Acute Lymphoblastic Leukaemia

Question 1

Define Acute Lymphoblastic Leukaemia? (ALL)

Answer 1

Malignancy of the bone marrow and blood characterised by the proliferation of lymphoblasts (primitive lymphoid cells)

Question 2

What is the aetiology of ALL?

Answer 2

Lymphoblasts undergo malignancy transformation and proliferation
This leads to the replacement of normal bone marrow elements, leading to bone marrow failure and infiltration into other tissues

Question 3

What are the risk factors for ALL?

Answer 3

Environmental (radiation, viruses)

Genetic (Down’s Syndrome, Neurofibromatosis type 1, Fanconi’s Anaemia, xeroderma pigmentosum)

Question 4

What is the epidemiology of ALL?

Answer 4

Most common malignancy of childhood
Peak Indidence: 2-5 years old
There is a second peak in incidence in the elderly
Annual UK incidence: 1/70,000

Question 5

What are the presenting symptoms of ALL?

Answer 5

Symptoms of Bone Marrow Failure

Symptoms of Organ Infiltration

Question 6

What are the symptoms of Bone Marrow Failure?

Answer 6

Anaemia (fatigue, dyspnoea)
Bleeding (spontaneous bruising, bleeding gums, menorrhagia)
Opportunistic Infections

Question 7

What are the symptoms of Organ Infiltration?

Answer 7

Tender bones
Enlarged Lymph Nodes
Mediastinal Compression
Meningeal Involvement (headache, visual disturbances, nausea)

Question 8

What are the signs of ALL on physical examination?

Answer 8

Signs of Bone Marrow failure

Signs of Organ Infiltration

Question 9

What are the signs of Bone Marrow Failure?

Answer 9

Pallor
Bruising
Bleeding
Infection

Question 10

What are the signs of Organ Infiltration?

Answer 10

Lymphadenopathy
Hepatosplenomegaly 
Cranial Nerve Palsies 
Retinal haemorrhage 
Papilloedema on fundoscopy 
Leukaemic infiltration of the anterior chamber of the eye 
Testicular Swelling

Question 11

What bloods would you do for ALL and what would you see?

Answer 11

FBC - normochromic normocytic anaemia, low platelets, variable WCC
High Uric Acid
High LDH
Clotting Screen

Question 12

What would you see on a blood film for ALL?

Answer 12

Abundant Lymphoblasts

Question 13

What would you see in a Bone Marrow Aspirate or Trephine Biopsy in ALL?

Answer 13

Hypercellular with > 20% lymphoblasts

Question 14

What other investigations could you do for ALL and how would they be used?

Answer 14

Immunophenotyping - using antibodies to recognise cell surface antigens
Cytogenic - karyotyping to look for chromosomal abnormalities or translocations
Cytochemistry
Lumbar Puncture - check for CNS involvement
CXR- may show mediastinal lymphadenopathy, lytic bone lesions

Question 15

What would you see in a bone radiograph for ALL?

Answer 15

Mottled apperance with punched out lesions due to leukaemic infiltration