Acute Lymphoblastic Leukemia

What is acute lymphoblastic leukemia (ALL)?

Leukemia is cancer of the blood. It starts in the bone marrow – the soft center part of bones where blood cells are made.

The most common type of cancer in children is acute lymphoblastic leukemia (uh-KYOOT LIM-foh-BLAS-tik loo-KEE-mee-uh), or ALL. It is also called acute lymphocytic leukemia.

ALL grows from early forms of white blood cells called lymphocytes. In ALL these lymphocytes do not mature. They crowd out healthy blood cells needed to fight infection, carry oxygen and make blood clot.  

Doctors do not know what causes the changes in cells that lead to ALL. There is no known way to prevent it. In most children, leukemia grows fast and gets worse quickly without treatment. This is called acute.

Acute Lymphoblastic Leukemia at Seattle Children’s

To have the best chance of a cure, your child needs care from top experts experienced in treating ALL in children and young adults. Our Leukemia and Lymphoma Program team treats more children with ALL than any other hospital in the region. Our doctors are world leaders in improving care and cure rates for young people with leukemia. We are experienced with all treatment options for ALL and lead research to improve outcomes and quality of life.

If you would like an appointment, ask your primary care provider to refer you to Seattle Children’s Cancer and Blood Disorders Center.

If you have a referral or would like a second opinion, contact the center at 206-987-2106 or by email.

Providers, see how to refer a patient.

  • Among the nation’s best cancer programs
    • Your child will benefit from the work of physician-scientists at Fred Hutchinson Cancer Center and UW Medicine, as well as at Seattle Children’s. The National Cancer Institute has named our partnership a comprehensive cancer center.
    • Most children are cured of ALL with standard treatments. But in about 15% of children, ALL does not respond to treatment (refractory) or comes back (relapsed). If that is the case for your child, they will be treated by our team of experts in high-risk leukemia research, diagnostics and treatment.
  • Advanced diagnostics and personalized medicine
    • In addition to standard diagnostics, our team uses state-of-the-art tests like molecular profiling and next-generation sequencing (NGS). We examine your child's cancer cells for certain proteins that can serve as targets for treatment and starting points for the design of new drugs.
    • These tests help us find what is different about your child’s leukemia and identify the best treatment options for them. Whenever possible, we use results from NGS to match your child with therapies that target their specific cancer. This approach is called precision (or personalized) medicine. These therapies could be medicines already approved for another disease or clinical trials of new treatments.
    • In addition to targeted therapies, we offer advanced treatment options such as new mixes of chemotherapy, immunotherapy, radiation therapy and stem cell transplants.
    • For children who need stem cell transplants, we work closely with Fred Hutch, whose doctors pioneered this lifesaving treatment. Our team works with your family through the whole process – preparing for transplant, doing the transplant here at Seattle Children’s and caring for your child as they recover.
  • Complete care from birth to young adulthood
    • Our specialty is treating children’s cancer while helping them grow up to be healthy and productive adults. We take care of your child from diagnosis through all phases of treatment and follow-up survivor care.
    • Our team cares for your whole child. We don’t just treat their disease. As needed, your child will receive care from specialists in nutrition, pain management, pharmacy, palliative care, physical therapy and emotional health. Read more about the supportive care we offer.
    • Children do not react to illness, injury, pain and medicine in the same way as adults. They need – and deserve – care designed just for them. Our experts focus on how treatments today affect growing bodies in the future. We plan your child’s treatment based on our years of experience and the newest research on what is best and safest for children.
    • We know that teens and young adults with cancer have different challenges than young children. Our Adolescent and Young Adult Cancer Program focuses on their needs, which may include fertility preservation.
    • People who have been cured of cancer may be affected for months or years by their disease or treatment. Our Cancer Survivor Program provides long-term follow-up care to help children and young adults stay healthy after being treated for cancer in childhood.
  • Support for your whole family
    • Learning that your child has leukemia can be scary. We help take positive steps right away by offering appointments in 1 to 3 days to children suspected to have cancer.
    • During visits, we take time to explain your child’s condition. We help you fully understand treatment options and make the choices that are right for your family.
    • Our child life specialists and social workers help your child and your family through the challenges of cancer. We connect you to community resources and support groups.
    • We work with children and families from around the Northwest and beyond. Whether you live nearby or far away, we can help with financial counseling, schooling, housing, transportation, interpreter services and spiritual care. Read about our services for patients and families.
  • Research to improve care and cure rates

Symptoms of Acute Lymphoblastic Leukemia

Symptoms of ALL tend to appear over a matter of days or weeks and get worse quickly. Many of the signs and symptoms of ALL happen because cancer cells crowd out healthy blood cells or build up in the lymph nodes or other parts of the body.

These symptoms may be caused by ALL or by another health problem. Check with a doctor if your child has:

  • Fever, which may be a sign of infection
  • Easy bruising or bleeding, even from small injuries
  • Weakness, tiredness or feeling dizzy
  • Pinpoint spots of blood under the skin caused by tiny broken blood vessels
  • Bone or joint pain
  • Painless lumps in the neck, underarm, stomach, groin and around the eyes
  • Pain and fullness under the ribs
  • Loss of appetite
  • Shortness of breath or coughing
  • Headaches or problems with vision, balance or muscle control

Diagnosing Acute Lymphoblastic Leukemia

To find out whether your child has ALL, the doctor will:

  • Do an exam to check your child’s general health
  • Ask about your child’s health and family health history
  • Test your child’s blood to tell if any blood cells are unhealthy and, if so, which type
  • Do a bone marrow aspiration or biopsy

If your child has ALL, we use next-generation sequencing to find what’s different about their leukemia. Doctors may do other tests to learn more about the unhealthy cells and help tell which subtype of leukemia your child has.

Leukemia cells almost always spread quickly from the bone marrow to the blood. They travel through the bloodstream. These tests help tell if leukemia cells have started to collect in other areas of the body:

  • Lumbar puncture
  • Biopsy
  • Chest X-ray
  • ALL subtypes

    ALL can come from 2 different cell types. The subtype of leukemia depends on which of these cell types is involved:

    • T lymphoblasts (subtype T-ALL).
    • B lymphoblasts (subtype B-ALL). This type is more common.

    Your child’s treatment will depend in part on the subtype and if cancer cells are found in their spinal fluid. 

  • ALL risk levels

    Leukemia is not “staged” the way most cancers are. Instead of stages, doctors use risk levels. For B-ALL, the following risk groups are used.

    Standard risk applies to children ages 1 through 9 years with white blood cell count less than 50,000 per cubic millimeter when their cancer is diagnosed.

    High risk if any of these applies:

    • A child is 10 years or older
    • White blood cell count is 50,000 or more

    Infant ALL applies to children under 1 year when they are diagnosed. Infant ALL is its own risk category.

    If your child’s team finds their leukemia is not responding well to standard therapies, they will get advanced care from our High-Risk Leukemia Program.

Treating Acute Lymphoblastic Leukemia

Our goal is to give your child the best chance of a long and healthy life. Your child’s healthcare team works with you to cure your child’s disease, prevent serious side effects, support your family during treatment and provide follow-up care.

For most children, treatment lasts 2 ½ to 3 ½ years and is most intense in the first 6 months.

We will recommend treatment for your child’s ALL based on:

  • Your child’s age
  • White blood cell count
  • The subtype (if it affects T cells or B cells)
  • Features of the cancer cells, such as chromosome changes
  • How your child’s cancer responds to treatment
  • Your child’s overall health
  • Your family’s preferences

We treat your child’s ALL as well as problems like infection, bleeding or anemia caused by low levels of healthy blood cells. We provide many types of supportive care to ease your child’s symptoms and side effects. As needed, specialists in nutrition, pain management, pharmacy, palliative care and emotional health will help care for your child and family. 

  • Phases of treating ALL

    We treat ALL in phases using many different anticancer medicines (chemotherapy). In the first phase (induction), your child gets chemotherapy to kill cancer cells. For most children with ALL, this phase takes about 1 month.

    During this time doctors learn more about your child’s leukemia and how it responds to treatment. If no ALL cells are found in tests at the end of this phase, your child is in remission. This is different from being cured. Your child still needs more treatment so the disease does not come back.

    For about 6 more months, your child will get chemotherapy to kill any cancer cells that remain and to prevent cancer from spreading. The timing and medicines depend on your child’s disease. They may take medicines by mouth or by injection into a muscle, under the skin, into a vein or into the fluid around their spinal cord.

    During the next 2 to 3 years (maintenance phase), your child will get smaller amounts of medicines to kill any cancer cells that might be left.

    • Most of the time, they will take a chemotherapy medicine by mouth each day.
    • Every 1 to 3 months, they will visit the clinic to get medicine through their vein (IV).
    • Every 3 months they will get a medicine injected into their spinal fluid.

    We have arranged with doctors in some communities so children can get this phase of chemotherapy closer to home if they do not live near Seattle.

    If your child’s ALL does not respond to treatment or comes back, experts in our High-Risk Leukemia Program will care for them.

  • Chemotherapy

    Chemotherapy means giving medicines that go throughout your child’s body to kill cancer cells. Most children with ALL get chemotherapy for 2 ½ to 3 ½ years. The first 6 to 8 months are very intense. Expert nurses and doctors will adjust your child’s treatment or supportive care based on how your child is doing.

    Our patients get chemotherapy at our hospital campus in Seattle. As much as possible, we will treat your child at our outpatient clinic. But at times they will stay overnight in our hospital’s Cancer and Blood Disorders Center - Inpatient.

    See more about getting chemotherapy at Seattle Children’s.

  • Stem cell transplant

    For some children with ALL, treatment includes a transplant of hematopoietic (him-at-oh-poy-EH-tik) stem cells. These are young cells that grow into different types of blood cells. Doctors may suggest your child have a stem cell transplant if:

    • They are younger than 1 year.
    • Their leukemia has very high-risk features that indicate it will be difficult to cure with chemotherapy alone.
    • Their cancer does not respond to treatment.
    • Their cancer comes back.

    We do the transplants here at Seattle Children's, working closely with our partner Fred Hutch. Fred Hutch is one of the largest stem cell transplant centers in the world.

    Learn more about the Pediatric Blood and Marrow Transplant Program.

  • Targeted therapies

    New targeted therapies have been created for some types of ALL. These new medicines target the specific genes and proteins involved in the growth and survival of cancer cells. An example is tyrosine kinase inhibitors (TKIs) that stop stem cells from turning into ALL cells. TKIs are used to treat a rare type of ALL that has an abnormal chromosome (“Philadelphia chromosome”) in its cells.

    Most often, targeted therapy is given along with chemotherapy.

  • Clinical trials, including immunotherapy

    Many children with ALL take part in research studies along with their other medical treatment. We offer many clinical trials through our membership in the Children's Oncology Group, a global group of researchers focused on improving treatments and cure rates for childhood cancers.

    Your child’s doctor will talk with you about any new options that might help your child. Then you can decide if you want to take part. It is always your choice.

    Learn more about cancer clinical trials at Seattle Children’s

Follow-up Care

Follow-up care is important after treatment ends. The follow-up routine will depend on your child’s type of ALL and their treatments. Your doctor will let you know the schedule that is right for your child.

During follow-up visits we check your child for:

  • Any signs that their cancer is returning
  • Effects that may happen months or years after treatment.

Our Cancer Survivor Program provides long-term follow-up care to help young people stay healthy after being treated for cancer in childhood.

Contact Us 

If you would like an appointment, ask your child’s primary care provider to refer you.

If you have a referral or would like a second opinion, contact the Cancer and Blood Disorders Center at 206-987-2106 or by email.

Providers, see how to refer a patient.

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