Overview of the presentation and diagnosis of acute lymphoblastic leukemia in

children and adolescents

INTRODUCTION Acute leukemia, the most common form of cancer in children, comprises
approximately 30 percent of all childhood malignancies, with acute lymphoblastic leukemia
(ALL) being five times more common than acute myeloid leukemia (AML) [1]. Each year in the
United States approximately 2500 to 3500 new cases of ALL are diagnosed in children. ALL
incidence is slightly higher in Whites (36 cases/million) and Hispanics (41 cases/million) than
in Black Americans (15 cases/million) [2].
Survival rates for ALL have improved dramatically since the 1980s, with a current five-year
overall survival rate estimated at greater than 85 percent [1,3,4]. This improvement is in large
part because of treatment of large numbers of children with sequential collaborative
standardized research protocols [5]. Approximately 75 to 80 percent of children with newly
diagnosed ALL participate in clinical research trials, the goals of which are to improve clinical
outcome and to minimize acute toxicities and late-occurring adverse events.
The presentation and diagnosis of ALL in children are reviewed here. The risk group
stratification and treatment of childhood ALL are discussed separately.
EPIDEMIOLOGY As mentioned above, approximately 2500 to 3500 new cases of ALL are
diagnosed in children each year in the United States with an incidence of approximately 3.4
cases per 100,000 [1]. ALL incidence is slightly higher in Whites (36 cases/million) and
Hispanics (41 cases/million) than in Black Americans (15 cases/million) [2].
It appears the incidence of childhood leukemia is increasing as demonstrated by the two
following studies:
In an analysis of the Surveillance, Epidemiology, and End Results (SEER) database, there
was a steady increase in ALL incidence from 1975 to 2010 with an average annual increase in
incidence of approximately 0.7 percent [1]. The estimated incidence increased from 25 cases
per million in 1975 to 34 cases per million in 2010.
In a study that used data from 63 European population-based cancer registries of children
diagnosed with cancer, the incidence of leukemia including ALL increased by an average of
1.4 percent from 1970 to 1999 [6].
In a study from Great Britain, the incidence of leukemia (mostly attributable to ALL) has
steadily increased from 3.83 to 4.61 per 100,000 persons by sex and age from the five-year
period of 1971 to 1975 and 1996 to 2000 [7].
In contrast, a study from four Nordic countries (Denmark, Finland, Norway, and Sweden)
reported that the incidence of childhood ALL remained stable at an approximate rate of 3.3
cases per 100,000 children below 15 years of age from 1983 to 2002 after an increase in
incidence between 1975 and 1983 [8].
The peak incidence occurs between two and five years of age [1,8,9], and it occurs more
commonly among boys than girls [1,8]. The vast majority of ALL cases are not associated with
genetic or environmental risk factors. However, certain genetic and immunodeficiency
syndromes (eg, Down syndrome, Neurofibromatosis type 1, Bloom syndrome, and ataxia
telangiectasia) place children at higher risk for ALL [10,11]. An increased risk of ALL
associated with higher birth weight has also been noted [12]. Studies of the relationship
between childhood ALL, urban/rural status and population density, as well as other possible

etiologic factors (eg, environmental exposures, abnormal immune response to common

infection[s]) have yielded inconsistent results [13-26].
Genomic studies have noted that somatic, polymorphic variants of ARD5B, IKZF1 (the gene
encoding Ikaros) and CDKN2A are associated with an increased risk of ALL (odds ratio 1.3 to
1.9) [27-30]. Other rare germline mutations in PAX5, ETV6, and particularly p53 can also
strongly predispose to the development of leukemia [4].
However, in most cases, childhood ALL is not considered to be a familial disease. Compared
with the general population, twin siblings of children with ALL are at markedly increased risk
of developing leukemia, while singleton siblings are at only slightly increased risk.
Importantly, ALL is a disease with a low incidence in the general population; as a result, a
large increase in the relative risk among siblings does not translate into a high likelihood of
developing leukemia. As an example, a study from Sweden and Finland that included 3994
children with ALL identified 36 siblings subsequently diagnosed with ALL [31]. When
compared with the general population, the standardized incidence ratio (SIR) for ALL was
higher for twin siblings (SIR 163) than for singleton siblings (SIR 3). With the current available
information, we do not recommend a screening program for siblings of patients with leukemia.
Screening of patients for familial leukemia is discussed separately.
EARLY SIGNS AND SYMPTOMS The most common presenting symptoms of ALL are
nonspecific (eg, fever, bleeding, bone pain, lymphadenopathy). Unexplained persistence of
any of these common signs or symptoms should prompt consideration of malignancy as a
possible cause. The characteristics of common presenting signs or symptoms of leukemia that
are suggestive of malignancy are discussed briefly below and in more detail separately.
Musculoskeletal pain Although bone pain occurs commonly among children, particularly
adolescents, it may be a symptom of ALL. Early bone marrow examination should be
considered in any child who has persistent bone pain and peripheral blood abnormalities.
Bone pain, particularly affecting the long bones, and caused by leukemic involvement of the
periosteum, is a presenting symptom in 21 to 38 percent of cases of acute leukemia [32-35].
Bone pain also results from aseptic osteonecrosis because of malignant cell necrosis in the
bone marrow [36,37]. Radiographic changes are present in as many as one-half of cases [32].
Young children with such pain may present with limp or refusal to bear weight [38].
Musculoskeletal pain associated with acute leukemia, particularly if it occurs in the joints, may
be mistaken for rheumatologic pain. Features that may be helpful in differentiating leukemic
from rheumatologic musculoskeletal pain are discussed separately.
Headache Although uncommon (<5 percent of cases), leukemia involving the central
nervous system (CNS) can present with symptoms of increased intracranial pressure,
including headache, vomiting, lethargy, and/or nuchal rigidity [39]. Rarely, leukemia can
present with cranial nerve abnormalities [40,41].
Lymphadenopathy Approximately 50 percent of children with ALL present with
lymphadenopathy, which is one of the indications of extramedullary leukemic spread [38]. As
a general rule, a lymph node is considered enlarged if it is >10 mm in its greatest diameter.
Exceptions to this rule include the following:
Epitrochlear nodes are enlarged if they are >5 mm.
Inguinal nodes are enlarged if they are >15 mm in greatest diameter.
Cervical nodes are enlarged if they are >20 mm.

Lymphadenopathy associated with malignancy usually is nontender, firm, rubbery, and

matted. Persistent or progressive lymphadenopathy that does not respond to antibiotic
therapy suggests the need for more extensive evaluation.
Testicular enlargement Although rare, painless unilateral testicular enlargement can be a
presenting sign of ALL. Any persistent, painless, solid testicular mass should be referred for
biopsy by a pediatric surgeon after evaluation by ultrasound. When testicular leukemia is
suspected, bilateral wedge biopsies are preferred to decrease sampling error. Histologic
interpretation can be challenging and requires the ability to differentiate leukemic
lymphoblasts from reactive lymphocytes.
Mediastinal mass Adolescents with ALL may present with many of the features of nonHodgkin lymphoma. Distinguishing between these two disorders can sometimes be difficult. T
cell ALL commonly occurs in older boys who present with high initial white blood cell (WBC)
counts and a large mediastinal mass. Patients who present with features of lymphoma, such
as mediastinal mass and lymphadenopathy, often have significant bone marrow involvement.
Malignant lymphoblasts found in T cell lymphoblastic lymphoma are indistinguishable from T
cell ALL; by convention, children having more extensive bone marrow involvement (>25
percent in the US) are classified as having leukemia
A large anterior mediastinal mass can narrow the trachea, causing respiratory distress. Such
masses can also be associated with pleural effusions, further compromising respiratory
function. In addition, a mediastinal mass can obstruct the superior vena cava, resulting in
superior vena cava syndrome, which is manifest as pain, dysphagia, dyspnea, or swelling of
the neck, face, and upper limbs.
Peripheral blood abnormalities Most children with ALL have anemia and/or
thrombocytopenia with either normal or slightly increased WBC counts, and lymphoblasts on
peripheral smear (picture 1 and picture 2) [42]. Approximately 50 percent of children have
WBC counts <10,000/microL, and 20 percent have an initial leukocyte count >50,000/microL
[38,42]. Approximately one-half of children with ALL present with bleeding (including
petechiae and purpura) and three-quarters have a platelet count <100,000/microL at the time
of diagnosis [38].
These findings suggest the need for bone marrow examination, which should be performed for
the following indications:
Atypical cells in the peripheral blood
Unexplained depression of more than one peripheral blood element (cytopenias).
Cytopenias are defined as an absolute neutrophil count (ANC) of <500/microL, Hgb <8 g/dL,
or a platelet count <150,000/microL.
Unexplained lymphadenopathy or hepatosplenomegaly associated with cytopenias
PATHOLOGIC FEATURES
Morphology Historically, childhood ALL has been classified morphologically using the
French-American-British (FAB) system that incorporates information regarding the size,
amount of cytoplasm, and prominence of nucleoli of tumor cells from the bone marrow
aspirate [43]. While some clinicians still use this system to describe the phenotype of the
tumor cells, FAB morphology has lost its prognostic value as our understanding of disease
biology has improved and treatment regimens have become more intense and successful. As
such, FAB subtype is not currently used in either diagnosis or treatment decisions.

According to the FAB system:

L1 lymphoblasts are small cells with scant cytoplasm, condensed nuclear chromatin, and
indistinct nucleoli (picture 3 and picture 1). Most children with ALL cases (85 to 89 percent)
are classified as having FAB L1 [44,45].

L2 lymphoblasts are larger cells with a moderate amount of cytoplasm, dispersed chromatin,
and multiple nucleoli (picture 4 and picture 2). In some studies, L2 has been associated with
worse prognosis than has L1 [44,46]. However, when patients are stratified according to age,
sex, and initial WBC, differences in prognosis between L1 and L2 are no longer observed [45].
Eleven to 14 percent of cases of ALL in children are classified as FAB L2 [44,45].

L3 lymphoblasts have deep cytoplasmic basophilia with prominent cytoplasmic vacuolation

(picture 5). L3 morphology correlates with a more guarded prognosis. The L3 cell usually has
mature B cell characteristics and often is treated using drugs effective for highly aggressive B
cell lymphoma variants (Burkitt lymphoma). Less than 1 percent of cases of ALL in children
are classified as FAB L3 [44,45].

Immunophenotype Leukemia cells in ALL are classified according to immunophenotype

using an extensive panel of monoclonal antibodies to cell surface "cluster of differentiation"
(CD) markers (table 1). Markers used to classify cells by lineage are the same as those used in
adult ALL. The immunologic subtype of the tumor cells is used in the risk group stratification
of childhood ALL.

Approximately 70 to 80 percent of cases of childhood ALL are of B-precursor lineage (ie,

precursor B cell leukemia or early pre-B cell ALL). B-precursor leukemia typically is CD10+,
CD19+, and sometimes CD20+. Leukemic lymphoblasts with the L3 morphology (described
above) usually have markers for mature-B cell ALL (CDs 10 19,20,22,25, and surface
immunoglobulin [sIg]).
Cases of T cell ALL (ie, precursor T lymphoblastic leukemia), which comprise 15 to 17 percent
of all cases of ALL, are positive for CD 2, 3, 4, 5, 7, and 8. Approximately 10 percent of those
with T cell ALL have a distinct immunophenotype (CD8-, CD5dim) and gene expression
signature, consistent with an early T cell precursor phenotype (ETP ALL) [47]. Initial studies
showed that these patients have a high rate of remission failure (57 to 75 percent) and a poor
overall survival [48]. However, data from more recent cohorts have shown that these patients
have a more intermediate-risk outcome (five-year event-free survival, 78 percent) when
treated on high-risk contemporary protocols [49]. Whole genome sequencing suggests that
ETP ALL has many of the genetic features of myeloid stem cells [50].
The expression of markers on the leukemic lymphoblasts does not strictly correlate with
normal lymphoid maturation. Some B-precursor ALL cells, for example, express myeloid
markers (ie, markers more typical of the granulocytic series) in addition to classic Blymphocyte markers. Although this does not affect long-term prognosis or risk group
assignment, it is one of the reasons why immunophenotyping should not be used as the sole
means of leukemia classification [38].
Cytogenetics Chromosomal abnormalities are common in childhood ALL. Although not
specifically used for diagnosis, cytogenetic findings are an essential part of the risk group
stratification of childhood ALL and help to guide therapy. Standard karyotype analysis is
complemented by molecular analysis of known predictive chromosomal abnormalities using
fluorescence in situ hybridization (FISH) and other molecular techniques.
The cytogenetic abnormalities used to classify pediatric ALL are similar to those used for adult
ALL [53]. A notable exception is that the classification of childhood ALL does not include either
t(5;14)(q31;q32) nor t(1;19)(q23;p13.3) in the risk group stratification due to their rarity and
uncertain prognostic value, respectively. The following is a summary of the genetic
abnormalities used to risk stratify childhood ALL, which are discussed in greater detail
separately.
Commonly recognized abnormalities associated with a poor outcome include the following
[54-63]:

t(9;22) BCR/ABL1 translocation (Philadelphia chromosome) Present in 3 to 4 percent of ALL

patients; often occurs in older children.
BCR/ABL1-like ALL A small percentage of patients have a distinct gene expression profile
that is very similar to Philadelphia positive ALL, but does not contain the t(9;22) translocation.
These patients have genetic alterations that involve either an ABL kinase or contain
mutations/fusions in the JAK-STAT pathway.
t(variable; 11q23) Rearrangements involving the MLL gene are present in 5 percent of
pediatric ALL patients and 60 percent of infant ALL patients.
iAMP21 Intrachromosomal amplification of chromosome 21
Extreme hyperdiploidy (59 to 84 chromosomes)
chromosomes) is associated with poor outcome.

or

hypodiploidy

(fewer

than

45

The following abnormalities are associated with a favorable prognosis [61]:

t(12;21) ETV6/RUNX1 (formerly referred to as TEL/AML1) rearrangement in B-precursor ALL,
which occurs in 20 to 25 percent of cases of childhood ALL [64,65].
Hyperdiploidy (54 to 58 chromosomes) Hyperdiploidy is present in 20 to 25 percent of
childhood ALL. Children with lymphoblasts exhibiting hyperdiploidy (not extreme
hyperdiploidy) have the best prognosis, particularly if associated with the combined trisomies
of chromosomes 4 and 10 [66,67]. Trisomy of 4 and 10 is commonly used to risk-stratify
patients to less intense chemotherapy.
Cytogenetics must be considered in the context of other risk factors and response to the first
month of chemotherapy. As an example, in one prospective study of 44 children with high-risk
ALL, as determined by age, WBC count, and immunophenotype, cytogenetic abnormalities did
not independently predict outcome .
DIAGNOSTIC EVALUATION
Initial evaluation Children who are suspected of having leukemia should be referred to a
pediatric cancer center for evaluation [69]. This evaluation will include clinical examination,
and bone marrow aspiration and biopsy, which will diagnose ALL and determine the leukemia
phenotype as well as the presence or absence of cytogenetic abnormalities. Bone marrow
aspirations are required if the patient is to be enrolled in a cooperative group trial. Bone
marrow aspirations are also preferred for diagnostic accuracy and often provide better
cytogenetics results. It is not standard in children or adolescents to diagnose leukemia from
the peripheral blood when lymphoblasts are present. However, in cases where it is difficult to
obtain either bone marrow aspirate or biopsy, peripheral blood can be substituted for bone
marrow. This initial information will be used to assign the patient to a treatment group based
upon risk stratification.
The initial laboratory evaluation also includes assessment for possible disease complications.
As an example, patients with a high tumor burden may have increased serum uric acid
concentration, which can cause uric acid nephropathy and renal failure if not addressed
before chemotherapy is started. The initial laboratory evaluation should include a complete
blood count with manual differential, PT, PTT, electrolytes, uric acid, and renal and liver
function tests. Baseline viral titers, including cytomegalovirus, Epstein Barr virus, human
immunodeficiency virus, hepatitis B virus, and varicella zoster virus often are included.

Several
abnormalities,
including
hepatic
dysfunction,
coagulation
abnormalities,
hypercalcemia, hypocalcemia, hyperkalemia, and hyperphosphatemia, may be noted [38].
Diagnosis The diagnosis and classification of leukemia are based upon specialized tests
that are performed on cells derived from a bone marrow aspirate or tissue biopsy specimens.
When clinical circumstances preclude bone marrow examination, the diagnosis can be made
from cells obtained from the peripheral blood or pleural effusions. The exact peripheral blood
minimum blast percentage has also not been defined for an accurate diagnosis in pediatrics.
The diagnosis of CNS leukemia requires one of the following:
Cytologic confirmation of the presence of leukemic cells in the cerebrospinal fluid (CSF)
Clinical signs of CNS leukemia such as facial nerve palsy, brain/eye involvement, or
hypothalamic syndrome
A tumor mass involving the CNS as determined by imaging studies
ALL can present clinically as either a mass lesion or as leukemia. Although the distinction in
some patients is arbitrary, ALL is the preferred term in the US when the bone marrow contains
more than 25 percent lymphoblasts, whereas lymphoma is the preferred term when the
process is confined to a mass lesion with minimal or no blood and bone marrow involvement
[70].
CNS involvement is often categorized into three groups:
CNS1 no blasts in the CSF
CNS2 <5 blasts in the CSF with or without RBC
CNS3 >5 blasts in CSF
It was initially thought that patients with low levels of CSF leukemia involvement (CNS2) did
as well as those with no CNS disease. However, with improvement in current treatment
regimens, it has become evident that patients with only low levels of leukemia have a lower
event-free survival, largely due to an increased rate of CNS relapse [71]. Although
controversial, many institutions elect to treat patients with CNS2 disease with more
aggressive CNS regimens.
Differential diagnosis As noted above, the presenting signs and symptoms of ALL are
nonspecific. A variety of malignant and nonmalignant conditions must be considered in the
differential diagnosis. They include [38,72]:
Juvenile idiopathic arthritis (see appropriate topic reviews)
Osteomyelitis
Epstein-Barr virus
Immune thrombocytopenia (ITP)
Pertussis, parapertussis
Aplastic anemia

Acute infectious lymphocytosis

Other malignancies with bone marrow involvement (eg, neuroblastoma, retinoblastoma,
rhabdomyosarcoma, and Ewing sarcoma) (see appropriate topic reviews)
Hypereosinophilic syndrome
RISK GROUP STRATIFICATION/CLASSIFICATION Current treatment protocols for ALL in
children emphasize risk-based therapy in order to reduce toxicity in low-risk patients
while ensuring appropriate, more aggressive therapy for those with a high risk of
relapse. Risk group stratification incorporates information regarding the tumor
immunophenotype, cytogenetic findings, patient age, white blood cell count at the time
of diagnosis, and response to initial therapy, including minimal residual disease (MRD)
assessment (table 2). This is discussed in more detail separately.