Katie Davis, Michelle Eads, Kate Jamis, Joe Kussman,
Michelle Robbins, TC Roope, & Becky Seifert
ALL: Acute Lymphocytic Leukemia
Pathophysiolgy
Hematopoietic: blood forming, refers to normal cell types usually
Lymphoblast: precursor to t-cells, b-cells and NK cells. They differentiate in the bone marrow.
B-cell: ingest antigens and manufacture antibodies, these are the ones that go haywire in the most common type of ALL
T-cell: called t-cells since they migrate from bone marrow to the thymus where they mature.
ALL is the result of clonal proliferation and overabundance of leukemic lymphoblasts in the bone marrow and other
lymphoid tissues.
May be present in the bone marrow, thymus, liver, spleen, lymph nodes, testes, and CNS.
The deviation in B-cell ALL occurs when the cell synthesizes immunoglobulins.
Examination of cell differentiation during remission shows differentiated hematopoiesis was restored
In others, the remission marrow had the same clonal product as found at diagnosis.
Detection of clonal hematopoiesis in remission was associated with relapse in 89% of these cases
Like most cancers ALL is caused by genetic damage that can allow 2 things to happen:
Faulty expression of the genes that regulate normal development of B cells and T cells (allows the undifferentiated
blast cells to become malignant).
Corruption of genes that control mutations (anti-oncogenes).
Signs & Symptoms
Rapid fatigue, Malaise, SOB during activity, Pale complexion, Frequent bruising, Prolonged bleeding, Petechiae, Bone
and joint pain, Fever, Enlarged lymph nodes, Headache, Vomiting
Incidence: See graph: ALL age-specific incidence rates 2000-2003
Differential Diagnosis
Acute Lymphocyctic
Leukemia (ALL)
Rapid
Onset of
Symptoms
Predomina Lymphoid Cell Line
nt Affected
Cell Line
15%
Incidence
Typical
Age
Symptoms
Survival
Rates
Mostly children (3-4 years
old) & adults under the age
of 40
Nonspecific fatigue &
weakness, bruising, fever,
persistent infection, weight
loss, abdominal fullness,
headaches, nausea,
vomiting, & blurred vision
Mean survival
5 yrs. with treatment
Long term survival
40% in adults
70% for children
Complete remission
95% of children
Acute Myelocytic
Leukemia (AML)
Rapid
Chronic Lymphocytic
Leukemia (CLL)
Late
Chronic Myelocytic
Leukemia (CML)
Late
Myeloid (granulocytes)
Cell Line
Lymphoid Cell Line
Myeloid (granulocytes)
Cell Line
33%
25%
10 to 15%
Adults
Median age=20
Older
Median Age=60
40-60 years old
Median age=49
Nonspecific fatigue &
weakness, bruising, fever,
persistent infection, weight
loss, abdominal “fullness”,
headaches, nausea,
vomiting, & blurred vision
Median survival
1 year with treatment
2-4 weeks without
treatment
Long term survival
20% of AML patients
25% of AML children
Complete remission
75% of children
Chronic fatigue, reduced
exercise capacity, fever,
night sweats, bone pain,
easy bruising, petechiae,
abdominal fullness, early
satiety with weight loss
Dependent on stage of
disease
Mean survival
6 years with treatment
Initial remission
90%
Chronic fatigue, reduced
exercise capacity, fever,
night sweats, bone pain,
easy bruising, petechiae,
abdominal fullness, early
satiety with weight loss
Dependent on stage of
disease
Median survival
3 years with treatment
Initial remission
90%
Diagnostic Procedures:
Sudan black or myeloperoxidase, Cytogenic analysis, Lumbar Puncture
Treatment: Chemotherapy
Drugs used to destroy cancer cells or stop their growth to either slow down the disease or to bring it into remission (no
disease signs)
3 Phases: induction, consolidation and maintenance
Causes:
Katie Davis, Michelle Eads, Kate Jamis, Joe Kussman,
Michelle Robbins, TC Roope, & Becky Seifert
Low numbers of white blood cells that can increase risk for infection
Low numbers of red blood cells cause anemia.
Low numbers of platelets can cause bruising and bleeding.
Side effects: Loss of hear, hunger, & weight, Sores in the mouth & throat, Nausea & vomiting, Constipation, Diarrhea,
Tiredness (fatigue), Numbness of fingertips or toes caused by damage to the nervous system, Damage to the heart, liver or
kidneys, Delays in growth & learning ability in some kids, Infertility, Risk of getting another kind of cancer later
Treatment: Radiation
Most patients do not receive radiation therapy
However, children who have signs of disease in the central nervous system (brain and spinal cord) or have a high risk of
the disease spreading to this area may receive radiation therapy to the brain
Treatment: Bone Marrow Transplant
Allogenic
Autologous (Foley)
Common Metastatic Sites
Because the cells are blood borne they can go to any site or organ
Liver, Spleen, Lymph Nodes, CNS, Kidneys, Gonads
Exercise Program
Research shows that kids undergoing treatment for ALL participate in significantly less moderate to vigorous physical
activity every week than their healthy peers.
Children participating in aerobic and resistance training showed significant increases in aerobic fitness, strength, and
functional mobility.
Physical therapy initiated early in treatment and with emphasis on endurance activities may improve quality of life and
stamina.
Exercise Program: Aerobic
Individual doses depending on degree of sickness and phase of chemotherapy
Light levels of activity during induction and consolidation (similar to phase I cardiac rehab)
Light-moderate activity on some days of the week during maintenance phase
Large muscle group activity (bike riding, swimming, playing soccer)
Working up to the guidelines and recommendations for healthy kids
At least 60 minutes & up to several hours of moderate to vigorous activity 5-7 days/week (several 15 min sessions)
Discourage periods of inactivity > 2 hours during the day
Exercise Program: Strength
Muscle strength and endurance training
3 days/week using exercise balls, medicine balls, and resistance bands (be creative!)
Emotional Aspect
Educate patient/parents
Support child
Keep normalcy in life – rules, chores, etc.
Support Groups
For family members/caregivers, peer-to-peer as kids get older
Fatigue
Make sure pt is having fun at therapy. Keep treatment fun, like with any child.
Back to school program
Info for school nurse, etc to help child adjust to school healthily.
Helps get child prepared to go back to school.
Emotional, physical, and cognitive effects of dealing with cancer/cancer treatment.
Make-a-Wish foundation, etc.
Children’s Hospice
Centered on child-based end of life care
Survival Rates
Five year relative survival rates for ALL in children < 15 years old
Prognosis
Negative Factors
Male, > 10 years old, Burkitt’s Type (B-cell) classification of ALL, B-cell immunophenotype, White Blood Cell
count >100,000, CNS involvement, Cytogenetic abnormalities