Acute childhood leukemia (Acute Lymphocytic Leukemia)

Acute Childhood Leukemia (Acute Lymphocytic Leukemia) – Treatment Options

Introduction
Acute lymphocytic leukemia (ALL) is the most common pediatric malignancy, characterized by uncontrolled proliferation of immature lymphoid precursors in the bone marrow and blood. It presents with anemia, thrombocytopenia, infections, bone pain, lymphadenopathy, and hepatosplenomegaly. Advances in chemotherapy have led to cure rates exceeding 85% in children. Treatment is risk-adapted, prolonged, and requires multidisciplinary care.

1. Initial Stabilization and Supportive Care

• Correction of cytopenias: Transfusion of packed red blood cells and platelets as needed.

• Infection management: Broad-spectrum antibiotics for febrile neutropenia; antifungals/antivirals as indicated.

• Tumor lysis syndrome prevention:

  • IV hydration.

  • Allopurinol or rasburicase to control uric acid.

• Central venous catheter placement: For long-term chemotherapy administration.

2. Multi-Phase Chemotherapy (Standard of Care)

• Induction phase (first 4–6 weeks):

  • Goal: Achieve complete remission (no detectable leukemia).

  • Agents: Glucocorticoids (prednisone or dexamethasone), vincristine, asparaginase, ± anthracyclines (daunorubicin).

• Consolidation/Intensification phase:

  • Goal: Eradicate residual disease.

  • Agents: High-dose methotrexate, cytarabine, cyclophosphamide, 6-mercaptopurine, and asparaginase.

• Maintenance therapy (up to 2–3 years):

  • Goal: Prevent relapse.

  • Agents: Daily oral 6-mercaptopurine, weekly oral or IV methotrexate, intermittent vincristine and corticosteroids.

• CNS prophylaxis (throughout therapy):

  • Intrathecal chemotherapy (methotrexate, cytarabine, hydrocortisone) ± cranial irradiation in high-risk cases.

3. Targeted and Advanced Therapies

• Tyrosine kinase inhibitors (imatinib, dasatinib): For Philadelphia chromosome–positive (Ph+) ALL.

• Monoclonal antibodies:

  • Blinatumomab (CD19-directed bispecific T-cell engager).

  • Inotuzumab ozogamicin (anti-CD22 antibody-drug conjugate).

• CAR-T cell therapy: Anti-CD19 CAR-T (tisagenlecleucel) for relapsed/refractory ALL.

4. Hematopoietic Stem Cell Transplant (HSCT)

• Considered in high-risk patients, relapsed disease, or those with poor response to initial therapy.

• Provides curative potential but associated with significant morbidity and mortality risks.

5. Supportive and Long-Term Management

• Infection prophylaxis: Trimethoprim-sulfamethoxazole for Pneumocystis jirovecii, acyclovir or antifungals in selected cases.

• Growth and fertility preservation: Monitoring for chemotherapy-induced endocrine dysfunction; fertility counseling.

• Neurocognitive and psychosocial support: School reintegration and psychological counseling.

• Vaccination: Inactivated vaccines when immune recovery permits; live vaccines avoided during therapy.

6. Multidisciplinary Care

• Pediatric oncologists/hematologists: For chemotherapy and risk-adapted therapy.

• Infectious disease specialists: For management of opportunistic infections.

• Radiologists and pathologists: For diagnosis and disease monitoring.

• Endocrinologists, cardiologists, neurologists: For managing late effects of therapy.

• Psychologists, social workers, and rehabilitation specialists: For emotional and developmental support.