Acute Lymphoblastic Leukemia

Original Editors - Erin Foster from Bellarmine University's Pathophysiology of Complex Patient Problems project.

Top Contributors - Erin Foster, Admin, Lucinda hampton, Kim Jackson, Elaine Lonnemann, Vidya Acharya, WikiSysop, Fasuba Ayobami, 127.0.0.1, Wendy Walker, Evan Thomas and Sarah Haerinck

Definition/Description

Acute lymphoblastic leukemia (ALL) is a cancer of the blood and bone marrow. Bone marrow is spongy tissue that fills the cavity of the long bones consisting of fat, red blood cells, and white blood cells. ALL affects the immature white blood cells.

• Acute leukemia accounts for up to 30% of all childhood malignancies. 
• ALL is the most common form of cancer in children. Repeated infection, bleeding, or fatigue/pallor not responding to treatment should raise the suspicion of ALL.

This type of cancer is classified by one of two subtypes.

1. B-cell- produce antibodies to fight infections.
   • Common ALL (50% of cases)
   • Early Pre-B ALL (10% of cases)
   • Pre-B ALL (10% of cases)
   • Mature B-cell ALL (4% of cases)
     
     
2. T-cell- assist B-cells in producing antibodies to fight infections.
   • Pre-T ALL (5-10% of cases)
   • Mature T-cell (15-20% of cases)
     

Prognostic factors include:

• Age: Younger patients have a better prognosis compared to older patients. The cure rate of children is approximately 80% and only 40% for adults.
• Initial white blood cell (WBC) count: Patients diagnosed with a WBC count below 50,000 tend to do better than patients with higher WBC counts.
• ALL subtype: The subtype of T cell or B cell affects prognosis. Patients with T-cell ALL tend to have a better prognosis than those with mature B-cell ALL.
• Response to chemotherapy: Patients who achieve complete remission within 4 to 5 weeks of starting treatment tend to have a better prognosis. Patients who do not achieve remission at any time have a poor prognosis. Evidence of minimal presence of leukemia cells in the bone marrow may also positively affect prognosis.

Etiology

• There is solid evidence that ALL has a genetic component.
• This is evidenced by many distinct translocations associated with the disease and a higher prevalence of the disease in monozygotic twins.
• ALL incidence has also been found to be higher in patients with immunodeficiency disorders such as Down syndrome, neurofibromatosis type 1, Bloom syndrome, and ataxia telangiectasia

Epidemiology

• 
  The estimated number of ALL new cases in the United States is approximately 6000 per year.
• ALL is primarily a disease of children younger than 6 years with a slight male predominance.
• About 85% of ALL cases are B-cell in origin, and 15% are T-cell in origin.
• T-cell ALL is more common in male, African Americans and adolescents.
• T-ALL accounts for approximately 25% of adults ALL.
  

Characteristics/Clinical Presentation

Most signs and symptoms of ALL mimic those of the flu. However, with all these signs and symptoms will not improve. Signs and symptoms include:

• Weight loss
• Bleeding from the gums
• Nosebleeds
• Pale skin
• Shortness of breath
• Fever
• Frequent infections
• Weakness
• Anemia: deficiency of red blood cells
• Pallor: deficiency of color, especially in the face
• Malaise: feeling of fatigue and discomfort
• Hypoxia: oxygen deficiency
• Hyperuricemia: abnormally high level or uric acid
• Lymphadenopathy: abnormally enlarged lymph nodes
  .

Associated Co-morbidities

The following co-morbidities are linked to ALL:

• Anemia: a deficiency of red blood cells.
• Diabetes:  disorder characterized by defects in the body's ability to produce or use insulin resulting in high blood glucose levels.
• Lupus: a chronic autoimmune disease that effects many systems in the body.
• Rheumatoid Arthritis: a chronic systemic inflammatory disorder.
• Multiple Sclerosis: an autoimmune disease that attacks the central nervous system.
  
  

Medications

Medications involved with ALL include:

• Chemotherapy drugs: L-asparaginase, Vincristine
• Steroid: Dexamethasone, Hydrocortisone
• Drugs for high-risk patients: Daunorubicin, Cytarabine
• Other drugs that may be given early: Methotrexate, 6-mercaptopurine.
  

Diagnostic Tests/Lab Tests/Lab Values

Diagnostic tests and results for ALL include:

Blood test: These tests reveal increased number of white blood cells, decreased number of red blood cells (anemia) and platelets (thrombocytopenia). A blood test may also reveal blast cells. Blast cells are immature blood cells in bone marrow.

• Red blood cells: These cells carry oxygen throughout the body. A low number of red blood cells can lead to feeling tired or weak, being short of breath and looking pale (anemia).
• White blood cells:  These cells fight infections. A low number of white blood cells can lead to fever and frequent infections that are hard to treat.
• Platelets: Platelets control bleeding. A low number of platelets can lead to slow healing, easy bruising or bleeding and tiny red spots under the skin (petechiae). 
• Leukemia cells: An increased number of these cells can cause pain in the bones or joints, lack of appetite, headache or vomiting

Bone marrow test: A needle is used to remove a sample of bone marrow from the hipbone to look for cancerous cells. Through this process, doctors can determine if the cells originated from the B lymphocytes or T lymphocytes according to certain changes in the cancer cells.

Lumbar puncture or spinal tap: A sample of spinal fluid is collected to determine if the cancerous cells have spread.

Imaging: X-ray and computerized tomography (CT) scan can help determine if the cancer has spread to other parts of the body.

Medical Management

Treatment for ALL can span from 2 ½ to 3 ½ years depending on each individual situation. General treatment for ALL is broken down into the following 4 phases:

1. Induction therapy: The purpose of this phase is to achieve remission by killing most of the cancer cells in the blood and bone marrow. During the first month, the patient may require many doctor's visits due to increase risk of infections. Patients often receive 3 drugs for the first month of treatment which include:
   • Chemotherapy drugs injected intrathecally
   • Steroids
   • A fourth drug in the anthracycline class is typically added for high-risk patients.
     
     
2. Consolidation therapy/ Post- remission therapy: During this more intensive phase, the goal is to destroy any remaining leukemia cells in the central nervous system. This phase of chemotherapy lasts typically 4 to 8 weeks. Intrathecal therapy is continued during this phase.
   
   
3. Maintenance therapy: This low dose treatment is given to prevent cancer cell re-growth. During the first few months of this phase, most treatments include 1 to 2 treatments similar to the initial induction. These 4 week intense treatments are called re-induction.
   
   
4. Preventive treatment to the spinal cord: Some cancer cells in the central nervous system can not be destroyed by chemotherapy drugs given by oral or intravenous means. During this phase, chemotherapy drugs are injected directly into the spinal cord fluid.
   

During these 4 phases the specific types of treatments include:

Chemotherapy: Chemotherapy is normally used in the induction therapy stage to kill the cancer cells. This drug can also be used in the consolidation and maintenance phases. All patients need spinal taps to inject chemotherapy into the cerebrospinal fluid (CSF) to kill any leukemia cells that may have spread to the brain and spinal cord. This intrathecal chemotherapy is usually given twice during the first month and four to six times during the next one to two months. It is repeated less often during the rest of consolidation and maintenance. A possible side effect of intrathecal chemotherapy is epileptic seizures during treatment.

Chemotherapy can be received several ways:

• Orally
• Intravenous injections
• Catheter placement involving a tube placed in a large vein for patients that require many IV treatments
• Intrathecal injections into the cerebral spinal fluid or through a catheter placed under the scalp

Targeted drug therapy: These drugs attack specific abnormalities that cause the cancer cell growth.

Radiation therapy: This treatment uses high-powered beams to destroy cancer cells. This is typically used when the cancer has spread to the central nervous system. Along with intrathecal chemotherapy, high-risk patients and those with leukemia cells detected in their CSF may be given radiation therapy to the brain and spinal cord. Doctors try to avoid this treatment if possible, especially in younger children, because it may cause problems in growth and development.

Stem cell transplant: This transplant may be used for patients at risk or currently going through a relapse. This procedure replaces cancer bone marrow through chemotherapy or radiation with healthy bone marrow from a compatible donor allowing re-establishment of healthy stem cells.

Physical Therapy Management

Therapy is determined on an individual basis depending on clinical presentation and response to medical intervention.

Suggested Physiotherapy Interventions

Area of Focus	Intervention	Frequency
Pain	Modalities Positioning Assistive Device Neuropathic pain Physician prescribed medication	As needed
Strengthening	Therapeutic exercise Functional Activity	3-5 days a week
Stretching	Continuous passive motion machine Splinting, bracing, orthotic Manual stretch, self stretching	1-5 times a week
Endurance	Walking Treadmill Bike Stair stepper Swimming	5 times a week
Manual Techniques	Manual guidance Neurodevelopmental treatment Self directed	As needed
Motor learning principles	Knowledge of performance Knowledge of results Blocked practice Random practice	As needed

Precautions should be taken for:

• Thrombocytopenia: low number of platelet
• Neutropenia: low number of neutrophils (WBC)
• Infection control: signs of infection include mucosal ulceration, skin abrasion, or other tears
• Anemia
• Medication side effect
• Drug induced mood changes

See also Oncology Physiotherapy Management

Differential Diagnosis

The following are possible differential diagnosis for ALL:

• Acute myelocytic leukemia
• Acute anemia
• Juvenile Rheumatoid Arthritis
• Leukocytosis
• Mononucleosis and Epstein-Barr virus 
• Neuroblastoma
• Non-Hodgkin Lymphoma
• Osteomyelitis
• Parvovirus B19 infection
• Rhabdomyosarcoma

Case Reports/ Case Studies

1. Gohar SF, Marchese V, Comito M. Physician referral frequency for physical therapy in children with acute lymphoblastic leukemia. Pediatr Hemotol Oncol. 2010; 27: 179-87.
2. Marchese VG, Chiarello LA, Lange BJ. Effects of physical therapy intervention for children with acute lymphoblastic leukemia. Pediatr Blood Cancer. 2004; 42: 127-33.
3. Tecklin J.S. Pediatric Physical Therapy. Lippincott, Williams and Wilkins. Baltimore, Maryland. Fourth Edition. 2008:551-552. 

Resources

• American Cancer Society
• National Marrow Donor Program
• Mayo Clinic
• Leukemia & Lymphoma Society
• American Society of Hematology