including any new symptoms or a change in symptoms.
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. However, knowing your risk factors and talking about them with your doctor may help you make more informed lifestyle and health care choices.
The cause of ALL is not known. In general, ALL is most likely to affect children and older adults. The following factors may raise a person's risk of developing ALL:
Age. Children younger than 15 and adults older than 50 are more likely to develop ALL.
Race. White people are somewhat more likely than black people to develop ALL for reasons that are not understood.
Genetic disorders. People with Down syndrome, ataxia telangiectasia, Li-Fraumeni syndrome, Klinefelter syndrome, Fanconi anemia, Wiskott-Aldrich syndrome, and Bloom syndrome are at higher risk for ALL than the general population.
High doses of radiation. People who have been exposed to high levels of radiation, such as long-term survivors of atomic bombs, may be more likely to develop ALL. Exposure to electromagnetic fields or high-voltage electric lines has not been proven to increase a person's risk of ALL.
Viruses. Occasionally, ALL or unique types of lymphoma can be associated with a previous viral infection, such as human T-cell leukemia virus-1 or Epstein-Barr virus.
Recent genetic research has shown that many young children who develop ALL may have had the disease before they were born, although it may take several years before the disease develops and causes symptoms.
Doctors use many tests to diagnose cancer and learn more about the disease. Some tests may also determine which treatments may be the most effective. For most types of cancer, a biopsy is the only way to make a definitive diagnosis of cancer. If a biopsy is not possible, the doctor may suggest other tests that will help make a diagnosis. Imaging tests may also be used. Your doctor may consider these factors when choosing a diagnostic test:
Age and medical condition
Type of cancer suspected
Severity of symptoms
Previous test results
The following tests may be used to diagnose ALL:
Blood tests. If the doctor believes a person has ALL based on the symptoms, he or she will examine the levels of different types of cells in the patient's blood through a test called a complete blood count (CBC). Low levels of red blood cells and platelets and high levels of white blood cells are common in people with ALL but can also be a sign of other medical problems. In addition, the blood may be examined under a microscope to determine if there are lymphoblasts or other abnormal cells in the blood.
Bone marrow biopsy and aspiration. If the blood test shows abnormalities in the number or appearance of the white blood cells, a bone marrow biopsy and aspiration will be done. These two procedures are similar and often done at the same time. Bone marrow has both a solid and a liquid part. A bone marrow biopsy is the removal of a small amount of solid tissue using a needle. An aspiration removes a sample of fluid with a needle. The sample(s) are then analyzed by a pathologist (a doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease). The sample is used to look for leukemia, and molecular testing and immunophenotyping (see below) may also be done. A common site for a bone marrow biopsy and 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 beforehand, and other types of anesthesia (medication to block the awareness of pain) may be used.
Molecular testing. Your doctor may recommend running laboratory tests on the leukemia cells to identify specific genes, proteins, and other factors unique to the leukemia. Results of these tests will help decide whether your treatment options include a type of treatment called targeted therapy.
Flow cytometry and cytochemistry (immunophenotyping) are tests that treat the cancer cells with chemicals or dyes to provide information about the leukemia and its subtype. ALL cells have distinctive markers on their surface called cell surface proteins. The pattern of these markers is called the immunophenotype. These tests are used to distinguish ALL from normal blood cells and from other types of leukemia, which can also involve lymphocytes. Both tests can be done from a blood sample.
Cytogenetics are used to examine the number and order of a cell's chromosomes (long pieces of DNA that contain genes). People with ALL may have specific chromosomal changes, including the addition or loss of certain chromosomes, as well as translocations, which means that parts of one chromosome have been moved to another chromosome. These changes can be seen under a microscope using special methods.
About 20% to 30% of adults with ALL have a particular change in their chromosomes called the Philadelphia chromosome. The Philadelphia chromosome is an example of a translocation, which, in this specific instance, means that genetic material from chromosome 9 breaks off and attaches to chromosome 22 [t(9;22)]. In this way, two specific genes called BCR and ABL are brought together to make one gene called BCR-ABL. Some people may have other types of translocations. For example, many children with ALL have a translocation between chromosomes 12 and 21 [t(12;22)]. These genes are called TEL and AML1.
Lumbar puncture (spinal tap). A lumbar puncture is a procedure in which a doctor uses a needle to take a sample of cerebral spinal fluid (CSF) to look for cancer cells, blood, or tumor markers (substances found in higher than normal amounts in the blood, urine, or body tissues of people with certain kinds of cancer). Because ALL tends to spread to the CSF surrounding the brain, lumbar punctures are done regularly during ALL treatment, and chemotherapy may be given in the CSF. Doctors generally give an anesthetic to numb the lower back before the procedure.
Imaging tests. A computed tomography (CT or CAT) scan (test that creates a three-dimensional picture of the inside of the body) or magnetic resonance imaging (MRI, a test that uses magnetic fields, not x-rays, to produce detailed images of the body) may be used to learn more about the cause of symptoms or to help diagnose infections in patients with ALL. They are not regularly used for assigning a classification to ALL since the disease has usually spread throughout the bone marrow and blood when it is diagnosed. These tests may not be done for every patient.
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