Acute lymphoblastic leukemia (ALL) is the most common childhood cancer and represents 80% of pediatric leukemia cases. ALL results from a maturation arrest in lymphoid progenitor cells causing sustained self-renewal over differentiation. Common presentations of ALL include neutropenia, thrombocytopenia, anemia, lymphadenopathy, hepatosplenomegaly, and occasionally mediastinal or testicular masses. Treatment involves remission induction chemotherapy for 4-6 weeks, intensification for 6 months, and 2 years of maintenance therapy. Prognosis is favorable in younger patients (<35 years old) with standard-risk features such as B-cell phenotype and normal white blood cell count, while older age and high

2.  Commonest form of malignancy in
childhood
 Represent 80% of pediatric leukemia
 Only 20% of adult acute leukemia
 Acute onset with short history of duration.

3.  Increase incidence in:
Radiation exposure and toxic
chemicals
Down syndrome
Obesity

4. ALL AML
CMLCLL
AGE
YOUNG
Elderly

5. Acute Leukemia
results from
a Maturation Arrest
Causing Sustained
SELF-RENEWAL
AT THE EXPENSE OF
DIFFERENTIATION

6. HEMOPOIESIS
MYELOID/ LYMPHOID
STEM CELLS
(CD34)
LYMPHOID
STEM CELLS
Pre-T
Thymocyte
Peripheral T
Cells
T-
Helper
T-
Supp.
Pro-B
Pre-B
B- Mature
LPC
PLASMA
CELL

7. HEMOPOIESIS
MYELOID/ LYMPHOID
STEM CELLS
(CD34)
LYMPHOID
STEM CELLS
Pre-T
Thymocyte
Peripheral T Cells
T-
Helper
T-
Supp.
Pro-B
Pre-B
B- Mature
LPC
PLASMA
CELL
ALL
CLL

8. What are common presentation in
ALL?
Ineffective hematopoiesis due to the
excessive proliferation of lymphoid
precursor cells in bone marrow:
 Neutropenia – fever, chills
Thrombocytopenia – bleeding, bruising
Anemia – weakness, fatigue

9.  LAP , HSM
 Sternal tenderness
 Mediastenal mass presented in 15%
of adult ALL
 Testicular swelling
 Retinal involvement
 CNS and meningeal involvement 5%

11. DIFFERENTIAL DIAGNOSIS
 Leukemic phase of Non Hodgkin's
Lymphoma
 Reactive lymphocytosis due to infections
(EBV ,pertussis)
 Metastatic tumors in bone marrow
 ITP
 AML

12. Diagnostic work up
 History & examination
 Peripheral Blood smear and peripheral
blood cytometry
 Bone marrow aspiration & biopsy
 PT , PTT , D- dimer fibrinogen
 LDH , uric acid , electrolyte
 CT / MRI of head if neurologic
symptoms
 CT chest (T-ALL)
 Echocardiogram to assess cardiac

14. How does ALL classified?
FAB
WHO
IMMUNOPHENOTYPIC

15. FAB classification (morphological)
 ALL L1
 ALL L2
 ALL L3 (Burkitts type)
 In childhood – L1 is the most common
type
 In adults – L2 is the most common
type

16. FAB 1
Lymphoblasts: Small &
Monomorphic

17. FAB 2
Lymphoblasts: Large &
Heterogeneous

18. FAB 3
Large varied cells with
vacuoles

19. WHO classification of ALL (2008)
1-B lymphoblastic leukemia/lymphoma nos
2- B lymphoblastic leukemia/lymphoma with
recurrent abnormalities
 t( 9; 22) , BCR ABL1
 t( v; 11q23) MLL rearrangement
 t (12;21) ETV6-RUNX1
 With hypodiploidy
 With hyperdiploidy
 t (5;14) il3 –igh
 t ( 1;19) E2A-PBX1 (tcf3-pbx1)
3-T lymphoblastic leukemia/lymphoma

20. Immunophenotyping (flow
cytometry)
According to the lymphoid cell involved:
B-cell ALL (85%)
• Early pre-B ALL (pro-B ALL) - 10%
• common ALL - 50%
• pre-B ALL - 10%
• mature B-cell ALL (Burkitt leukemia) - 4%
T-cell ALL (15%)
• pre-T ALL - 5% to 10%
• mature T-cell ALL - 15% to 20%

21. Treatment of ALL

22. Remission induction
4-6 weeks
Intensification
6 months
Maintenance therapy
2 years

24. Q:Why we give CNS
prophylaxis?
 Because CNS is a sanctuary area for
leukemia cells and without
chemotherapy the risk of relapse is
about 30%.
Q: Dexamethasone has replaced
prednisone in ALL induction therapy
because improve penetration to:
A. Testes
B. Spleen
C. Bone marrow
D. Brain

25.  Q: which of the following targeted agents
have been shown to be beneficial in adult
ALL?
A. Imatinib
B. Alemtuzumab
C. Gemtuzumab
D. Sunitinib

26. Questions?????
 Does my patients cure?
 There is possibility of relapse?
 Does my patient need bone marrow
transplant? And at which time?

27. What Minimal Residual Disease
MRD means?
 Its assess response to chemotherapy
 Can identify VERY LOW number of leukemic
cells (1:10000)
 It can be done either by flow cytometry or
RT-PCR analysis
 It’s the most important predictor factor of
relapse
 Its done after completion of initial treatment

28. Timing of bone marrow
transplant
 Primary induction failure and relapse
 Presence of MRD after initial
treatment
 After second complete remission
 High resolution HLA donor is
recommended at diagnosis for all
patients

29. Prognosis
favorableunfavorable
≤ 35 y>35 yAge
≤ 30 ,000 /mm>30,000 /mmWhite blood cell
otherB-cell precursorImmunophenotype
othert(9;22)
t(4;11)
t(1;19)
Cytogenetics
< 4 weeks> 4 weeksTime to complete
response

30. Survival
Children
• CR 97%
• At 5 years DFS >75%
Adult
• CR 75-90%
• 5 –years DFS 25-50%