Acute lymphocytic leukemia (ALL) is a form of leukemia, or cancer of the body’s blood-forming cells. Leukemia is the most common cancer in children and adolescents, accounting for approximately one-third of all cancers in children under the age of 15 and one quarter of all cancers occurring before the age of 20. ALL is the most common form of leukemia in children.

Also known as acute lymphoblastic leukemia, ALL affects the body’s blood making system, including bone marrow and the lymphatic system. ALL develops from lymphoblasts (a type of white blood cell) in the bone marrow. Bone marrow is the soft, inner component of bones. All forms of blood cells are produced in the bone marrow including white blood cells, red blood cells and platelets.

In children with ALL, the bone marrow manufactures a large number of abnormal white blood cells. Over time they can begin to build up, crowding out normal white blood cells, red blood cells and platelets.

ALL develops in the bone marrow but typically spreads quickly into the blood. Eventually it spreads further into the lymph nodes, the liver, the spleen, the brain, the spinal cord and the testicles. Without successful treatment, the disease is usually fatal.

The exact cause of ALL has not been identified. Researchers, however, have gained a greater understanding of how specific changes in DNA can cause cells to develop into leukemia. In most cases of leukemia, the DNA changes are acquired (occurring after birth), rather than inherited. A number of risk factors have also been identified, including age and exposure to high levels of radiation. 

Symptoms of ALL in children vary depending on where it has spread in the body. General signs and symptoms include unexplained weight loss, fever and weakness.

ALL may be first diagnosed in routine blood tests. However, additional tests are typically necessary to examine blood and ibone marrow cells. Diagnostic tests for ALL may include bone marrow tests and  and lumbar puncture. The treatment and prognosis for ALL depends on the subtype of the disease, as well as certain additional factors including the child’s age and white blood cell count at diagnosis. Chemotherapy is the most common treatment method, and children usually respond very well to it.

According to the American Cancer Society (ACS), nearly 2,800 children under age 19 will be diagnosed with ALL in 2007.  This number accounts for about 73 percent of all of the diagnosed cases of childhood leukemia. ALL most often develops in younger children, peaking between 2 and 3 years of age. The disease is more common in children than adults.

The survival rate for children diagnosed with ALL has increased steadily over time due to advances in treatment. The five-year survival rate for children with ALL is now estimated to be 87 percent.

Acute lymphocytic leukemia (ALL) is a type of leukemia, or cancer of the body’s blood-forming cells. Leukemia, which affects the body’s blood making system, including bone marrow and the lymphatic system, is the most common cancer in children. It accounts for approximately one-third of all cancers in children under the age of 15 and one-quarter of cancers occurring before the age of 20.

ALL is the most common form of leukemia in children. The American Cancer Society (ACS) predicts that about 3,800 children under age 19 will develop leukemia in 2007. Of these children, approximately 73 percent, or 2,800 children, will be diagnosed with ALL. Although the disease is more common in children than adults, the mortality rate is lower in children than in adults with ALL.

Also known as acute lymphoblastic leukemia, ALL develops from lymphocytes, a type of white blood cell, in the bone marrow. Bone marrow is the soft, inner component of bones. It is composed of blood-forming cells, fat cells, and tissues that support the growth of blood cells. All forms of blood cells are produced in the bone marrow from a cell called the stem cell. Blood cells produced in the bone marrow include:

• White blood cells that fight infection.
  
  
• Red blood cells that carry oxygen to tissues all over the body.
  
  
• Platelets that help develop blood clots and control bleeding.

ALL develops in the bone marrow but typically spreads quickly into the blood. Eventually it spreads further into the lymph nodes and to other organs including the liver, brain, spinal cord and testicles.

Lymphocytes are one of the three main types of white blood cell. They are the chief type of cell found in the lymphoid tissue, a major part of the immune system. Lymphoid tissue is found in the bone marrow, as well as the lymph nodes, thymus, spleen, tonsils and adenoids. The two main types of lymphocytes are:

• B lymphocytes (B-cells). B-cells defend the body from bacteria and other foreign substances (antigens) by changing into plasma cells. The antibodies then mark the antigens for destruction.
   
• T lymphocytes (T-cells). T-cells destroy antigens and infected cells directly.

ALL can develop from early forms of either B-cells or T-cells. In children with leukemia, the bone marrow manufactures a large amount of abnormal white blood cells. Since they are defective, these cells are unable to defend the body from disease. As the disease progresses they can begin to build up, crowding out normal white blood cells, red blood cells and platelets. As a result, production of normal white blood cells is affected, and the body’s ability to fight off infection is impaired. In addition, decreased production of red blood cells and platelets results in anemia and bleeding disorders. Eventually, the cancer cells spill from the bone marrow into the bloodstream and spread to other areas of the body.

There are many different types and subtypes of leukemia. In general, the disease is first classified according to:

• How quickly it progresses (acute vs. chronic). Acute leukemia develops from early cells known as blast cells. It progresses quickly and can be fatal within months if not treated. Leukemias that develop in children are usually acute. Chronic leukemia develops from more mature cells and progresses more slowly.
  
  
• The type of blood cells from which it developed (myeloid cells vs. lymphocytes).

ALL is classified as acute because it develops from blast cells and lymphocytic because it develops from bone marrow lymphocytes

ALL most commonly occurs in children, usually developing between ages 2 and 3. It develops more often in boys than girls, and is slightly more common in white children than African American or Asian American children. The five-year survival rate for ALL in children has increased over the years and is now 87 percent. The five-year survival rate refers to the percentage of children who live at least five years after their cancer is diagnosed. Many children live much longer than five years and the prognosis continues to improve due to advances in treatment.

The exact cause of acute lymphocytic leukemia (ALL) in children has not been identified. Researchers, however, have gained a greater understanding of how specific changes in DNA can cause bone marrow stem cells to develop into leukemia.

Some forms of cancer are caused by DNA mutations that “turn on” oncogenes (genes that speed up cell division) or “turn off” tumor suppressor genes (genes that slow down cell division or cause cells to die at the right time). In children with leukemia, these mutations are normally acquired after birth. Some of these mutations, such as those caused by exposure to radiation, can occur in developing fetuses and are already present at birth. 

One form of DNA abnormality that can cause leukemia to develop is a translocation. A translocation is the transfer of DNA from one chromosome to another. This abnormality can turn on oncogenes which causes rapid cell division. 

In addition, researchers have identified a number of factors that may make a child more likely to develop ALL. These risk factors include:

• Chemotherapy. Children treated with certain chemotherapy drugs, including alkylating agents, are at an increased risk of developing ALL later in life. Typically the leukemia develops five to ten years after treatment, and is difficult to treat.
  
  
• Down syndrome. Children with this condition have an extra copy of chromosome 21. Having this disorder makes a child 15 times more likely to develop ALL than the average child.
  
  
• Having a sibling with leukemia. A child with an identical twin who develops ALL before 6 years of age has a 20 to 25 percent chance of developing leukemia.  Fraternal twins and other siblings have a slightly higher risk than average children. They are two to four times more likely to develop leukemia.
  
  
• Exposure to high levels of radiation. Children who have been exposed to high levels of radiation, such as x-rays, are at an increased risk of developing ALL. Children who were exposed to radiation within the first few months of development in the womb are five times more likely to develop ALL. Children who have received radiation therapy as treatment for other forms of cancer have an increased risk of developing leukemia.
  
  
• Immune system suppression. Children receiving immunosuppressive drugs (immune system suppressing drugs) are at an increased risk of developing ALL. These drugs are mainly prescribed after an organ transplant.
  
  
• Age. ALL occurs most often in children between the ages of 2 and 3.
  
  
• Race. ALL is slightly more common in white children than African American or Asian American children.
  
  
• Gender. Boys are more likely to develop ALL than girls.
  
  
• Li-Fraumeni syndrome. This condition, resulting from the inheritance of a mutation in the p53 tumor suppressor gene, may increase the risk of developing ALL in some children.
  
  
• Klinefelter syndrome. Boys with this genetic condition have an extra “X” chromosome. Having this disorder makes a boy more likely to develop ALL.
  
  
• Congenital immune deficiency diseases. Being born with an abnormal or deficient immune system increases a child’s risk of developing ALL.
  
  
• Neurofibromatosis. This inherited disorder causes tumors to develop on nerves. Children with this condition are at an increased risk of developing ALL.
  
  
• Ataxia telangiectasia. This rare inherited disorder affects the brain and numerous other tissues and body systems. Children with this condition are at an increased risk of developing ALL.
  
  
• Wiskott-Aldrich. A condition that affects only boys, this inherited disorder is characterized by abnormal antibodies and T-cells, a low platelet count and eczema. Boys with this disorder have a higher risk of developing ALL.
  
  
• Fanconi’s anemia. This inherited disease affects the bone marrow, resulting in decreased production of blood cells. Having this disorder increases a child’s risk of developing ALL.

Although acute lymphocytic leukemia is associated with these risk factors, most children with the disease have no known risk factors.

Acute lymphocytic leukemia (ALL) can be classified into subtypes based on cytogenic studies, flow cytometry and molecular genetic studies. These tests look for foreign substances (antigens) in the cells, and abnormalities in the genes and chromosomes of the cells. The cells are then further classified as either B-cells or T-cells.  Subtypes of ALL that occur in children include:

• B-cell ALL. B-cell ALL accounts for approximately 85 percent of ALL cases in children. Subtypes of B-cell ALL include:
  
  
• Early pre-B ALL. This type is the most common subtype of ALL in children, accounting for between 57 and 65 percent of cases.
  
  
• Pre-B-cell ALL. This subtype accounts for 20 to 25 percent of cases in children.
  
  
• Mature B-cell ALL (Burkitt's leukemia). The least common type of ALL in children, this subtype accounts for 2 to 3 percent of cases. The disease is very similar to Burkitt's lymphoma, and as a result, it is treated differently than most leukemias.
  
  
• T-cell ALL. T-cell ALL accounts for approximately 13 to 15 percent of ALL in children. It typically affects boys more often than girls and generally affects children at an older age than B-cell ALL.

The classification of these subtypes is based on an older classification system known as the French-American-British (FAB) Classification of ALL. Based on the appearance of the cancer cells under a microscope (morphology), this system consists of three subtypes including:

• L1. In this type, the lymphoblasts are small cells. It is the most common type of ALL in children.
  
  
• L2. In this type the lymphoblasts are larger. It accounts for 10 percent of ALL cases in children.
  
  
• L3. Also known as Burkitt type leukemia, this subtype is the rarest.

Acute lymphocytic leukemia (ALL) can cause a variety of signs and symptoms in children. Children may exhibit a general decline in well-being, including:

• Weight loss
• Fever
• Loss of appetite
• Weakness

Other signs and symptoms may develop from the reduction of normal red blood cells, white blood cells, and platelets caused by the disease. Anemia (an abnormally low amount of red blood cells) can trigger a variety of signs and symptoms including pale skin, fatigue and shortness of breath.

Children with ALL usually have a high white blood cell count. However, these white blood cells do not function normally and do not provide adequate protection against infection. As a result, infection or chronic illness may be a sign of the disease.

Another condition that may result from ALL is thrombocytopenia, which is an abnormally low number of platelets. This condition can lower the body's ability to repair holes in damaged blood vessels and can cause excessive bleeding. Symptoms can include frequent or severe nosebleeds, bleeding gums or excessive bruising. It also may cause petechiae (pinpoint spots of blood under the skin).

ALL can also cause enlargement of the spleen (splenomegaly) and liver (hepatomegaly). Enlargement of these organs can result in a fullness or swelling of the abdomen.

Spread of ALL outside of the bone marrow to the organs, central nervous system, or other parts of the body can result in a variety of signs and symptoms depending on the area affected.

Signs and symptoms of ALL spreading to the central nervous system (brain and spinal cord) include:

• Headaches
• Weakness
• Seizures
• Vomiting
• Difficulty maintaining balance
• Blurred vision
• Poor performance in school

Spread of ALL to the surface of the bone or into the joint can cause bone pain or joint pain. If the disease spreads to the lymph nodes, it may result in enlarged lymph nodes (swollen glands), particularly in the neck or armpit.

A variety of symptoms may occur when leukemia affects the thymus, a gland in the upper chest that is part of the immune system. An enlarged thymus may press on the neighboring windpipe and cause shortness of breath, coughing, or in severe cases, suffocation.

Compression of the superior vena cava (a large vein that returns blood to the right atrium of the heart from the upper half of the body) by leukemia cells can result in a condition known as SVC syndrome. A life-threatening condition, SVC can result in swelling of the head and arms.

Early symptoms of ALL may be overlooked because they may resemble symptoms of more common illnesses, such as influenza. Parents are encouraged to contact their child’s physician when they experience any symptom of ALL. The earlier the disease is diagnosed, the earlier treatment may begin.

If acute lymphocytic leukemia (ALL) is suspected, a physician will take the child’s medical history and perform a complete physical examination. During the physical examination, the physician may inspect the lymph nodes, spleen and liver for swelling.

Next, a variety of tests may be ordered to diagnose and classify the leukemia. Samples of cells from the child’s blood and bone marrow will be examined by a pathologist to verify the diagnosis. Tests will be conducted to determine if the ALL has spread to the central nervous system (brain and spinal cord) or to other areas of the body. Additional tissue and cell samples may be needed to guide treatment.

Common tests include:

• Complete blood count and blood smear. A complete blood count (CBC) is a blood test that measures the number of red blood cells, white blood cells and platelets in a sample of blood. The test also measures the amount of hemoglobin in the red blood cells as well as other factors.  Changes in the numbers of different blood cell types and the appearance of the cells can suggest leukemia. Children with ALL usually have too many white blood cells and many of the cells will be lymphoblasts, an early form of lymphocyte. Many children with ALL also have too few red blood cells and platelets.
  
  
• Blood chemistry tests. These tests measure the level of specific chemicals in the blood. They are used to monitor changes in liver or kidney function caused by leukemia or treatment with certain chemotherapy drugs. The tests may also be ordered to determine whether treatment is required to correct abnormally low or high levels of certain minerals or to detect infection in the child’s bloodstream.
  
  
• Bone marrow tests. A bone marrow aspiration involves using a thin needle to collect a small sample of liquid bone marrow. A bone marrow biopsy uses a larger needle to remove a piece of bone marrow. Usually performed at the same time, these procedures may be ordered to determine if leukemia is present or to monitor treatment.
  
  
• Lumbar puncture. Also known as a spinal tap, this procedure uses a needle to remove a sample of cerebrospinal fluid (CSF) from between the bones in the lower spine. The sample is then examined for leukemia cells. The test may also be ordered to deliver chemotherapy drugs into the spinal fluid when leukemia cells are found there.
  
  
• Testicular biopsy. This procedure involves removing a sample of tissue or cells from the child’s testicles. The sample is then examined under a microscope for signs of cancer.

Additional tests include laboratory tests to diagnose and classify the leukemia. These include:

• Cytochemistry. This test involves placing cells on glass microscope slides and exposing them to chemical stains. The stains then react with certain types of leukemia cells and change color. The test may be ordered to distinguish one form of leukemia from another.
  
  
• Flow cytometry. This procedure uses fluorescent antibodies to detect certain molecules on the surface of leukemia cells. This test may be ordered to determine the exact type of leukemia or to distinguish leukemia from other diseases. It is also used to determine the amount of DNA in the cancer cells, an important factor in determining the child’s prognosis (outlook).
  
  
• Cytogenetics. This test uses a microscope to evaluate the characteristics of cells including their formation, function and structure. It may be ordered to determine if the cells have too many chromosomes, or if the chromosomes have any translocations (the transfer of DNA from one chromosome to another). Identifying translocations helps to distinguish certain types of ALL and is important in determining the child’s prognosis.
  
  
• Immunocytochemistry (immunotherapy).This procedure uses special antibodies to detect certain molecules on the surface of leukemia cells. The cells being examined are treated with the antibodies, which attach themselves to certain types of molecules. The cells containing these molecules then change color. The cells are then examined under a microscope. This test may be ordered to determine the exact type of leukemia or to distinguish leukemia from other diseases. 
  
  
• Molecular genetic studies. These tests examine leukemia cell DNA. They may be ordered to detect translocations that are too small to detect under a microscope with cytogenic tests. Molecular genetic studies are useful in classifying ALL because many of its subtypes have distinctive translocations. Information about the translocations can also be used to predict the child’s response to treatment. After treatment, the tests may be ordered to detect leukemia cells that can be missed under a microscope. 

ALL rarely forms visible tumors. For that reason, imaging tests have limited value. If imaging tests are done on patients with ALL, they are usually being conducted to diagnose infections or related problems rather than the leukemia. Imaging tests that may be ordered include:

• Chest x-ray. This test uses low doses of radiation to produce images of the chest on film paper or fluorescent screens. It can reveal signs of a lung infection and detect enlargement of the thymus or lymph nodes in the chest.
  
  
• Computed tomography (CT) scan. Also known as a computed axial tomography (CAT) scan, this test allows for multiple x-rays to be taken from different angles around the child. It also may be performed with a contrast medium (dye) to define the structures in the body more clearly. CT scanning is helpful in detecting an accumulation of leukemia cells as well as enlarged lymph nodes or organs.

• Magnetic resonance imaging (MRI). This test uses a powerful magnetic field to create images of structures and organs within the body allowing a computer to produce very clear cross-sectional or three-dimensional images. It may be ordered to determine if the disease has spread to the spinal cord or brain. As with CT scans, a contrast medium may be injected into the patient to help define structures.
  
  
• Gallium scan and bone scan. In these procedures, a child receives an injection of a radioactive substance that is often absorbed by areas of the body where ALL is present or bone is damaged. The tests may be ordered when a child has bone pain that may be due to ALL or an infection.
  
  
• Ultrasound. This procedure uses high-frequency sound waves to produce images of internal organs. The ultrasound machine emits high-frequency sound waves, which reflect off the area of the body being examined. The reflected waves are picked up by a computer that translates the information into an image. This test is useful for detecting an enlarged kidney, liver or spleen. 

As with all cancers, treatment for acute lymphocytic leukemia (ALL) is usually coordinated by a cancer care team, headed by a primary care physician and/or medical oncologist. For children with ALL, specialists may include a hematologist, pediatric oncologist and radiation oncologist.

There are a variety of methods used to treat ALL in children. The exact treatment method chosen for each child depends on the risk group of the leukemia as well as certain prognostic factors including the child’s age and white blood cell count at the time of diagnosis. Children may receive one method of treatment or a combination of treatments.  

Since leukemia is a blood disorder and does not form tumors, surgery is not a form of treatment. Common treatment methods for ALL in children include:

• Chemotherapy. This treatment method uses powerful drugs to destroy cancer cells. It may also be used to prevent the cancer from spreading to the brain and spinal cord. When used to treat ALL, a combination of drugs is given to the child over a long period of time. Chemotherapy is the most common treatment method for ALL, and children tend to respond better to chemotherapy than adults.
  
  
• Radiation therapy. Radiation therapy uses high-energy rays to destroy cancer cells and shrink tumors. It may be ordered to treat leukemia that has spread to the brain, spinal fluid or testicles. On rare occasions, radiation treatment may be ordered as an emergency treatment to reduce the size of a mass pressing on the trachea.
  
  
• Bone marrow/stem cell transplantation. This method allows a child to receive high levels of chemotherapy, radiation or a combination of both. Although the high dose treatment destroys the leukemia cells, it also destroys normal blood cells in the bone marrow. After the treatment, the child receives an infusion of healthy stem cells through a vein. The stem cells may come from a matched donor or from the patients themselves. As a result, new blood cells begin to develop from the transplanted cells. This procedure is still fairly new and complex and cannot be used with all children.

Children with ALL will be treated according to the severity of their cancer. Since ALL is a cancer of the blood, the treatments are designed to treat the entire body. Chemotherapy is the primary treatment and provided in the following stages:

• Induction. This the most aggressive stage with the goal of destroying as many cancer cells as possible and putting the disease in remission. More than 95 percent of children with ALL will enter remission after the first month of treatment. The child usually receives a combination of chemotherapy drugs designed for the specific type of leukemia.
  
  
• Consolidation. During this phase, different types of drugs are given to destroy those cells that remain after the induction phase. This phase also focuses on preventing the spread of cancer cells to other areas, particularly the central nervous system (CNS). If cancer cells are noted in the spinal fluid at this time, the child may receive radiation therapy to the brain and spinal cord (part of the CNS).
  
  
• Maintenance. This is the last phase of treatment which may continue for two to three years. This part of treatment is less intensive and may consist mainly of medications (pills) given at home. Occasionally, the child may need to receive intravenous medications during this phase. The type of medication and dose will depend on the characteristics of the child’s cancer.

Usually, the total duration of therapy for most children with ALL is two to three years. After treatment a child will require regular visits to their physician for several years. Frequent checkups enable their physician to detect any changes in health and treat them immediately. Checkups may include a physical examination, x-rays, blood tests, and other lab tests.

Parents are encouraged to report the development of any new symptoms in their child to their physician. They may be a sign of recurrent ALL or side effects of treatment. If a relapse occurs, it typically occurs while the child is undergoing treatment, or within six months of completing treatment. The disease can come back in the blood, bone marrow, or other parts of the body. It is unusual for ALL to return if there are no signs of the disease two years after treatment. According to the American Cancer Society (ACS), the five-year survival rate for children with ALL is 87 percent. This high cure rate is mainly due to advancements in treatment.

Currently, there is no known method of preventing acute lymphocytic leukemia (ALL) in children because it is not linked to preventable lifestyle risk factors. Children with a known risk factor, such as Down syndrome or treatment with chemotherapy or radiation therapy, should receive regular medical check-ups. The earlier the disease is diagnosed, the earlier treatment may begin. In addition, pregnant women should always inform their physician before undergoing tests or medical procedures that involve radiation, including x-rays.

Most types of cancer are classified by a process known as staging. Staging assigns numbered stages to cancers based on tumor size and how far the cancer spreads from the original site. Leukemia, however, is not staged because it involves all the bone marrow in the body and in many cases also spreads to other organs. For cases of acute lymphocytic leukemia (ALL) in children, risk groups are used instead of stages.

Certain prognostic factors have been identified to help a physician determine if a child requires more or less treatment. Based on these factors, the child is placed in a certain risk group. Treatment for the child depends on the risk group. These groups are:

• Low-risk
• Standard-risk
• High-risk
• Very-high risk

Prognostic factors for children with ALL include:

• Age at diagnosis. Children between the ages of 1 and 9 generally do better, while children younger than 1 or older than 10 are considered high-risk.
  
  
• White blood cell count. Children who have a white blood cell count greater than 50,000 cells per cubic millimeter at the time of diagnosis are classified as high-risk and are usually subjected to more intensive treatment.
  
  
• Gender. Girls with ALL have a slightly higher cure rate than boys.
  
  
• Race. African American and Hispanic children with ALL typically have a lower chance of being cured than children of other races.
  
  
• Organ spread. In boys with ALL, spread of the disease to the spinal fluid or the testicles increases the risk of a poor outcome.
  
  
• Immunophenotype of the leukemia cells. Immunophenotyping determines whether the cancer cells began from B-cells or T-cells. Children with early pre-B-cell or pre-B-cell ALL have a higher cure rate than those with T-cell or mature B-cell leukemia (Burkitt leukemia).
  
  
• Number of chromosomes. Children whose cancer cells have an increased number of chromosomes (hyperdiploidy) have a higher cure rate. Often, hyperdiploidy is expressed as a “DNA index” of more than 1.16. Likelihood of being cured is especially high when there is an extra chromosome 4 or 10. Children whose cancer cells have fewer cells than normal (hypodiploidy) have a lower cure rate.
  
  
• Translocations. A translocation is the transfer of DNA from one chromosome to another. Children whose cancer cells have a translocation between chromosomes 12 and 21 have a higher cure rate. Those with a translocation between chromosomes 9 and 22 (the Philadelphia chromosome), 1 and 19, or 4 and 11 have a lower cure rate.
  
  
• Response to chemotherapy. Children whose ALL responds completely to chemotherapy within one to two weeks of treatment have a better prognosis than those who do not respond as well.

Age at diagnosis and white blood cell count at diagnosis are considered the two most important prognostic factors in determining a child’s risk level.

Other factors that influence prognosis and treatment choices include:

• How quickly and how low the child’s white blood cell count falls after the initial treatment.
  
  
• Whether there are specific changes in the chromosomes of the lymphocytes.
  
  
• Whether the ALL has spread to the brain and spinal cord.

According to the American Cancer Society (ACS), the cure rate for the various risk levels of ALL in children includes:

There is a great deal of research being done in the area of acute lymphocytic leukemia (ALL) in children. Scientific studies and clinical trials are being conducted in laboratories and medical centers by a number of cancer specialists. Areas of research for ALL in children include:

• Targeted therapy. This type of treatment uses drugs specifically designed to attack cells that have the Philadelphia chromosome. This is a translocation mutation that is found in many ALL patients. A newer drug called imatinib has shown promise for treating patients with the Philadelphia chromosome. Clinical trials continue to study the effectiveness of this drug alone as well as in combination with chemotherapy for treating various forms of leukemia. 
  
  

  Researchers are studying two additional drugs that work as targeted therapies in ALL patients. These drugs, dasatinib and nilotinib, are being studied as treatment for ALL patients with the Philadelphia mutation. Clinical trials have suggested these drugs may be beneficial for patients who are intolerant or resistant to imatinib.
  

• Genetics. Scientists continue to research how changes in DNA can cause normal bone marrow cells to develop into abnormal leukemia cells. Advances in cytogenetics are helping researchers analyze chromosomal abnormalities to help with earlier detection and treatment.
  
  Research in genetics has lead to the development of a highly sensitive test known as the polymerase chain reaction (PCR) test. This test can identify one tumor cell among millions, based on DNA changes. Other techniques, such as gene expression profiling may help identify risk factors and plan targeted therapy.
  
  
• Chemotherapy drugs. Research continues to work on the development of new chemotherapy drugs and combinations that can provide the most effective treatment with fewer side effects. Scientists are also focusing on techniques to prevent or reverse leukemia cells from becoming resistant to drugs.
  
  
• Monoclonal antibodies. These proteins are developed in laboratories and are designed to attach to the surface of ALL cells. Radioactive chemicals or cell poisons can also be attached to the antibodies and transported to the leukemia cells in an approach known as radioummunotherapy. When the antibodies are injected into patients with leukemia, the antibodies either destroy the cells directly or allow the poison to kill the cells. There are several monoclonal antibodies being studied for the treatment of ALL.
  
  
• Stem cell transplantation. Research continues to study transplant techniques that can increase the effectiveness of treatment and reduce the complications from the procedure. Additionally, researchers are studying which patients benefit the most from bone marrow and stem cell transplants.

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Parents or patients may wish to ask their doctor the following questions about acute lymphocytic leukemia (ALL):

1. What signs might indicate ALL in my child?
   
   
2. How is ALL different from other forms of leukemia?
   
   
3. What tests will be used to diagnose the disease?
   
   
4. When and from whom will we receive the results?
   
   
5. What type of ALL does my child have?
   
   
6. What is the prognosis for this type of ALL?
   
   
7. What are the treatment options?
   
   
8. What are the risks associated with these treatments?
   
   
9. If a bone marrow transplant is needed, can I be a donor for my child?
   
   
10. How will we know if the treatment has been successful?
    
    
11. How do you know if a person is in remission?
    
    
12. What are the chances of ALL returning after remission?
    
    
13. Is my child a candidate for any clinical trials?
    
    
14. Does ALL place my child at risk for other types of cancer?
    
    
15. How will my child be monitored after treatment?
    
    
16. If a parent has ALL, does it increase the risk of a child developing the disease?
    
    
17. If one child has ALL, are my other children at greater risk of developing leukemia?
    
    
18. Can you recommend a leukemia support group?