Acute Lymphoblastic Leukemia

What is acute lymphoblastic leukemia?

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 leukemia in children is acute lymphoblastic leukemia (pronounced uh-KYOOT LIM-foh-BLAS-tik loo-KEE-mee-uh). It is also the most common of all childhood cancers.

Acute lymphoblastic leukemia (ALL) grows from early forms of white blood cells called lymphocytes. In ALL these lymphocytes do not mature. They cannot fight infection as they normally would. ALL is also called acute lymphocytic leukemia.

The cancer cells crowd out the 3 types of healthy blood cells:

  • White blood cells that fight infection
  • Red blood cells that carry oxygen
  • Platelets that make the blood clot to stop bleeding

There are 2 types of lymphocytes: B cells and T cells. Cancer most often affects B cells.

Almost all children who have leukemia have an acute form. Another acute type is acute myeloid leukemia (AML). Acute leukemia grows fast and gets worse quickly if your child does not get treatment. Very few children get chronic leukemia, which develops more slowly.

Children with leukemia need care from doctors who specialize in treating children with blood cancers (pediatric oncologists). Children with ALL also benefit from a team that can meet their physical, emotional, nutritional and other needs. Seattle Children’s has the team to best treat your child.

  • Doctors do not know what causes the changes in cells that lead to leukemia. There is no known way to prevent it.

    Most children who have leukemia have no clear risk factors. But the chance of ALL is higher in children who:

    • Have a genetic condition such as Down syndrome or Li-Fraumeni syndrome.
    • Are taking drugs to suppress their immune system (for example, because they have had an organ transplant)

Leukemia at Seattle Children’s

USNWR BadgeThe experts in our Leukemia and Lymphoma Program have lots of experience diagnosing and caring for children with all types of leukemia. If your child’s leukemia has features that make it harder to treat or more likely to come back after treatment, they will get advanced care from our High Risk Leukemia Program.

The programs are part of our Cancer and Blood Disorders Center. Please contact us at 206-987-2106 for more information, a second opinion or to make an appointment.

  • For more than a decade, our Cancer Center has been consistently ranked among the top pediatric oncology programs in the country by U.S. News & World Report.

    At Seattle Children’s Cancer Center, our survival rates for a wide range of cancers have been significantly better than the national average for 20 years. See our statistics and outcomes.

    Through our partnership in the Seattle Cancer Care Alliance (SCCA), our patients benefit from the work of physician-scientists at Fred Hutch and UW Medicine, as well as at Seattle Children’s. The National Cancer Institute has designated our partnership a comprehensive cancer center.

    Our experience helps us recommend the right treatment at the right time to have the best results for your child and your family.

  • Our doctors are experts in caring for children with blood cancers and know the most effective ways to treat leukemia. Treatments include new mixes of medicine (chemotherapy and targeted therapy), immunotherapy, stem cell transplants and radiation therapy.

    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.

    Our childhood cancer doctors meet regularly with transplant doctors to talk about each high-risk leukemia patient in detail and plan their treatment.

    Each patient gets a personalized treatment plan. It includes:

    • How to get your child’s disease in remission
    • The best kind of transplant for your child
    • How to reduce the risk of cancer coming back after transplant

    We care for your whole child. We don’t just treat their leukemia. Your family has a full team behind you, including specialists in nutrition, pharmacy, nursing, pain management, physical therapy, social work and emotional health. Read more about the supportive care we offer.

  • Seattle Children’s is well known for developing promising new leukemia treatments and leading research studies with the goal of improving cure rates. We work hard to find the best research study (clinical trial) for your child.

    As a national leader in cancer research, we can offer our patients the very latest treatments being studied, including phase 1 clinical trials. These early studies are especially important if your child’s cancer does not respond well to treatment or comes back.

    Our clinical trial options include reprogramming the body’s infection-fighting T cells to find and destroy ALL cells (PLAT studies).

  • Children don’t react to illness, injury, pain and medicine in the same way as adults. They need – and deserve – care designed just for them. They need a healthcare team specially trained to understand and meet their needs.

    Our cancer doctors have special training in how to diagnose and treat children with cancer. Our experts are focused on how treatments today affect growing bodies in the future. They base their treatment plans on years of experience and the newest research on what works best – and most safely – for children.

    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.

  • Learning that your child has leukemia can be scary. We help right away by offering appointments within 1 to 3 days for children who are suspected of having cancer.

    During visits, we take time to explain your child’s condition. We help you fully understand your 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.

    At Seattle Children’s, we work with many 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.

Symptoms of Acute Lymphoblastic Leukemia

Symptoms of acute leukemia tend to appear over a matter of days or weeks and to get worse quickly. Many of the signs and symptoms of ALL happen because cancer cells crowd out healthy blood cells. Other symptoms happen if leukemia cells build up in the lymph nodes or organs (such as the brain, spleen or liver).

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

  • Fever, which may be a sign of infection. Risk of infection is greater if white blood cell levels are low.
  • Easy bruising or bleeding, even from small injuries. This may be a sign of low platelets.
  • Weakness, tiredness or feeling dizzy. A lack of red blood cells (anemia) may cause these symptoms.
  • Pinpoint spots of blood under the skin caused by tiny broken blood vessels (petechiae). This is another sign of low platelets.
  • Bone or joint pain from cancer cells building up there.
  • Painless lumps in the neck, underarm, stomach, groin and around the eyes.
  • Pain and fullness under the ribs from an enlarged liver or spleen.
  • Loss of appetite. This may happen if the liver or spleen is enlarged.
  • Shortness of breath or coughing. This can be caused by swelling of lymph nodes in the chest or swelling of a gland in the neck (thymus) that is part of the immune system.
  • Headaches or problems with vision, balance or muscle control. These may happen if leukemia has spread to the brain.

Diagnosing Acute Lymphoblastic Leukemia

To find out whether your child has ALL, your child’s 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
  • Common blood tests to check for leukemia include:

    • Complete blood count (CBC) – Tells how many cells of each type are moving through the bloodstream
    • Peripheral blood smear – Shows how the blood cells look
    • Blood chemistry – Finds chemicals in the blood that may be signs of cancer
  • Doctors may do other blood tests to learn more about the unhealthy cells and help tell which subtype of leukemia your child has. Doctors may:

    • Use advanced gene sequencing to find what’s different about your child’s leukemia
    • Look for proteins on the surface of the cancer cells
    • Look at the chromosomes in the cancer cells
  • Leukemia cells almost always spread quickly from the bone marrow to the blood. They travel through the bloodstream to other parts of the body. These tests help tell if leukemia cells have started to collect in other areas of the body:

    • Lumbar puncture: To tell if cancer has spread to your child’s brain or spinal cord. This is also called a spinal tap.
    • biopsy: Taking a small tissue sample from the testicles or skin helps doctors tell whether the cancer has spread there.
    • A chest X-ray: To look into the chest area.
  • Leukemia is not “staged” the way most cancers are. Instead of stages, doctors use risk levels for ALL.

    Standard risk applies to children ages 1 through 9 years with a 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
    • T cells are affected

    Very high risk:

    • A child is under 1 year
    • The leukemia cells have features linked to a high risk of relapse
    • Disease does not go into remission quickly with treatment

    The subtype of your child’s ALL also helps doctors decide the best treatment plan. ALL subtypes are based on:

    • Whether it affects the T cells or B cells
    • How mature the leukemia cells are

    If your child has high risk leukemia, they will get advanced care from our High Risk Leukemia Program.

Phases of Treating Acute Lymphoblastic Leukemia

Before leukemia itself is treated, some children will need treatment for problems like infection, bleeding or anemia. These are caused by low levels of healthy blood cells.

Treatment for ALL always includes chemotherapy. Your child may also need radiation or other therapy, depending on their disease. Treatment happens in phases:

  • This phase of treatment uses chemotherapy to kill cancer cells in the blood and the bone marrow. 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 leukemia 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.

  • This phase of treatment aims to kill any cancer cells that are left in your child’s body after induction. It also aims to prevent cancer from spreading to the brain or spinal cord, or to treat any cancer that is already there.

    This phase often lasts 2 months. Your child will receive different chemotherapy drugs than in the first phase. Medicines are given by mouth and into your child’s vein through a tube. Injecting medicine into a vein is called intravenous (IV).

  • The chemotherapy medicine your child gets during this phase depends on their disease. During this 2-month phase, your child will visit the clinic every week or so to get medicine by IV. At times your child may receive higher doses that require them to spend a night in the hospital.

  • For 2 more months, your child receives chemotherapy medicine to help prevent leukemia from coming back. The timing and drugs depend on your child’s disease.

  • During this phase, your child gets lower doses of medicines to kill any cells that might be left. This phase usually lasts 2 to 3 years.

    During most of this time, your child will take a chemotherapy medicine by mouth every day. They will visit the clinic every month to get medicine through their vein (IV). Every 3 months they will get a medicine that is injected into their spinal fluid.

    We have arrangements with doctors in some communities so children who do not live near Seattle can get maintenance chemotherapy closer to home.

Treating Recurrent ALL

If your child’s ALL comes back (recurs), treatment options include:

  • More chemotherapy. The drugs used depend on how soon ALL comes back after treatment.
  • A clinical trial of T-cell immunotherapy, if leukemia returns sooner than 3 years after remission.
  • Stem cell transplant.

Treatment Options for Acute Lymphoblastic Leukemia

Our goal of treatment is to give your child or teen the best chance of a long and healthy life.

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

  • Your child’s age
  • White blood cell count
  • Whether 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

Treatment for ALL always includes chemotherapy using many medicines. Depending on your child’s leukemia, they may also need radiation therapy, immunotherapy or a stem cell transplant. Seattle Children’s offers all of these standard treatments and clinical trials of promising new therapies.

If your child’s leukemia comes back, they will get care from experts in our High Risk Leukemia Program.

  • Chemotherapy means giving medicines that go throughout your child’s body to kill cancer cells. Researchers are testing new mixes of chemotherapy medicines to find the best ones for each type of leukemia.

    Children with leukemia get chemotherapy through a vein or by mouth. These medicines help kill cancer cells that are in the blood, bone marrow and other places where cancer may have spread.

    All children with leukemia also get chemotherapy directly into their spinal fluid. This is to keep the cancer from spreading to the brain and spinal cord or to treat any cancer already there. It is called intrathecal chemotherapy or central nervous system (CNS) prophylaxis.

    Most children with ALL get chemotherapy for 2½ to 3½ years. The first 6 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’s main campus in Seattle. As much as possible, we will treat your child at our outpatient clinic. But some of the time they may need to stay overnight in our hospital’s Cancer Care Unit.

    See more about getting chemotherapy at Seattle Children’s.

  • If your child’s cancer has spread or may spread to the brain, spinal cord or testicles, your child’s doctors may suggest radiation to one of those areas. Doctors also use radiation to prepare a child’s body for a stem cell transplant.

    Radiation uses high-energy X-rays to kill cancer cells. A machine outside the body delivers strong beams of X-rays. We focus beams as precisely as possible to help limit damage to healthy areas.

    Radiation can harm a child’s developing nervous system, their bones or ability to have children in the future. Our radiation oncologistDr. Ralph Ermoian, is experienced working with children. He helps your child’s team decide if radiation may be helpful and what type of radiation to use. We work with patients to protect their ability to have biological children (fertility preservation).

    Children treated for leukemia at Seattle Children’s receive radiation therapy through our partner UW Medicine.

    Learn more about Seattle Children’s Radiation Therapy Service.

  • For some children with ALL, treatment includes a transplant of blood-forming (hematopoietic) stem cells. These are immature 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, like abnormal chromosomes
    • Their cancer does not respond to treatment
    • Their cancer comes back

    First your child will get high doses of chemotherapy. They may also get radiation. This kills cancer cells and makes space for new stem cells your child will get during the transplant.

    Then your child receives stem cells through their vein. The cells have been taken from a healthy family member or other donor. These healthy cells then create new bone marrow.

    A transplant using stem cells from another person is called an allogeneic (pronounced a-low-gen-AY-ik) transplant.

    Our patients who have a stem cell transplant receive this care through Seattle Children’s and our partner in the Seattle Cancer Care Alliance, Fred Hutch.

    Learn more about the Pediatric Blood and Marrow Transplant Program.

  • New targeted therapies have been created for some types of ALL. Targeted therapy fights cancer by finding a specific substance (target) and attaching to it. The target may be a protein on cancer cells or substances that help cancer grow.

    These are examples of targeted therapy we offer:

    • Tyrosine kinase inhibitors (TKIs) block signals that help tumors grow. Blocking the tyrosine kinase enzyme stops 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.
    • Monoclonal antibodies are synthetic versions of immune system proteins that fight disease. Doctors are studying a type of monoclonal antibody that binds to 2 different proteins at the same time. This brings ALL cells and immune cells together and triggers an immune system attack.

    Targeted therapy is usually given along with chemotherapy.

  • Many children, adolescents and young adults with leukemia participate in research while receiving their standard medical treatment. Seattle Children’s doctors who care for your child also work on new treatments to improve the outlook for all children with blood cancers. Research studies of new drugs and other promising treatment approaches are called clinical or therapeutic trials.

    As leaders in pediatric cancer research, we can offer our patients options that are not available at all centers. At Seattle Children’s these include:

    • Phase 1 and phase 2 trials of T-cell therapy for children and young adults with ALL. 
    • New ways to prepare children for transplant if they do not have a fully matched stem cell donor. Drs. Lauri Burroughs and Ann Woolfrey lead these studies.
    • Dr. Marie Bleakley is leading a phase 1 trial testing a type of T-cell therapy for patients with acute leukemia that has come back or does not respond to treatment after a donor stem cell transplant. Read about HA-1 T TCR immunotherapy
    • Approaches designed to avoid graft-versus-host disease (GVHD) after transplant. Dr. Marie Bleakley works on ways to control T cells from donors so they don’t attack the cells of transplant patients.

    Learn more about cancer clinical trials at Seattle Children’s

    We offer clinical trials with treatments developed here at Seattle Children’s and through our membership in:

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. Most children visit the Leukemia and Lymphoma Program at Seattle Children’s each month for the first year after active treatment ends. Follow-up visits happen less often as time goes by.

If you do not live in the Seattle area, you can see a doctor in your own community for most follow-up care. Your doctor will let you know the schedule that is right for you.

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.

Through our partnership in Seattle Cancer Care Alliance, our patients who have had a stem cell transplant get care from the SCCA’s Long-Term Follow-Up program.

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, call the Cancer and Blood Disorders Center at 206-987-2106 or by email.

Providers, see how to refer a patient.