Diagnosis and Management of B-cell Acute Lymphoblastic Leukemia (B-ALL) in Children

Introduction to B-ALL

The National Comprehensive Cancer Network recommends that children with B-cell Acute Lymphoblastic Leukemia (B-ALL) should be treated at specialized cancer centers with expertise in ALL management to achieve optimal outcomes 1, 2

Children with ALL may present with symptoms related to infiltration of blasts in bone marrow, lymphoid system, and extramedullary sites, including pain in extremities or joints, which may be the only presenting symptom in children 1
Diagnosis requires demonstration of ≥20% bone marrow lymphoblasts on hematopathology review of bone marrow aspirate and biopsy materials 1, 2
The National Comprehensive Cancer Network recommends morphologic assessment, including Wright-Giemsa–stained bone marrow aspirate smears and hematoxylin and eosin–stained core biopsy and clot sections, for diagnosis 1, 2, 4

Hypodiploidy (<44 chromosomes) is an unfavorable risk feature in B-ALL 4
t(9;22)(q34.1;q11.2), BCR-ABL1 (Philadelphia chromosome), is an unfavorable risk feature in B-ALL 5
KMT2A (MLL) rearrangements are an unfavorable risk feature in B-ALL 2
Intrachromosomal amplification of chromosome 21 (iAMP21) is an unfavorable risk feature in B-ALL 4

The National Comprehensive Cancer Network recommends a treatment approach with tyrosine kinase inhibitors for Philadelphia Chromosome-Positive (Ph+) B-ALL 2
Clinical trials are a preferred treatment option for relapsed/refractory disease 4
Tisagenlecleucel (CAR T-cell therapy) is a treatment option for relapsed/refractory disease 6
Inotuzumab ozogamicin is a treatment option for relapsed/refractory disease 6

The National Comprehensive Cancer Network recommends adequate hydration and allopurinol before starting steroids or chemotherapy to prevent tumor lysis syndrome 3
Infection control measures, including hand hygiene and isolation precautions, are essential in B-ALL management 3
Nutritional support is necessary to prevent malnutrition, which can impair immunity and decrease tolerance to chemotherapy 3

Regular assessment of bone marrow aspirate is necessary for suspected relapse 5
Monitoring for late effects, including echocardiogram for anthracycline-related cardiotoxicity, neuropsychological testing for neurotoxicity, and monitoring for obesity, is essential in B-ALL follow-up 5