Leukemias

Acute lymphocytic leukemia

Acute lymphocytic leukemia (ALL) starts in cells that become lymphocytes, a type of white blood cell. Acute leukemias progress quickly and need to be treated soon after diagnosis.

Diagnosing ALL

In addition to a physical exam, blood, bone marrow and genetic tests may be used to diagnose ALL. These diagnostic tests can include the following:

  • Complete blood count (CBC) measures the number of white blood cells, red blood cells and platelets in the blood.
  • Bone marrow aspiration and biopsy are often done at the same time. During these procedures, bone marrow tissue samples are removed for examination. A bone marrow biopsy involves removal of a sample of marrow from within the bone (usually the pelvic bone). For bone marrow aspiration, liquid bone marrow is removed, usually from the back of the pelvic bone or the breastbone.
  • Flow cytometry helps determine whether an increase in lymphocytes is caused by ALL or another disorder.
  • Genetic tests determine whether there are chromosomal or other genetic changes in lymphocytes.

Imaging tests, such as computed tomography (CT), magnetic resonance imaging (MRI), ultrasound and X-ray are not necessary to diagnose ALL but may be done to help determine the extent of the disease.

Classifying ALL

Most types of cancer are assigned numbered stages to describe their extent, based on the size of the tumor and how far the cancer has spread. ALL usually does not form tumors, so the disease is not staged this way. Instead, it is classified according to the immunophenotype, which is determined by the type of lymphocyte (B cell or T cell) the leukemia comes from and how mature those leukemia cells are.

Treating ALL

Once ALL is diagnosed and classified, your doctors will work with you to choose the best treatment option. Chemotherapy, targeted therapy and stem cell transplantation are the main treatments for ALL. Immunotherapy may be used for B cell types of ALL, and radiation therapy may be used in rare cases. Participating in a clinical trial may be another option for you. Ask your doctor if you may be a candidate for a clinical trial.

Chemotherapy

Chemotherapy is the main treatment for ALL. Chemotherapy drugs stop the growth of cancer, either by killing cancer cells or by preventing them from dividing and growing. These drugs are usually given by injection into a vein (IV) or taken by mouth. Chemotherapy is considered a systemic treatment because the drugs travel throughout the body in the bloodstream. This makes it useful for leukemia, which spreads throughout the body.

Chemotherapy for ALL is given in three phases: induction (or remission induction), consolidation (intensification) and maintenance. Going through these phases usually takes about two years, with the maintenance phase being the longest. The goal of the first stage, induction chemotherapy, is remission. With remission, leukemia cells are not found in bone marrow samples, the normal marrow cells return and the results of blood counts are normal. Remission is not necessarily a cure, though. Induction involves intensive chemotherapy and usually lasts about a month. If the leukemia goes into remission, consolidation is the next phase of chemotherapy. The goal of this phase is to destroy any remaining leukemia cells. Consolidation usually lasts for a few months. After consolidation, people with ALL usually begin a maintenance program, which is designed to prevent any new leukemia cells from growing.

Chemotherapy drugs commonly used to treat ALL include:

  • cyclophosphamide (Cytoxan)
  • cytarabine
  • daunorubicin (Cerubidine)
  • doxorubicin (Adriamycin)
  • L-asparaginase (Elspar)
  • liposomal vincristine (Marqibo)
  • mercaptopurine (Purinethol)
  • pegaspargase (Oncaspar)
  • vincristine (Oncovin)

Targeted therapy

Targeted therapy drugs fight cancer by targeting specific parts of cancer cells, such as proteins, and can be useful in treating certain people with ALL. About 25 percent of adults with ALL have leukemia cells with an abnormal chromosome called the Philadelphia chromosome. The Philadelphia chromosome forms a new gene, which makes an abnormal protein that helps leukemia cells grow. The Philadelphia chromosome also occurs in the cells of chronic myeloid leukemia (CML). Targeted therapy drugs, originally developed to treat CML by targeting this abnormal protein, are sometimes used to treat people in whom ALL cells include the Philadelphia chromosome. These drugs are called tyrosine kinase inhibitors (TKIs) and include dasatinib (Sprycel), imatinib (Gleevec) and ponatinib (Iclusig). These targeted therapy drugs may be added to chemotherapy or given after chemotherapy.

Immunotherapy

Immunotherapy is an innovative approach that helps repair or stimulate a person’s own immune system to find and destroy cancer cells, much like it fights off foreign bacteria. Monoclonal antibodies are a type of immunotherapy used to treat ALL. They are laboratory-made versions of antibodies (proteins made by the immune system) that are designed to attach to proteins on the surface of cancer cells. Blinatumomab (Blincyto) is a monoclonal antibody used to treat B-cell types of ALL.

Stem cell transplantation

Stem cell transplantation (also known as a bone marrow transplant) is an infusion of healthy stem cells into the body. After a person receives high-dose chemotherapy to kill the cancer cells, a transplant can occur. The healthy cells can be collected from blood or bone marrow from the patient. It can also be collected from umbilical cord blood, a family member or another donor. An autologous stem cell transplant is a transplant of the patient’s own stem cells, from either the bone marrow or blood. In an allogeneic stem cell transplant, the stem cells come from a volunteer donor whose tissue type closely matches that of the patient. Because using the patient’s own stem cells could reintroduce leukemia cells, allogeneic stem cell transplants are the preferred type of stem cell transplants for people with ALL.

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