Understanding Acute Lymphoblastic  leukemia- Symptoms, Causes, and Treatment

Acute lymphoblastic leukemia is a rare but serious cancer affecting white blood cells. This type of cancer progresses rapidly and aggressively, requiring immediate treatment. 

This article will explore what acute lymphoblastic leukemia is, its symptoms, causes, and treatment options.

What is Acute Lymphoblastic Leukaemia?

Acute lymphoblastic leukemia is cancer that affects the white blood cells in the bone marrow. This type of cancer is also known as acute lymphocytic leukemia. Normally, the bone marrow produces stem cells that develop into red blood cells, white blood cells, and platelets. 

However, too many white blood cells are produced in acute lymphoblastic leukemia before they are fully developed. These immature white blood cells are known as blast cells. 

As a result, the number of red blood cells and platelets decreases, causing symptoms of anemia and an increased risk of excessive bleeding.

Symptoms of Acute Lymphoblastic Leukaemia

The symptoms of acute lymphoblastic leukemia vary from person to person. Some people may experience only a few of these symptoms, while others may experience several. 

The symptoms of acute lymphoblastic leukemia usually start slowly before rapidly becoming severe as the number of immature white blood cells in the blood increases. 

The most common symptoms of acute lymphoblastic leukemia include the following:

• Pale skin
• Feeling tired and breathless
• Repeated infections over a short time
• Unusual and frequent bleeding, such as bleeding gums or nosebleeds
• High temperature
• Night sweats
• Bone and joint pain
• Easily bruised skin
• Swollen lymph nodes (glands)
• Tummy (abdominal pain) – caused by a swollen liver or spleen
• Unintentional weight loss
• A purple skin rash (purpura)

The affected cells can sometimes spread from the bloodstream into the central nervous system. This can cause neurological symptoms such as headaches, seizures or fits, sickness, blurred vision, and dizziness. 

If you or your child has some or all of these symptoms, seeing a  doctor as soon as possible is important because any condition that causes these symptoms needs prompt investigation and treatment.

Causes of Acute Lymphoblastic Leukaemia

The exact cause of acute lymphoblastic leukemia is not yet fully understood. However, a genetic mutation in the stem cells causes immature white blood cells to be released into the bloodstream. 

Certain risk factors have been identified, including:

• Previous chemotherapy: If you have had chemotherapy to treat another type of cancer in the past, your risk of developing acute lymphoblastic leukemia is increased. The risk relates to certain types of chemotherapy medicine, such as etoposide, and how much treatment you had.
• Smoking is a known risk factor for acute lymphoblastic leukemia, especially in adults.
• Exposure to radiation: High radiation levels, such as those experienced during nuclear accidents or radiation therapy for cancer, can increase the risk of developing acute lymphoblastic leukemia.
• Genetic disorders: Certain genetic disorders, such as Down syndrome, increase the risk of developing acute lymphoblastic leukemia.

Acute lymphoblastic leukemia develops quickly, so treatment usually begins a few days after diagnosis.

Stages of treatment

Treatment for acute lymphoblastic leukemias is usually done in 3 stages.

Stage 1 is remission induction. Remission induction aims to kill the leukemia cells in your bone marrow, restore the balance of cells in your blood, and relieve your symptoms.

Stage 2 is consolidation. This aims to kill any remaining leukemia cells.

Stage 3 is maintenance. This involves taking regular doses of chemotherapy medicines to stop leukemia from coming back.

Remission induction

The remission induction stage of treatment is done in a hospital or specialist center.

You’ll probably need regular blood transfusions because your blood lacks enough healthy cells.

You’ll also be vulnerable to infection, so you must be in a sterile environment where your health can be carefully monitored, and any infections can be treated quickly.

Antibiotics may also be given to help prevent infection.

Chemotherapy

You’ll have chemotherapy to kill the leukemia cells in your bone marrow. The chemotherapy medicine used is called methotrexate.

Although this medicine comes as a tablet, you’ll also need it to be given as injections.

To make injections easier, you may have a flexible tube (a central line) put into a vein in your chest that gives you medicines.

You may also have chemotherapy medicine injected into the fluid surrounding and protecting your spine (cerebrospinal fluid) to kill any leukemia cells that may have spread to your nervous system and brain. This is given in a similar way to a lumbar puncture.

After an injection into your spine, you’ll have to lie flat for a few hours with your head slightly lower than your feet. You may have a headache or feel sick afterward.

Methotrexate is also given into a vein (intravenously) in adults with acute lymphoblastic leukemia after remission induction therapy and before consolidation.

Common side effects of chemotherapy include:

• feeling and being sick
• diarrhea
• loss of appetite
• mouth ulcers
• tiredness
• skin rashes
• infertility
• hair loss

The side effects should get better once treatment has finished.

Steroid therapy

You may also be given steroid (corticosteroid) injections or tablets to help improve the effectiveness of chemotherapy.

Targeted therapies

Suppose you have a type of leukemia called Philadelphia chromosome-positive acute lymphoblastic leukemia (which affects around 20 to 30% of people with acute lymphoblastic leukemia). In that case, you’ll also be given a medicine called imatinib.

Imatinib is a targeted therapy that blocks signals in the cancerous cells that cause them to grow and reproduce. This kills the cancerous cells.

Imatinib comes as a tablet. The side effects are usually mild and should improve over time.

They include:

• feeling or being sick
• swelling in the face and lower legs
• muscle cramps
• skin rash
• diarrhea

Depending on how well you respond to treatment, the remission induction phase can last from 2 weeks to several months.

Sometimes you can leave the hospital and receive treatment on an outpatient basis if your symptoms improve.

If other treatments do not work, your cancer comes back or you have a certain type of acute lymphoblastic leukemia, you may be given a different targeted therapy. The 2 alternative medicines used are:

• dasatinib
• ponatinib

These come as a table and cause similar side effects to imatinib.

Consolidation

Consolidation treatment aims to ensure that any remaining leukemia cells are killed. The consolidation phase involves regular injections of chemotherapy medicine.

This is usually done outpatient, so you will not have to stay in the hospital overnight.

But you may need short hospital stays if your symptoms suddenly worsen or you get an infection.

The consolidation phase lasts several months.

Maintenance

The maintenance phase is a further step to help ensure leukemia does not return. It involves taking regular doses of chemotherapy medicine while having regular check-ups to monitor your treatment.

The maintenance phase can often last for 2 years.

Other treatments

Other treatments and chemotherapy, steroids, and targeted therapies are sometimes used.

Radiotherapy

Radiotherapy is where high doses of controlled radiation are used to kill cancerous cells.

It’s usually used to treat acute lymphoblastic  leukemia when: 

• acute lymphoblastic  leukemia has spread to the nervous system or brain
• the body needs to be prepared for a bone marrow transplant

Side effects of radiotherapy include:

• hair loss
• feeling sick
• fatigue

These side effects should pass after your course of radiotherapy has finished.

Your skin may be very sensitive to the effects of light for several months after treatment. If this happens, avoid sunbathing or exposure to artificial sunlight, such as sunbeds, for several months.

Many young children treated with radiotherapy will have restricted physical growth during puberty.

A small number of people develop cataracts several years after having radiotherapy. Cataracts are cloudy patches in the transparent structure at the front of the eye (the lens) that can blur or misty your vision.

They can usually be successfully treated using cataract surgery.

Stem cell and bone marrow transplants

A stem cell and bone marrow transplant is an alternative treatment option if you do not respond to chemotherapy.

A transplant of bone marrow and stem cells is usually more successful if the donor has the same tissue type as you, so the ideal donor is usually a brother or sister.

Before a transplant can happen, the person receiving the transplant must have high-dose chemotherapy and radiotherapy to destroy any cancerous cells in the body.

This can put a big strain on the body, so transplants are usually only successful when they’re done in:

• children and young people
• older people who are in good health
• when there’s a suitable donor, such as a brother or sister

Recent research has shown that people over 40 can have a reduced-intensity stem cell transplant. 

This is where lower-than-normal doses of chemotherapy and radiotherapy are used before the transplant, which places less strain on the body.

Immunotherapy

Immunotherapy is a type of treatment where medicines are used to encourage the body’s immune system to target and kill cancerous cells.

Immunotherapy may be recommended if you do not respond to other treatments or cancer returns after other treatments.

There are 2 immunotherapy medicines used to treat acute lymphoblastic leukemia:

• blinatumomab
• inotuzumab ozogamicin

These medicines are given through a drip into a vein.

Side effects of immunotherapy include:

• flu-like symptoms, such as high temperature, chills, and muscle aches
• dizziness
• headaches
• bleeding
• feeling and being sick

Immunotherapy can also make you more vulnerable to infection. Talk to your care team for advice if you suddenly feel very unwell.

Clinical trials

In the UK, clinical trials are currently being done to find the best way to treat acute leukemia types.

These studies use new techniques to see how well they treat and possibly cure acute leukemia.

It’s important to be aware of new studies so you can choose which treatments to have.

But there’s no guarantee the techniques being studied in the clinical trial will be more effective than current treatments.

Your care team will be able to tell you whether there are any clinical trials available in your area and can explain the benefits and risks involved.

Complications

Having a weakened immune system (being immunocompromised) is a possible complication for some people with acute lymphoblastic leukemia.

A weakened immune system may be caused by a lack of healthy white blood cells, which means your immune system is less able to fight infection.

It can also be caused by many of the medicines used to treat acute lymphoblastic leukemia.

Having a weakened immune system makes you more vulnerable to infections. It also means that any infection you have is more likely to cause serious complications.

You may be advised to take regular doses of antibiotics to prevent infections.

Tell your care team or doctor immediately if you have any symptoms of infection because prompt treatment may be needed to prevent serious complications.

Symptoms of infection may include:

• high temperature
• headache
• aching muscles
• diarrhea
• tiredness

Avoid contact with anyone who has an infection, even if it’s a condition you were immune to in the past, such as chickenpox or measles. This is because your previous immunity to these conditions will probably be lower.

Going outside regularly for exercise and well-being is important, but you should avoid crowded places and use public transport during rush hour.

Also, make sure all your vaccinations are up to date. Your doctor or care team will be able to advise you about this.

You will not be able to have any vaccine containing “live” viruses or bacteria such as the:

• measles, mumps, and rubella (MMR) vaccine
• polio vaccine
• oral typhoid vaccine
• BCG vaccine (used to vaccinate against tuberculosis)
• yellow fever vaccine

Bleeding

If you have acute leukemia, you’ll bleed and bruise more easily because of your blood’s low levels of platelets (clot-forming cells).

Although heavy bleeding is uncommon, you need to be aware of the symptoms that can happen in different parts of the body.

Bleeding can happen:

• inside the skull (intracranial hemorrhage)
• inside the lungs (pulmonary hemorrhage)
• inside the stomach (gastrointestinal hemorrhage)

All 3 types of heavy bleeding (hemorrhage) are medical emergencies. Call 911 for an ambulance if you think your child has a heavy bleed.

Symptoms of an intracranial hemorrhage are:

• severe headache
• stiff neck
• being sick
• change in mental states, such as confusion

Common symptoms of a pulmonary hemorrhage are:

• coughing up blood from your nose and mouth
• breathing difficulties
• a bluish skin tone (cyanosis)

Common symptoms of a gastrointestinal hemorrhage are:

• vomiting blood
• poo that is very dark or tar-like

Infertility

Many of the medicines used to treat acute lymphoblastic leukemia can cause infertility.

People who are particularly at risk of becoming permanently infertile have received high doses of chemotherapy and radiotherapy in preparation for a stem cell and bone marrow transplant.

It may be possible to guard against any risk of infertility before you begin your treatment. 

For example, men can store sperm samples. Similarly, women can store fertilized embryos, which can be put into their wombs following treatment.

Psychological effects of leukemia

Diagnosing leukemia can be very distressing, particularly if a cure is unlikely. At first, the news may be difficult to take in.

It can be particularly difficult if you do not currently have any leukemia symptoms, but you know it could cause a serious problem later on. Waiting many years to see how leukemia develops can be very stressful and trigger feelings of anxiety and depression.

If you’ve been diagnosed with leukemia, talking to a counselor or a doctor who specializes in treating mental health conditions (psychiatrist) may help you combat feelings of depression and anxiety. Antidepressants or medicines that help reduce feelings of anxiety may also help you cope better.

Conclusion

Treatment of acute lymphoblastic leukemia typically involves several phases, including chemotherapy, targeted therapy, radiation therapy, and stem cell transplant. 

The treatment choice depends on the patient’s age, overall health, and the type of acute lymphoblastic leukemia they have.

Overall, the outlook for acute lymphoblastic leukemia varies depending on the patient’s age and overall health and the type of acute lymphoblastic leukemia they have. 

Treatment can be successful in many cases, but some patients may experience a disease recurrence. Regular follow-up care is important to monitor for any signs of relapse and to manage any long-term side effects of treatment.