Acute Lymphoblastic Leukemia (ALL)
Treatment Options & Assessment of Response
Updated: September 2010
Patients with acute lymphoblastic leukemia usually require urgent treatment to reduce symptoms and return blood counts to normal. This is called complete remission. Once a remission is achieved, additional treatment is given to consolidate remission and help prevent recurrence.
Chemotherapy
Chemotherapy is the main treatment for all forms of leukemia. Chemotherapy targets fast-dividing cells by disrupting critical parts of the cell cycle. Since cancer cells divide faster than normal cells, more cancer cells than normal cells are killed. Of course, a significant number of normal cells are damaged, which causes the many familiar side effects of chemotherapy. Chemotherapy may be given by mouth (pills), intravenously through an IV or catheter, or into the cerebrospinal fluid (intrathecally). Most often, combinations of chemotherapy drugs are used to achieve the optimal therapeutic outcome.
Chemotherapy is usually given in cycles, sometimes starting with intensive induction treatment, which takes several weeks. This is followed by a few weeks without treatment, allowing the patient to recover from side effects, mostly related to lower blood counts. The sequence is then repeated. Patients who achieve initial remission require additional treatment, usually given over a period of years (in acute lymphoblastic leukemia) in order to prevent recurrence. Treatment for acute leukemia is intensive and usually requires hospitalization.
Chemotherapy for ALL usually is intensive, involves a number of agents given in repeated cycles over 2-3 years and requires hospitalization initially for induction chemotherapy.
The following is a common induction combination protocol:
Other drugs that may be used include:
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Doxorubicin, cytarabine, also known as cytosine arabinoside or ara-C, etoposide, teniposide, 6-mercaptopurine, Methotrexate, cyclophosphamide, dexamethasone
Other drugs that may be used include:
Beyond Chemotherapy: Advances in Treating Leukemia
Stem Cell Transplantation
Hematopoietic cell transplantation (HCT) and peripheral blood stem cell transplantation are therapeutic treatments that use stem cells (immature blood cells) to treat a patient's malignancy, or to repair diseased or defective bone marrow. Transplants are sometimes performed early in the course of treatment to improve outcomes. In some patients, they are utilized when other treatments are not working.
These transplant procedures include intensive chemotherapy with or without radiation to destroy the cancerous cells. This is followed by an infusion of healthy new stem cells, which have the ability to grow back into the bone marrow and begin making normal blood cells again.
If a patient receives stem cells from a matched donor (using related, unrelated or cord blood), the transplant is called allogeneic. Like other tissue transplants, allogeneic stem cell transplants require a genetic match between the donor and recipient.
In allogeneic transplants, the donor is preferably a sibling. Alternatively, a matched unrelated donor who has a similar genetic type may be used. In some cases, a patient’s own stem cells may be used. This is called an autologous (self) transplant. Autologous transplant has no role in the management of ALL and is not indicated anymore for this disease.
Non-myeloablative HCT
A new transplant procedure has been developed to treat patients with leukemia and myelodysplasia who are older or have underlying medical problems. Reduced-Intensity Conditioning Transplant (RICT) or Non-myeloablative HCT, also called “mini-HCT or “mini transplant,” involves less intensive chemotherapy and radiation treatments.
Researchers now understand that the immune cells created by the transplanted donor stem cells may recognize any remaining cancer cells in the patient as “foreign,” and kill them – thus helping to fight the cancer. This RICT /mini-HCT strategy is showing great promise for leukemia and many other cancers, and is being used to treat patients who are not eligible for full myeloablative allo-transplantation. The role of RICT and/or Non-myeloablative HCT for ALL is still experimental.
Radiation Therapy
Radiation therapy uses high-energy X-rays or other types of radiation to kill cancer cells. Radiation therapy is used for prophylaxis whole brain irradiation in ALL in combination with intrathecal chemotherapy. Also it has an important role as part of the conditioning regimens before allogeneic transplantation. In addition as for many other types of cancer, radiation therapy plays a role in palliation for end stage symptomatic patients with bulky disease causing discomfort, compression or pain.
Prognosis
Acute lymphoblastic leukemia (ALL) in adults is characterized by its high response rate to induction chemotherapy: multiagent chemotherapy induces remission in 74%-92% of ALL patients; however the majority will relapse and succumb to their disease leaving only 27%-40% of adult patients younger than 60 years to enjoy long-term disease-free survival (DFS). Research is still ongoing to improve the results of patients with adult ALL, this includes using new agents, applying pediatric protocols (same agents, same dose intensity), and using allogeneic stem cell transplantation.
| The information contained in these guidelines is a statement of consensus of Leukemia/BMT Program of BC professionals regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult these documents is expected to use independent medical judgment in the context of individual clinical circumstances to determine any patient’s care or treatment. Use of these guidelines and documents is at your own risk and is subject to the Leukemia/BMT Program of BC’s terms of use available at Terms of Use. |