Acute lymphoblastic leukemia (ALL) is a relatively common type of childhood acute leukemia with a relatively good prognosis, and some children have already been cured.

bubble_chart Clinical Manifestations

(1) Morphological Classification (FAB Classification)

1. L1 type: Predominantly small lymphoblasts (>75%), with round nuclei, inconspicuous nucleoli, coarse nuclear chromatin, and scanty cytoplasm.
2. L2 type: Larger lymphoblasts than L1 (>25%) (cell diameter greater than the sum of two small lymphocyte diameters). Nuclei are irregular, may show folding, nucleoli are large and prominent, nuclear chromatin is loose, and cytoplasm is abundant.
3. L3 type: Predominantly large lymphoblasts with vacuoles, uniform in size, nuclear chromatin is finely stippled, nuclei are relatively regular, nucleoli are single or multiple and prominent. Cytoplasm often appears honeycombed, resembling Burkitt lymphoma cells.

Generally divided into the following five types:

1. T-lymphocyte type (T-ALL): Positive for T-lymphocyte markers such as CD1, CD2, CD3, CD4, CD5, CD7, CD8, and TdT.
2. Early pre-B-lymphocyte type (early preB-ALL): Also known as early preB-ALL type heat stranguria, positive for HLA-DR and CD19 or (and) Cy CD22, while other B-lineage markers are negative.
3. Common type heat stranguria (C-ALL): Also known as early preB-ALL type II heat stranguria (early preB-AILⅡ), CD10 positive, CyIg and SmIg negative, while other B-lineage markers such as CD19, Cy CD22, and HLA-DR are mostly positive.
4. Pre-B-lymphocyte type (preB-ALL): CyIg positive, SmIg negative, other B-lineage markers such as CD19, Cy_CD22, CD10, CD2, and HLA-DR are often positive.
5. Mature B-lymphocyte type (B-ALL): SmIg positive, CyIg negative, other B-lineage markers such as CD19, Cy CD22, CD10, CD20, and HLA-DR are often positive.

Commonly associated abnormal changes include: t(12;21), t(9;22), t(4;11), t(8;14), t(11;14), etc.

(4) Clinical Classification

The classification criteria have been revised multiple times. In 1998, a national conference proposed the following classification recommendations. Patients with any one or more of the following risk factors are classified as high-risk (HR-AIL), otherwise as standard-risk (SR-ALL).

1. Peripheral blood white blood cell count at diagnosis >50×10⁹/L.
2. Presence of central nervous system leukemia (CNSL) at diagnosis.
3. Immunophenotype is mature B-ALL.
4. Chromosomal karyotype shows t(4;11) or t(9;22) abnormalities.
5. < 12個月的嬰兒白血病。
6. Poor response to prednisone induction test (i.e., after administering prednisone 60mg/(m²‧d) × 7 days, peripheral blood leukemia cells on day 8 ≥1×10⁹/L).
7. Failure to achieve complete remission (CR) after 6 weeks of induction chemotherapy.

bubble_chart Treatment Measures

Chemotherapy

(I) Induction of remission

1. Regimen 1: DA regimen: DNR (Daunorubicin) 30～40mg/(m²‧d), iv, days 1～3; Ara-C (Cytarabine) 150～200mg/(m²‧d), divided into 2 doses iv or im, days 1～7.
2. Regimen 2: HA regimen: H (Homoharringtonine) 4mg/(m²‧d), iv, days 1～9. Ara-C same as DA regimen.
3. Regimen 3: DA + VP-16 regimen: DNR 20mg/(m²‧d), iv, days 1～4 and 15～18. Ara-C 150mg/(m²‧d), divided into 2 doses im, days 1～4 and 15～18. VP-16 100～150mg/(m²‧d), iv, days 1～4 and 15～18.

1. Consolidation therapy: A total of 6 cycles, each cycle lasting 28 days, alternating high-dose Ara-C (HD Ara-C) with DA, HA, and VP-16 + Ara-C regimens for half a year. Specific method: Cycles 1, 3, and 5 use HD Ara-C therapy, with two options:
   1. Regimen 1: HD Ara-C + L-Asp regimen: Ara-C 1～2g/dose, every 12 hours, totaling 8 doses, iv, days 1, 2, 8, and 9. L-Asp: Administer 6000U/m², iv, 42 hours after every 4 doses of Ara-C, days 4 and 11.
   2. Regimen 2: VP-16 + HD Ara-C regimen: VP-16 100mg/m2, iv, days 1～3. HD Ara-C 1～2g/(m²‧dose), every 12 hours, totaling 6 doses, days 4, 5, and 6. Cycles 2, 4, and 6 use HA, DA, and EA regimens respectively [EA regimen: VP-16 100mg/(m²‧d), iv, days 1, 2, and 3; Ara-C 100～150mg/(m²‧d), days 1～7]. After completing consolidation therapy, treatment may be discontinued for observation or proceed to the following maintenance therapy.
2. Maintenance therapy: Select three regimens from COAP, HA, EA, and AT (Ara-C + 6μG), administered sequentially at regular intervals until continuous complete remission (CCR) reaches 2～2.5 years, then observe. In the first year, each cycle lasts 2 months; in the second year, each cycle lasts 3 months.
3. CNSL (Central Nervous System Leukemia) prevention: Triple intrathecal drug injection method is the same as heat stranguria. During the induction remission stage, administer once every 2 weeks for a total of 4 times. During post-remission consolidation therapy, administer once in cycles 2, 4, and 6. During maintenance therapy, administer once every 3～6 months. For M4 and M5, cranial radiotherapy may be added, with the same method as heat stranguria.

Induction of remission may use ATRA (All-Trans Retinoic Acid) 30～60mg/(m²‧d), divided oral doses until complete remission, then alternate RA with COAP or DA, HA regimens. General acute non-lymphocytic leukemia regimens may also be used. Discontinue treatment when CCR reaches 2～2.5 years. CNSL prevention is the same as other ANLL.