Acute Lymphoblastic Leukemia (2023)


  • 1 Definition/Description
  • 2 Etiology
  • 3 Epidemiology
  • 4 Characteristics/Clinical Presentation
  • 5 Associated Co-morbidities
  • 6 Medications
  • 7 Diagnostic Tests/Lab Tests/Lab Values
  • 8 Medical Management
  • 9 Physical Therapy Management
  • 10 Differential Diagnosis
  • 11 Case Reports/ Case Studies
  • 12 Resources
  • 13 References

Definition/Description[edit|edit source]

Acute Lymphoblastic Leukemia (1)

Acute lymphoblastic leukemia (ALL) is a cancer of thebloodand bone marrow. Bone marrow is spongy tissue that fills the cavity of the long bones consisting of fat, red blood cells, and white blood cells. ALL affects the immature white blood cells.

  • Acute leukemia accounts for up to 30% of all childhood malignancies.
  • ALL is the most common form of cancer in children. Repeated infection, bleeding, or fatigue/pallor not responding to treatment should raise the suspicion of ALL[1].

This type of cancer is classified by one of two subtypes.[2][3][4][5]

  1. B-cell- produce antibodies to fight infections.
    • Common ALL (50% of cases)
    • Early Pre-B ALL (10% of cases)
    • Pre-B ALL (10% of cases)
    • Mature B-cell ALL (4% of cases)
  2. T-cell- assist B-cells in producing antibodies to fight infections.
    • Pre-T ALL (5-10% of cases)
    • Mature T-cell (15-20% of cases)

Prognostic factors include:[6] [7]

  • Age: Younger patients have a better prognosis compared to older patients. The cure rate of children is approximately 80% and only 40% for adults.
  • Initial white blood cell (WBC) count: Patients diagnosed with a WBC count below 50,000 tend to do better than patients with higher WBC counts.
  • ALL subtype: The subtype of T cell or B cell affects prognosis. Patients with T-cell ALL tend to have a better prognosis than those with mature B-cell ALL.
  • Response to chemotherapy: Patients who achieve complete remission within 4 to 5 weeks of starting treatment tend to have a better prognosis. Patients who do not achieve remission at any time have a poor prognosis. Evidence of minimal presence of leukemia cells in the bone marrow may also positively affect prognosis.

Etiology[edit|edit source]

  • There is solid evidence that ALL has a genetic component.
  • This is evidenced by many distinct translocations associated with the disease and a higher prevalence of the disease in monozygotic twins.
  • ALL incidence has also been found to be higher in patients with immunodeficiency disorders such as Down syndrome, neurofibromatosis type 1, Bloom syndrome, and ataxia telangiectasia[1]

Epidemiology[edit|edit source]

  • Acute Lymphoblastic Leukemia (2)

    The estimated number of ALL new cases in the United States is approximately 6000 per year.
  • ALL is primarily a disease of children younger than 6 years with a slight male predominance.
  • About 85% of ALL cases are B-cell in origin, and 15% are T-cell in origin.
  • T-cell ALL is more common in male, African Americans and adolescents.
  • T-ALL accounts for approximately 25% of adults ALL[1].

Characteristics/Clinical Presentation[edit|edit source]

Most signs and symptoms of ALL mimic those of the flu. However, with all these signs and symptoms will not improve. Signs and symptoms include[2][4][5]:

  • Weight loss
  • Bleeding from the gums
  • Nosebleeds
  • Pale skin
  • Shortness of breath
  • Fever
  • Frequent infections
  • Weakness
  • Anemia:deficiency of red blood cells
  • Pallor: deficiency of color, especially in the face
  • Malaise: feeling of fatigue and discomfort
  • Hypoxia: oxygen deficiency
  • Hyperuricemia: abnormally high level or uric acid
  • Lymphadenopathy:abnormally enlarged lymph nodes[7]

Acute Lymphoblastic Leukemia (3)

Associated Co-morbidities[edit|edit source]

The following co-morbidities are linked to ALL[7][8]:

  • Anemia:a deficiency of red blood cells.
  • Diabetes:disorder characterized bydefects in the body's ability to produce or use insulin resulting in high blood glucose levels.
  • Lupus: a chronic autoimmune disease that effects many systems in the body.
  • Rheumatoid Arthritis: a chronic systemic inflammatory disorder.
  • Multiple Sclerosis: an autoimmune disease that attacks the central nervous system.

Acute Lymphoblastic Leukemia (4)

Medications[edit|edit source]

Medications involved with ALL include[9]:

  • Chemotherapy drugs: L-asparaginase, Vincristine
  • Steroid: Dexamethasone,Hydrocortisone
  • Drugs for high-risk patients: Daunorubicin,Cytarabine
  • Other drugs that may be given early: Methotrexate, 6-mercaptopurine.

Acute Lymphoblastic Leukemia (5)

Diagnostic Tests/Lab Tests/Lab Values[edit|edit source]

Diagnostic tests and results for ALL include[2][5]:

Blood test:These tests reveal increased number of white blood cells, decreased number of red blood cells (anemia)and platelets (thrombocytopenia). A blood test may also reveal blast cells. Blast cells are immature blood cells in bone marrow.

  • Red blood cells:These cells carry oxygen throughout the body. A low number of red blood cells can lead to feeling tired or weak, being short of breath and looking pale (anemia).
  • White blood cells:These cells fight infections. A low number of white blood cells can lead to fever and frequent infections that are hard to treat.
  • Platelets:Platelets control bleeding. A low number of platelets can lead to slow healing, easy bruising or bleeding and tiny red spots under the skin (petechiae).
  • Leukemia cells:An increased number of these cells can cause pain in the bones or joints, lack of appetite, headache or vomiting

Bone marrow test:A needle is used to remove a sample of bone marrow from the hipbone to look for cancerous cells. Through this process, doctors can determine if the cells originated from the B lymphocytes or T lymphocytes according to certain changes in the cancer cells.

Lumbar puncture or spinal tap:A sample of spinal fluid is collected to determine if the cancerous cells have spread.

Imaging:X-ray and computerized tomography (CT) scan can help determine if the cancer has spread to other parts of the body.

Medical Management[edit|edit source]

Treatment for ALL can span from 2 ½ to 3 ½ years depending on each individual situation. General treatment for ALL is broken down into the following 4 phases[2][4][5][9]:

  1. Induction therapy:The purpose of this phase is to achieve remission by killing most of the cancer cells in the blood and bone marrow. During the first month, the patient may require many doctor's visits due to increase risk of infections.Patients often receive 3 drugs for the first month of treatment which include:
    • Chemotherapy drugs injected intrathecally
    • Steroids
    • A fourth drug in the anthracycline class is typically added for high-risk patients.
  2. Consolidation therapy/ Post- remission therapy:During this more intensive phase, the goal is to destroy any remaining leukemia cells in the central nervous system. This phase of chemotherapy lasts typically 4 to 8 weeks. Intrathecal therapy is continued during this phase.
  3. Maintenance therapy:This low dose treatment is given to prevent cancer cell re-growth.During the first few months of this phase, most treatments include 1 to 2 treatments similar to the initial induction. These 4 week intense treatments are called re-induction.
  4. Preventive treatment to the spinal cord:Some cancer cells in the central nervous system can not be destroyed by chemotherapy drugs given by oral or intravenous means. During this phase, chemotherapy drugs are injected directly into the spinal cord fluid.

During these4 phasesthe specific types of treatments include:

Chemotherapy:Chemotherapy is normally used in the induction therapy stage to kill the cancer cells. This drug can also be used in the consolidation and maintenance phases. All patients need spinal taps to inject chemotherapy into the cerebrospinal fluid (CSF) to kill any leukemia cells that may have spread to the brain and spinal cord. This intrathecal chemotherapy is usually given twice during the first month and four to six times during the next one to two months. It is repeated less often during the rest of consolidation and maintenance. A possible side effect of intrathecal chemotherapy is epileptic seizures during treatment.

Chemotherapy can be received several ways:[10]

  • Orally
  • Intravenous injections
  • Catheter placement involving a tube placed in a large vein for patients that require many IV treatments
  • Intrathecal injections into the cerebral spinal fluid or through a catheter placed under the scalp

Targeted drug therapy:These drugs attack specific abnormalities that cause the cancer cell growth.

Radiation therapy:This treatment uses high-powered beams to destroy cancer cells. This is typically used when the cancer has spread to the central nervous system. Along with intrathecal chemotherapy, high-risk patients and those with leukemia cells detected in their CSF may be given radiation therapy to the brain and spinal cord. Doctors try to avoid this treatment if possible, especially in younger children, because it may cause problems in growth and development.

Stem cell transplant:This transplant may be used for patients at risk or currently going through a relapse. This procedure replaces cancer bone marrow through chemotherapy or radiation with healthy bone marrow from a compatible donor allowing re-establishment of healthy stem cells.

Physical Therapy Management[edit|edit source]

Therapy is determined on an individual basis depending on clinical presentation and response to medical intervention.[7]

Suggested Physiotherapy Interventions[11]

Area of FocusInterventionFrequency

Assistive Device
Neuropathic pain
Physician prescribed medication

As needed

Therapeutic exercise
Functional Activity

3-5 days a week

Continuous passive motion machine
Splinting, bracing, orthotic
Manual stretch, self stretching

1-5 times a week

Stair stepper

5 times a week
Manual Techniques

Manual guidance
Neurodevelopmental treatment
Self directed

As needed
Motor learning principles

Knowledge of performance
Knowledge of results
Blocked practice
Random practice

As needed

Precautions should be taken for:[7]

  • Thrombocytopenia: low number of platelet
  • Neutropenia: low number of neutrophils (WBC)
  • Infection control: signs of infection include mucosal ulceration, skin abrasion, or other tears
  • Anemia
  • Medication side effect
  • Drug induced mood changes

See alsoOncology Physiotherapy Management

Differential Diagnosis[edit|edit source]

The following are possible differential diagnosis for ALL:

Case Reports/ Case Studies[edit|edit source]

  1. Gohar SF, Marchese V, Comito M.Physician referral frequency for physical therapy in children with acute lymphoblastic leukemia. Pediatr Hemotol Oncol. 2010; 27: 179-87.
  2. Marchese VG, Chiarello LA, Lange BJ.Effects of physical therapy intervention for children with acute lymphoblastic leukemia.Pediatr Blood Cancer. 2004; 42: 127-33.
  3. Tecklin J.S.Pediatric Physical Therapy. Lippincott, Williams and Wilkins. Baltimore, Maryland. Fourth Edition. 2008:551-552.

Resources[edit|edit source]

References[edit|edit source]

  1. 1.0 1.1 1.2 Kaseb H, Gupta G. Cancer, Lymphoblastic Lymphoma. InStatPearls [Internet] 2019 Jun 26. StatPearls Publishing.Available from; accessed 15.7.2020)
  2. 2.0 2.1 2.2 2.3 Mayo Clinic. Acute Lymphoblastic Leukemia. 2010. Available at: Accessed March 7, 2011.
  3. American Cancer Society. Leukemia—Acute Lymphocytic Overview. 2010. Available at: Accessed March 7, 2011.
  4. 4.0 4.1 4.2 National Marrow Donor Program. Acute Lymphblastic Leukemia. 2011. Available at: Accessed March 7, 2011.
  5. 5.0 5.1 5.2 5.3 The Chicago University Medical Center. Adult Acute Lymphoblastic Leukemia Treatment. 2011. Available at: Accessed March 7, 2011.
  6. University of Maryland Medical Center. Acute Lymphocytic Leukemia- Prognosis. 2011. Available at: Accessed March 7, 2011.
  7. 7.0 7.1 7.2 7.3 7.4 Goodman, C., Boissonault, W. Pathology: Implications for the Physical Therapist. Saunders. Philadelphia, Pennsylvania. Third edition. 2009.
  8. Goodman C, Snyder T. Differential Diagnosis for Physical Therapists: Screening for referral. Saunders, St. Louis, Missouri. Fourth Edition. 2007.
  9. 9.0 9.1 American Cancer Society. Treatment of Children with Acute Lymphocytic Leukemia. 2011. Available at: Accessed March 7, 2011.
  10. MedicineNet. Leukemia. 2011. Available at: Accessed April 5, 2011.
  11. Tecklin J.S. Pediatric Physical Therapy. Lippincott, Williams and Wilkins. Baltimore, Maryland. Fourth Edition. 2008.


What is the survival rate for acute lymphoblastic leukemia? ›

While acute lymphoblastic leukemia in children is more common than other types of cancer, it has high cure rates. Survival rates are lower in adults, but they are improving. The 5-year relative survival rate for ALL is 68.8%. The statistics further break down to 90% in children and 30-40% in adults.

Is acute lymphoblastic leukemia serious? ›

Acute lymphocytic leukemia (ALL) is also called acute lymphoblastic leukemia. “Acute” means that the leukemia can progress quickly, and if not treated, would probably be fatal within a few months.

What is acute lymphoblastic leukemia caused by? ›

Acute lymphoblastic leukaemia is caused by a DNA mutation in the stem cells causing too many white blood cells to be produced. The white blood cells are also released from the bone marrow before they are mature and able to fight infection like fully developed white blood cells.

What is the acute lymphoblastic leukemia? ›

A type of leukemia (blood cancer) that comes on quickly and is fast growing. In acute lymphoblastic leukemia, there are too many lymphoblasts (immature white blood cells) in the blood and bone marrow. Also called acute lymphocytic leukemia and ALL.

What is the life expectancy of someone with ALL leukemia? ›

Life expectancy will depend on a person's age, the type of leukemia, and other factors. For children with acute lymphocytic leukemia (ALL), the 5-year survival rate is now around 90%, according to the American Cancer Society. For other types, however, the chance of living 5 years or more with leukemia may be lower .

Can you live a long life with ALL leukemia? ›

almost 90 out of 100 (almost 90%) will survive their leukaemia for 5 years or more after diagnosis.

Who is most at risk for acute lymphoblastic leukemia? ›

ALL is usually diagnosed in children, with children under five years old at highest risk for the disease. Adults can develop ALL (also called acute lymphocytic leukemia), with boys and men at slightly higher risk than girls and women.

Who normally gets acute lymphoblastic leukemia? ›

The average person's lifetime risk of getting ALL is about 1 in 1,000. The risk is slightly higher in males than in females, and higher in White people than in African Americans. Most cases of ALL occur in children, but most deaths from ALL (about 4 out of 5) occur in adults.

Is acute leukemia a terminal illness? ›

Although AML is a serious disease, it is treatable and often curable with chemotherapy with or without a bone marrow/stem cell transplant (see the Types of Treatment section).

How fast does acute lymphoblastic leukemia spread? ›

ALL usually develops quickly over days or weeks. It is the most common type of leukaemia to affect children but can also affect adults.

Where does acute lymphoblastic leukemia start? ›

Acute lymphoblastic leukaemia (ALL) is a type of blood cancer that starts from white blood cells called lymphocytes in the bone marrow. Adults and children can get it but it is most often diagnosed in younger people. Chemotherapy is the main treatment.

What are the stages of acute lymphoblastic leukemia? ›

The phases of ALL:
  • Untreated ALL.
  • ALL in remission (after treatment, you have no signs or symptoms of leukemia)
  • Minimal residual disease (ALL appears to be in remission, but tests find a few leukemia cells in your bone marrow)
  • Refractory ALL (the leukemia is not responding to treatment)

How is acute lymphoblastic leukemia cured? ›

The main treatment for acute lymphoblastic leukaemia (ALL) is chemotherapy. But depending on your subtype of ALL you might have another treatment. This might include a targeted cancer drug, immunotherapy, or a stem cell or bone marrow transplant. Some people might have their treatment as part of a clinical trial.

What is end stage lymphoblastic leukemia? ›

End stage leukemia has signs and symptoms that show the person is in the final days of life: Slow breathing with long pauses; noisy breathing with congestion. Cool skin that may turn a bluish, dusky color, especially in the hands and feet. Dryness of mouth and lips.

What are acute lymphoblastic leukemia survivors at risk of? ›

Children who have been treated for leukemia are often at higher risk of developing other cancers later in life. One of the most serious possible side effects of acute lymphocytic leukemia (ALL) therapy is a small risk of getting acute myeloid leukemia (AML) later on.

What is the most survivable leukemia? ›

Chronic lymphocytic leukemia (CLL) 5-year survival rate is 88%. Acute lymphocytic leukemia (ALL) 5-year survival rate is 71.3%. Chronic myeloid leukemia (CML) 5-year survival rate is 70.6%. Acute myeloid leukemia (AML) 5-year survival rate is 31.7%.

What is the most curable leukemia? ›

Treatment for patients with acute promyelocytic leukemia (APL) differs from treatment for patients with other AML subtypes. Because of advances in diagnosis and treatment of this disease, APL is now considered the most curable form of adult leukemia.

How fast does acute lymphoblastic leukemia progress? ›

ALL usually develops quickly over days or weeks. It is the most common type of leukaemia to affect children but can also affect adults.


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