Acute Lymphocytic Leukaemia (ALL) Treatment in Delhi, India

Acute Lymphocytic Leukaemia (ALL), also known as acute lymphoblastic leukaemia, is a type of blood cancer that occurs when there is an immature formation of lymphocytes (a type of white blood cell). ALL develops in the bone marrow - a soft part of the bones where the blood cells are made. Acute lymphocytic leukaemia can occur at any age, but more commonly affects children.

The word 'acute' denotes that the disease has progressed rapidly and can become fatal within months. The word 'Lymphocytic' in ALL stands for the immature white blood cells called lymphoblasts. In some cases, ALL can also spread to other parts of the body, like the liver, spleen, spinal cord, brain, testicles, and lymph nodes.

Acute Lymphocytic Leukaemia (ALL) can be categorised into different types based on various factors, including the specific type of lymphocytes involved or certain genetic characteristics. The main types of ALL depending on the immunophenotypic characters include:

• B-cell ALL (B-ALL)
• T-cell ALL (T-ALL)

Subtypes may also exist within B-ALL and T-ALL based on specific genetic mutations or chromosomal abnormalities. The identification of these subtypes is important for treatment decisions and prognosis.

In general, acute lymphocytic leukaemia occurs due to a mutation in the DNA of a cell developed in the bone marrow. However, it is still not clear what is the root cause for ALL. There is a lot of research going around to understand how some changes in the DNA in bone marrow cells can transform them into leukaemia cells.

For better understanding, the DNA inside makes up genes, which give instructions to the cell to function in a set manner. However, when there is a mutation - which can happen due to multiple reasons - the blood cell production goes out of control. This may result in the production of immature cells or lymphoblasts. These immature cells fail to function in the set manner and hamper the production of healthy cells.

Acute Lymphoblastic Leukaemia (ALL) symptoms may include:

• Fatigue: Persistent tiredness or lack of energy that interferes with daily activities.
• Weakness: Generalised lack of strength or power in the muscles.
• Pale skin: Anaemia-related symptoms characterised by a noticeably lighter complexion.
• Frequent Infections: Increased susceptibility to illnesses due to a weakened immune system. 
• Fever: Fever is often associated with an underlying infection or inflammation.
• Easy bruising or bleeding: Unexplained and frequent occurrence of bruises or bleeding, indicating potential issues with blood clotting.
• Petechiae (small red spots on the skin): Tiny, red or purple spots on the skin resulting from bleeding under the skin.
• Bone pain: Discomfort or aching sensations originating from the bones. 
• Joint Pain: Discomfort, pain or stiffness in the joints.
• Swollen Lymph Nodes: Enlargement of lymph nodes, commonly found in the neck, armpit, or groyne.
• Enlarged liver or spleen: Abnormal enlargement of these organs, often palpable during a physical examination. 
• Headaches: Persistent or severe headaches, which can be a symptom of increased pressure in the skull.
• Vision changes: Alterations in eyesight, which may be indicative of neurological involvement or other complications.
• Loss of appetite: Reduced desire to eat, leading to decreased food intake.
• Weight loss: Unintentional reduction in body weight over a period of time. 
• Difficulty breathing: Shortness of breath or a feeling of breathlessness.
• Pain in the abdomen: Discomfort or pain in the abdominal area, possibly due to organ enlargement or other complications.

Diagnosing Acute Lymphocytic Leukaemia (ALL) involves a series of medical assessments and tests to confirm the presence of leukaemia cells in the bone marrow and blood. The diagnostic process typically includes the following steps:

• Medical History and Physical Examination: The healthcare provider will inquire about the patient's symptoms, medical history, and perform a thorough physical examination to identify any signs indicative of leukaemia.

• Blood Tests: A complete blood count (CBC) is conducted to assess the levels of red blood cells, white blood cells, and platelets. Abnormalities may suggest the presence of leukaemia cells.

• Bone Marrow Aspiration and Biopsy: A bone marrow aspiration and biopsy involve the extraction of a small sample of bone marrow and bone tissue from the hip or another large bone. These samples are then examined under a microscope to detect leukaemia cells and assess their characteristics.

• Cytogenetic Analysis: Cytogenetic testing examines the chromosomes within leukaemia cells to identify any abnormalities. Certain chromosomal changes can help in determining the subtype of ALL and guide treatment decisions.

• Immunophenotyping: This test analyses the specific markers present on the surface of leukaemia cells, helping to identify the type of lymphocytes involved (B-cell or T-cell) and further refine the diagnosis.

• Lumbar Puncture (Spinal Tap): In some cases, a lumbar puncture may be performed to examine the cerebrospinal fluid for the presence of leukaemia cells, as leukaemia can sometimes spread to the central nervous system.

Once the diagnostic process is complete and ALL is confirmed, further tests may be conducted to find out if any targetable mutation is present and to guide the development of an appropriate treatment plan. It's essential to consult with a haemato-oncologist for an accurate diagnosis and personalised treatment approach based on the specific characteristics of the leukaemia cells.

Once a patient is tested positive for acute lymphocytic leukaemia, the doctor may suggest certain phases of treatment. These treatments can be divided into four phases.

• First Phase (Induction Therapy): This is the first phase of the treatment in which certain drugs are given to kill most of the leukaemia cells in the blood and bone marrow.

• Second Phase (Consolidation Therapy): This is the second phase, which is also known as post-remission therapy. In this phase, you will be given multiple cycles of intensive chemotherapy over six to nine months. The aim is to destroy the remaining leukaemia cells.

• Third Phase (Maintenance Therapy): The third phase of the treatment is aimed at stopping the growth of leukaemia cells.

Apart from this, there are other treatments for acute lymphocytic leukaemia. These may include:

Radiation Therapy

In this therapy, high-powered beams like X-rays or protons are used to kill the cancer cells. Radiation therapy is performed when the cancer cell has spread to the central nervous system.

Targeted Therapy

During targeted therapy, some targeted drugs are given to the patient that can target specific abnormalities present within the cancer cells. This therapy can be used in conjunction with chemotherapy to kill the leukaemia cells present in the body.

Chemotherapy 

Chemotherapy is one of the most commonly used therapy in ALL. In this, chemotherapy drugs are given to kill the cancer cells.

Bone Marrow Transplant

Bone Marrow Transplant is a procedure that is used to remove cancerous bone marrow stem cells by donors' healthy stem cells. During this procedure, stem cells are removed from the blood or bone marrow of the patient or a donor. The stem cells are then frozen and stored. Once the chemotherapy is completed, stem cells are given back to the patient via an infusion technique. The stem cells then grow and restore the blood cells in the body.

Immunotherapy

In immunotherapy, certain drugs are given that will boost one's own immune cells to slow down the growth of cancer cells.

Clinical Trials

Clinical trials are studies of new drugs or treatments on people to test the feasibility of the new treatments or methods. Clinical trials can provide state-of-the-art cancer treatment. However, it is important to note that these treatments have a fair share of benefits and risk factors. Therefore, it is important to discuss all the aspects with your doctor.

It is not clear what causes the mutations in the DNA, and therefore there is no known way to prevent it.

What is the survival rate of acute lymphocytic leukaemia?

Complete remission is achieved in approximately 90 per cent of the patients, with almost 40 per cent of them enjoying long-term survival rates. However, about 5 percent of patients die during some treatment-related complications during the initial phase of therapy.

Can ALL recur after successful treatment?

Recurrence is possible, and regular follow-up appointments are crucial to monitor for any signs of relapse.

How does ALL impact mental health?

Coping with a cancer diagnosis can be challenging; patients may experience emotional distress, and support services are available to help address mental health needs.

Are there specific dietary recommendations for individuals with ALL?

While a balanced diet is important, specific dietary guidelines may vary. The neutropenic patients are advised to be on a neutropenic diet. Neutropenic diet means avoidance of raw fruits and vegetables or salads; to eat well cooked home food/hospital food; to strictly eat fresh food and avoid junk/restaurant food during the initial phase of treatment. It's advisable to consult with a healthcare professional or a registered dietitian for personalised recommendations.

What are the potential long-term effects of ALL treatment?

Treatment side effects can have long-term implications, including impacts on fertility, organ function, and secondary cancers. Discussing potential long-term effects with the healthcare team is important.

How does ALL affect children differently than adults?

ALL children may have different treatment protocols and outcomes compared to adults.

Are there any specific lifestyle changes recommended during and after ALL treatment?

Adopting a healthy lifestyle, including regular exercise and stress management, can be beneficial. However, individual recommendations may vary.

Can genetic factors play a role in ALL?

In some cases, genetic factors may contribute to the development of ALL. Genetic counselling may be considered for individuals with a family history of leukaemia.

How is ALL research contributing to advancements in treatment?

Ongoing research is identifying new therapies and improving treatment outcomes. Clinical trials may offer innovative options for eligible patients.

What supportive care measures are available for ALL patients?

Supportive care includes managing side effects, addressing emotional well-being, and providing resources for financial and logistical challenges.

Can ALL impact fertility, and what options are available for preserving fertility during treatment?

Some treatments may affect fertility, and options such as fertility preservation methods should be discussed with the healthcare team before starting treatment.

Reviewed By Dr. Karuna Jha, Consultant - Bone Marrow Transplant, Haemato-Oncology And Haematology, and Dr. Nivedita Dhingra, Principal Consultant - Medical Oncology (Haematology, Hemato – Oncology, BMT) , Cancer Care /Oncology, Medical Oncology on 15 May 2024.