Acute Lymphocytic Leukemia Diagnosis and Staging

April 19, 2024 
This page was reviewed under our medical and editorial policy by Guido Marcucci, M.D., Chair, Department of Hematologic Malignancies Translational Science, City of Hope Duarte

Acute lymphocytic leukemia (ALL) is a type of blood cancer diagnosed using a variety of medical tests. If ALL is diagnosed in a patient, additional testing is performed to determine the cancer’s stage and subtype in order to create a personalized treatment plan.

This guide to acute lymphocytic leukemia is designed to help patients and their families learn more about diagnosis and staging of ALL.

How Is Acute Lymphocytic Leukemia Diagnosed?

A patient’s health care team may perform a series of tests if ALL is suspected. The most commonly used tests throughout the diagnostic process are listed below.

Physical exam: During a physical exam, a doctor reviews a patient’s medical history and discusses potential risk factors. The doctor examines the patient and discusses any symptoms, such as bleeding, bruising or frequent infections.

Blood test: A blood test — also known as a complete blood count (CBC) — tests the numbers of red and white blood cells and platelets in the body. A peripheral blood smear might also be performed, which is another type of blood test that examines blood cells under a microscope to look for cell abnormalities.

Bone marrow aspiration and biopsy: During a surgical procedure, a thin, hollow needle is used to remove a sample of liquid bone marrow, using local anesthetic to avoid discomfort. A biopsy may also be performed with a slightly larger needle in order to remove a sample of bone and marrow tissue. These samples allow doctors to test for the presence of leukemia.

Aspirations and biopsies are diagnostic tools, but they may also be used to determine how a patient is responding to treatment.

Lymph node biopsy: During a lymph node biopsy, all or part of a lymph node is surgically removed to look for the presence of cancer. However, this procedure is more commonly used when diagnosing lymphomas than leukemias.

Lumbar puncture: A lumbar puncture — sometimes referred to as a spinal tap — may be used as a staging tool to check if the cancer has spread to the spinal cord and brain. During this procedure, a small needle is used to collect spinal fluid for testing.

Imaging tests: Imaging tests — such as X-ray, computed tomography (CT), magnetic resonance imaging (MRI) and ultrasound — are less commonly used in ALL patients. However, they might be used to see if the cancer has spread to other organs in the body or to look for evidence of infections or other problems.

Acute Lymphocytic Leukemia Stages

Unlike most cancer types, blood cancers don’t form solid tumors. This means no standard staging system for ALL exists. As a result, ALL cancers are classified differently than other cancers.

In adults, ALL is categorized as untreated, in remission or recurrent. These categorizations, listed below, are determined by a number of factors, including the patient’s blood and bone marrow counts and ALL symptoms.

Untreated ALL: Newly diagnosed cancer that hasn’t been treated yet, where patients also have:

• Normal blood counts
• More than 5% of bone marrow cells with leukemia.
• Symptoms of leukemia

In remission: This cancer category has already gone through treatment. In this stage, patients will have:

• Normal blood counts
• Fewer than 5% of bone marrow cells with leukemia
• No symptoms of leukemia beyond bone marrow

Recurrent: ALL has returned after treatment and may have:

• Returned to the blood
• Returned to the bone marrow
• Spread to other areas of the body

Subtypes of ALL

ALL is broken down into more detailed classifications, known as subtypes. The most commonly used system for ALL types is the World Health Organization (WHO) system, which identifies cancer subtypes based on their genetic and chromosomal makeup.

The WHO system for ALL subtypes includes those listed below.

B cell ALL: This type of ALL begins in immature cells that are supposed to develop into healthy B cell lymphocytes. There are many subtypes of B cell ALL based on which chromosomes are affected.

T cell ALL: This type of ALL develops in immature cells that would normally develop into T cell lymphocytes. It is less common than B cell ALL.

Mixed lineage acute leukemias: This acute leukemia type has features of both lymphocytic and myeloid leukemia cell changes.

Each cancer subtype is biologically unique and may be treated differently. It may be confusing to understand exactly what a subtype means for each patient’s acute lymphocytic leukemia treatment plan, but the patient’s health care team is available and ready to answer questions and provide support.