1. Acute lymphoblastic leukemia in children
Professor Hala Al-Rimawi
JUST & KAUH
2016

2. Objectives Over view of childhood leukemia
Discussion of a case of acute lymphoblastic leukemia
The common signs and symptoms of ALL
The methods of diagnosis of ALL
Outline the treatment of ALL

3. Over view
Acute leukemia is the most common form of childhood cancer, representing 32% of all cancers
ALL is most commonly originate from early stage of B lymphocytes (pre-B)
There are 2 type of lymphoblastic leukemia, B-cells and T-cells.
ALL (80%)
AML (20%)
What do we know about ALL?
Acute Leukemia is defined as uncontrolled proliferation of immature blood cells, which called blasts
The peak incidence occurs between 2-5 years of age

4. Case study
His physical examination revealed, pallor, multiple bruises and petechial rash were noticed on his face and extremities, spleen is enlarged 6 cm BCM, and has generalized lymphadenopathy.
The cardiac and chest examination were normal
Mohammad is 2.5 year old boy who presented with general weakness, bone pain and fever of 4 weeks duration.

5. Signs and Symptoms of ALL
As Lymphoblasts reproduce out of control, crowd out normal cells in the bone marrow
Decrease in red cells  anemia , pallor, lethargy, general weakness,
Decrease platelets  bleeding tendency, bruises petechial rash
Decrease neutrophils  recurrent infection , fever
Increased pressure inside Bone marrow by malignant cells  bone pain
It can go into peripheral bloodstream and invade any organ/tissue  enlarged lymph nodes, enlarged liver and spleen, mediastinal mass
Usually symptoms become clear after 2-4 weeks

6. Case study Mohammad Laboratory investigation showed
CBC: WBCs 50 X 109 /L , with neutrophils of 1%, platelets count of 16 X 109 /L , and a Hb of 7 gm/dl. And a suspicious cells is seen in peripheral smear (lymphoblast)
Bone marrow aspirate done
Confirm B-lineage ALL
Chest X ray no mediastinal mass
lumber puncture for spinal fluids showed presence of few lymphoblast

7. Diagnosis of ALL Complete blood counts (CBC)
Bone marrow examination
Morphology: confirm presence of blast cells (L1-L3)
Immune-phenotype: to define the type of cells
B cells: CD10+, CD19+, CD34 and CD20+. OR
T cells: CD2+, CD4+, CD5+, CD6+, CD7+ and CD8+
Cytogenetics: find any chromosomal abnormality, for prognosis
t(4,11), t(9,22) Ph. Chromosome  poor prognosis in ALL
t(12;21) in B-precursor ALL  favorable prognosis
Hyperdiploidy (54 to 58 chromosomes) good prognosis,
Complete blood counts (CBC)
Increased total number of WBCs (blasts) to more than 10 × 109/L with low numbers of normal white blood cells (neutropenia),
decrease in hemoglobin, decrease in platelets count
Blood film may show presence of abnormal cells (blasts)
Bone marrow sample ( aspirate and trephine) is needed
to confirm the diagnosis no
lumber puncture to examine spinal fluid for malignant cells
Chest x ray or CT: for mediastinal mass

8. We put central venous line to Mohammad which allow us to give chemotherapy , and we started intensive chemotherapy :

9. Treatment of ALL Induction phase : intensive chemotherapy :
aimed to destroy all malignant cells. 4-6 weeks by the end the BM will be clear for blast cells
Consolidation and CNS prophylaxis phase:
aimed to maintain the remission and preventing the spread of blasts into the brain and spinal cord, duration 8-12 weeks
Maintenance phase:
aimed to maintain the remission and eliminating any residual disease,
duration up to total (2 years for girls and 3 years for boys)
CNS radiotherapy
Bone marrow transplant
Cure rate in childhood ALL now > 80%