Acute lymphocytic leukemia in adults

Many people are familiar with the term “blood cancer”, which is used to refer to leukemia. One sub-type of leukemia is acute lymphocytic leukemia (ALL).

ALL originates in the bone marrow, where blood cell production (known as hematopoiesis) occurs. ALL is caused by uncontrolled reproduction of immature white blood cells in the body. The medical term for these immature white blood cells is “lymphoblasts”. For this reason, acute lymphocytic leukemia is also known as acute lymphoblastic leukemia.

Lymphoblasts spread through the bone marrow, lymph nodes, spleen, and liver. They can affect other organs also.

ALL has various sub-types, all of which progress differently and are treated differently by doctors. ALL occurs most frequently in children and adolescents. The medication and doses used to treat these young patients differ to some extent from those used for adults.

As leukemia cells spread through the bone marrow, they disrupt the normal process of blood cell production. This triggers many typical symptoms of acute lymphocytic leukemia (ALL). At the same time, the greatly increased number of leukemia cells can damage various internal organs, as well as the brain and spinal cord.

The following symptoms may indicate ALL: 

• fatigue and lassitude
• pale skin
• bleeding skin and mucosal bleeding
• infections and fever
• swollen lymph nodes
• bone and limb pain
• abdominal pain
• headaches, visual impairments, vomiting

The severity of symptoms experienced with ALL differs from one patient to the next. However, the symptoms do not always indicate the presence of leukemia – many of these may also be due to conditions that are harmless by comparison.

The causes of acute lymphocytic leukemia (ALL) remain largely unknown. It is not usually possible to pinpoint the cause of leukemia in individual patients.

However, certain risk factors increase the likelihood of leukemia occurring. These include, for example, exposure to genetically harmful radioactive radiation/x-rays or substances that damage the bone marrow, such as benzene. Certain forms of chemotherapy can also increase the risk.

The symptoms of acute lymphocytic leukemia (ALL) usually develop very quickly, i.e. within a few weeks. The leukemia cells spread through the bone marrow and the body, damaging blood production and vital organs. If left untreated, this serious disease can cause death within a matter of months.

If it is suspected that a patient’s symptoms may be due to acute leukemia, the doctor will begin by testing the blood. If this points towards leukemia, a specialist in blood diseases and cancer (hematology and oncology) will test the bone marrow.

Doctors can determine, by means of a palpation examination and ultrasound, whether the liver, spleen, or lymph nodes are affected. In addition, various imaging techniques (scans) can provide information about other organs that could be affected by leukemia cells. Doctors use x-rays, magnetic resonance imaging (MRI), computed tomography (CT) scans, and/or nuclear medicine scans (skeletal scintigraphy) for this purpose.

The specialist will also take a sample of cerebrospinal fluid from the lumbar spine area and examine it to determine whether the brain and spinal cord are affected. This procedure is known as a lumbar puncture or spinal tap.

Detailed information about how scans are used in cancer diagnosis is available on the website of the Cancer Information Service of the German Cancer Research Center (in German).

For most patients with acute lymphocytic leukemia (ALL), treatment is intended to cure the disease by permanently eliminating the leukemia cells and restoring normal, healthy blood cell production.

The key component of treatment for ALL is chemotherapy. It is divided into a number of treatment phases, in which doctors use various medications in different combinations. In total, treatment takes about two and a half years.

Pre-phase therapy

The initial phase of ALL treatment consists of a mild course of chemotherapy. In the first few days, it begins to kill the leukemia cells gradually and on a modest scale.

Induction therapy

Pre-phase therapy is normally followed by an intensive course of chemotherapy, known as induction therapy. The goal is to kill most of the leukemia cells and restore normal blood cell production. If this phase is successful, experts refer to a full or complete remission.

Consolidation therapy

Therefore, the next phase consists of another intensive course of treatment. During this phase, a hematopoietic (blood) stem cell transplant with donor stem cells (allogenic transplant) may form part of the treatment. Doctors use this option for patients who are at a very high risk of relapse.

Maintenance therapy

Following consolidation, patients who have not received a transplant undergo another course of mild chemotherapy. This can usually be administered on an outpatient basis.

Other treatments

The side-effects of intensive chemotherapy may be severe if the patient does not also receive adequate supportive therapy. Measures to prevent or alleviate the side-effects of chemotherapy therefore play an important role in treating leukemia.

When ALL is diagnosed, leukemia cells may be detected in the brain and spinal cord, i.e. in the central nervous system (CNS). This means that the CNS also needs to be treated. For this purpose, doctors inject chemotherapy drugs directly into the patient’s cerebrospinal fluid at regular intervals. They may also use radiation therapy to treat the brain and cerebral membranes.

Radiotherapy may also be used if patients have a large tumor in the central part of the thoracic cavity, or as part of high-dose therapy for patients who receive a blood stem cell transplant.

Doctors also use targeted drug treatment in addition to chemotherapy for some ALL patients. These drugs attack specific characteristics of cancer cells.

For detailed information on the treatment of acute lymphocytic leukemia and its side-effects, see the website of the Cancer Information Service of the German Cancer Research Center (in German).

All of the intensive therapy used to treat ALL is usually very debilitating, both physically and mentally. It is frequently followed by medical rehabilitation (rehab) to help ease the patient’s return to daily life. Medical rehabilitation is intended to help them recover their strength and to cope as best they can with the effects of the disease and the treatment. Rehab programs are therefore based on patients’ personal medical history and physical limitations.

Medical rehab following treatment for leukemia may include:

• physiotherapy and sport
• psycho-social counseling and support
• nutrition advice

Patients with acute lymphocytic leukemia (ALL) normally receive very intensive treatment. Both the disease itself and the treatment can affect patients physically and psychologically. Some of these effects may only come to light as late complications after treatment has ended. There is also a risk of recurrence.

Aftercare for acute leukemia is intended to ensure early detection of any relapse and any long-term effects of treatment.

Regular consultations with doctors, physical examinations, and blood and bone marrow testing are the pillars of follow-up care. These tests will initially be performed very frequently. As more time passes since the disease was diagnosed and since treatment ended, the intervals between tests become increasingly long.

For general information about aftercare for cancer patients, see the website of the Cancer Information Service of the German Cancer Research Center (in German).

Everyday life will continue as normal for very few people who are diagnosed with leukemia. The rapid progression of acute lymphocytic leukemia (ALL) and the lengthy treatment as an in-patient and out-patient present a challenge and a burden both to the patients themselves and to their loved ones.

A patient’s quality of life can be significantly impacted by symptoms such as pain, tiredness, and physical limitations, combined with the strain of undergoing intensive treatment.

Psycho-social and psycho-oncological counseling by trained experts is often provided to patients while they are still in hospital. Other supports for patients and their families include psycho-social cancer counseling centers and registered psycho-oncologists.

Self-help organizations provide patients with important support in dealing with a range of issues and with information from other people in a similar situation.

On the website of the Cancer Information Service of the German Cancer Research Center, you can find addresses of cancer counseling centers, outpatient psycho-oncologists working in psychotherapy, and self-help organizations (in German).

Most people with acute lymphocytic leukemia (ALL) are treated in accordance with therapy plans that have been developed by experts in the field and are improved on an ongoing basis.

The German Multicenter Study Group for Adult Acute Lymphoblastic Leukemia provides valuable information (in German) on the diagnosis and treatment of ALL.

This study group is part of the Kompetenznetz Leukämie (the German competence network for leukemia).

The therapy protocols for children and adolescents with ALL differ from those for adults. The focus of rehab and aftercare also differs due to the young age of these patients.

Information about leukemia in children and adolescents is provided on the website of the German competence network for pediatric oncology and hematology – kinderkrebs.info.

ALL should be treated by a team of experienced doctors from a number of different specialties. Hospitals that are particularly experienced in the treatment of patients with leukemia can become certified as oncology centers specializing in “hematological neoplasms”. The German Cancer Society (DKG), in conjunction with the German Society for Hematology and Medical Oncology (DGHO), regularly checks these hospitals for compliance with certain requirements.

You can find the addresses of centers with this designation on the OncoMAP website. To do this, select “Hematological Neoplasms” in the search panel under “Centre”.