Acute lymphocytic leukemia is a cancer of immature lymphocytes (lymphoblasts) that crowd out the normal bone marrow, and it is the most common cancer in children, peaking at ages 2 to 5. Most children are cured with modern chemotherapy, while adults have a harder course.
Key symptoms
- Fatigue and pale skin
- Fever and frequent infections
- Easy bruising, nosebleeds and tiny red spots (petechiae)
- Bone or joint pain; a child who refuses to walk
- Swollen glands or a full belly
What you find on exam
- Pallor, petechiae and bruises
- Enlarged lymph nodes
- Enlarged liver and spleen
- Testicular swelling in boys; signs of a chest mass such as breathlessness or facial swelling
Tests
- Blood count with smear: blasts, low hemoglobin and platelets; white count low, normal or very high
- Bone marrow aspirate and biopsy with flow cytometry and genetic tests
- Tumor lysis labs: potassium, phosphate, calcium, uric acid, creatinine and LDH
- Lumbar puncture for spread to the brain; chest X-ray for a mediastinal mass
Treatment basics
- Multi-drug chemotherapy in phases: induction, consolidation and maintenance over about 2 to 3 years
- Central nervous system therapy with intrathecal methotrexate
- Prevent tumor lysis with IV fluids and allopurinol or rasburicase
- Philadelphia chromosome positive: add a tyrosine kinase inhibitor such as imatinib or dasatinib
- Relapse: blinatumomab, CAR T-cell therapy or stem cell transplant
Red flags
- Fever with low neutrophils (neutropenic fever)
- Breathing trouble or facial swelling from a chest mass
- Signs of tumor lysis: high potassium, kidney failure or arrhythmia
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.