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ALL, also known as Acute Lymphocytic Leukaemia, is a type of blood cancer that starts from the lymphocytic white blood cells produced in the bone marrow. There is an overproduction of abnormal white blood cells, which crowds the bone marrow and prevents the production of normal blood cells. ALL can affect both children and adults. In adults, this is known as Adult ALL.
There are no proven causes for Adult ALL, but certain risk factors have been identified:
Adult ALL may cause a variety of symptoms, which are mainly the result of having insufficient normal blood cells in the body. Common symptoms of Adult ALL are:
A physical examination, blood test and bone marrow biopsy will help in confirming a diagnosis of adult ALL.
In the physical examination, the doctor will check for general signs of health, and look for swelling in the liver, spleen and lymph nodes, unusual bleeding or bruising, and signs of infection.
The blood test, called a full blood count, involves a sample of blood being sent to the laboratory for investigation. The blood sample will be checked for the number of red blood cells,white blood cells and platelets. A high proportion of white blood cells may indicate Adult ALL.
A bone marrow biopsy involves taking a sample of bone marrow, usually from the hip bone. This is done under local anaesthetic and takes 15 – 20 minutes. The sample will also be sent for investigation by the laboratory, to be examined for cancerous cells.
Further tests may be done to determine the extent of the Adult ALL and to help determine the best treatment options. Some of these tests are lumbar puncture (or spinal tap), genetic testing, and imaging tests (X-rays and scans).
For most cancers, staging or determining the stage of cancer is helpful in deciding on treatment options. Adult ALL, however, starts in the bone marrow and traditional solid cancer staging is not applicable, Adult ALL is classified into few subtypes and risk stratified based on genetic profile and response to initial treatment.
The French-American-British (FAB) classification classifies Adult ALL into three subtypes, L1, L2 and L3, based on the appearance of the cancerous cells when examined under the microscope.
The newer World Health Organization (WHO) classification divides Adult ALL into several groups:
There are two phases in treatment for Adult ALL: remission induction therapy and post-remission therapy. In remission induction therapy, the goal is to destroy all the cancer cells in the blood and bone marrow. In post-remission therapy, additional treatment is given to ensure any remaining but inactive cancer cells are destroyed, to prevent a relapse.
During both phases of therapy, an additional treatment called Central Nervous System (CNS) sanctuary prevention therapy is usually given. This consists of high-dose systemic chemotherapy, intrathecal chemotherapy (placed directly into the cerebrospinal fluid) and radiation therapy to the brain. CNS sanctuary therapy is given to destroy the cancer cells that may have ‘taken sanctuary’ in the CNS (the brain and spinal cord), where standard doses of chemotherapy may not have reached.
The standard treatments used in the two phases are chemotherapy, radiation therapy, chemotherapy with stem cell transplant and targeted therapy.
Chemotherapy uses drugs to destroy cancer cells or stop them from multiplying. Systemic chemotherapy refers to chemotherapy taken by mouth or injection, where the drugs reach cancer cells throughout the body via the bloodstream. Regional chemotherapy refers to chemotherapy that is placed directly into an organ or body cavity or into the cerebrospinal fluid, so that the drugs destroy mainly the cancer cells in that particular site.
In radiation therapy, high-energy X-rays are used to destroy cancer cells in the body. Radiation therapy, in combination with chemotherapy is often used during the stem cells transplant as conditioning regime for transplant.
Chemotherapy destroys the healthy blood-forming cells along with the cancer cells in the bone marrow while stem cells transplant replaces the blood-forming cells with donor cells. Stem cells from a donor will attack the residual leukaemia cells in ALL patients.
The doctor will assess the risks and benefits of a stem cell transplant based on the patient’s ALL genetic profile, response and medical history.
A new treatment called Chimeric Antigen Receptor T cells (CART) is a type of cell therapy which trains the patient’s T cell to recognise and attack the cancerous B cells. This therapy is promising and may change how stem cells transplant is being conducted in the future.
In targeted therapy, drugs or other substances target specific cancer cells to destroy or block their growth, while leaving normal cells unharmed. Currently in adult ALL, there are new small molecules and monoclonal antibodies available in clinical practice which, have shown to improve the survival of patients.
Although there is no known way to prevent Adult ALL, the following may lower the risk of developing it:
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