



































Special Edition: Junior Clinical Research (2022), Vol. 2 No. S2 
 https://doi.org/10.47488/dhrp.v2iS2.62 

 

 

 
 
 DHR Proceedings ǀ http://dhrproceedings.org  23 2022, Vol. 2 No. S2 23-29 

 

 

COMMENTARY 

Pediatric Acute Lymphocytic Leukemia 
 

 

Paris Canales1,2, Ashley Contreras1,2, Gerald Esguerra1,2, Raul Garcia1,3, Kimberly Garza1,3, 

Matthew Gonzalez1,2, Danika Lopez-Torres1,3, Edith Paez1,3, Nolan Salinas1,3, Kayra Serna-

Herrera1,3 

 
12nd Annual Junior Clinical Research Internship, South Texas Academy for Education & Training in Research, DHR Health 

Institute for Research & Development 

2 Nikki Rowe High School, McAllen TX 

3 Edinburg North High School, Edinburg TX 

 

All correspondence should be addressed to Program Director, 2nd Annual Junior Clinical Research Internship Program, DHR 

Health Institute for Research & Development, 5323 S McColl Road, Edinburg Texas, 78539 

 

Received 07/21/2022 

Accepted for publication 08/03/2022 

Published 08/03/2022 

 

 
 

 

Introduction 
 

Leukemia is a type of cancer that most commonly 

affects the bone marrow and other blood forming 

organs to produce an increased number of blastic 

leukocytes. Additionally, leukemia isn’t just a cancer 

that affects the white blood cells, it also affects the 

erythrocytes. The effect that leukemia has on the 

erythrocytes could also cause various types of anemia. 

Moreover, leukemia is responsible for 1 out of 3 

cancers found in the pediatric group [1]. But in the 

years 2013-2017, leukemia and lymphoma accounted 

for nearly 40% of all cancers found in people less than 

20 years old [2].  

 

Types of Leukemia 

 
Furthermore, there are different types of 

leukemia and are categorized as chronic (slow) or 

acute (fast). Digging deeper into the types of 

leukemias, there are 2 major types of variants, 

lymphocytic and myelogenous [3].  Myelogenous 

leukemia is a type of leukemia that starts in the bone 

marrow while lymphocytic leukemia starts in the 

white blood cells (leucocytes). These 2 types also 

come in a chronic and acute form. There are also more 

rare types of leukemias like hairy cell leukemia, 

myelodysplastic syndromes, and myeloproliferative 

disorders [4].  

 

Acute Lymphocytic Leukemia  
 

The most common of these leukemias in 

children is acute lymphocytic leukemia (ALL). 

Approximately, 75% of all leukemia cases around the 

world are diagnosed in children residing in the United 

States [3]. 

 

Symptoms 
  

Acute lymphocytic leukemia being an extremely rare 

and fast paced disease. Many times, children 

diagnosed with acute lymphocytic leukemia 

experience little to no symptoms within the months, 

weeks, and even days before being diagnosed due to 

the white blood cells in the blood expanding at a rapid 

rate [5]. 

The most common or first symptom is extreme fatigue. 

Many patients cannot move for the reason that when 

their blood count is checked, their red blood cell count 



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is drastically low, and they are not getting enough 

oxygen. Developing pneumonia is also really 

common. Antibiotics do not work after developing 

pneumonia because the immune system is really low 

[5]. 

 

Symptoms of Acute Lymphocytic Leukemia are the 

following:  

● Anemia occurs when red blood cells are not 

produced due to the center of the bones 

overflowing with Leukemic cells. 

● Bleeding and/or bruising happens when the 

bone marrow does not manufacture sufficient 

platelets also known as megakaryocytes. 

● Bone and joint pain can occur due to the bone 

marrow being overfilled with leukemic 

blasts. 

● Recurrent fevers/infections may demonstrate 

elevated quantities of white blood cells that 

are immature and do not fight infection.  

● Abdominal pain happens when leukemic 

cells gather in the kidneys, liver, and spleen 

occasioning the expansion of the organs. 

● Swollen lymph nodes can occur when 

leukemia cells gather in the lymph nodes 

causing them to swell.  

● Difficulty breathing happens when cells build 

up together in the thymus and underneath the 

breastbone surrounding the throat [6]. 

 

Diagnosis 
 

The identification of a disease is known as a diagnosis. 

There are two tests that can accurately diagnose acute 

lymphocytic leukemia in children and determine the 

severity of the disease: blood testing and bone marrow 

tests [7]. A blood sample must be taken before a blood 

test may start. Since pediatric oncologists work with 

children, a lancet, a device that pricks a finger to draw 

blood from the capillary vein found there, must be 

used to take a sample of their blood [7]. Once pediatric 

oncologists collect their blood samples and send them 

to a lab, a complete blood count and blood smear will 

be performed to determine if the kids have leukemia 

and make a diagnosis. A complete blood count is a 

numerical result of how many blood cells are in a 

patient’s blood [7]. An abnormal blood cell count in 

children is a critical indicator for any pediatric 

oncologist to begin to suspect leukemia. A blood 

smear is a droplet of blood that is put on a glass slide 

and examined under a microscope [7]. A closer 

examination of a pediatric patient’s blood may further 

bring a pediatric oncologist to make a diagnosis 

because a change in the appearance of these cells may 

lead them to suspect ALL. A pediatric oncologist's 

concerns may be raised by an unusual blood cell count 

and a change in the appearance of a child's blood cells, 

but ALL cannot be definitively identified without 

analyzing a sample of the child's bone marrow cells. 

Bone marrow is a semi-solid tissue found within the 

spongy, also known as cancellous, portions of bones. 

The spongy tissue can be found within a person’s hip 

and thigh bones. There are two bone marrow sample 

collection methods that can be utilized: bone marrow 

aspiration and biopsy. Both of these procedures are 

typically carried out simultaneously, but both are 

necessary for testing ALL. A little amount of liquid 

bone marrow is aspirated using a syringe after a thin, 

hollow needle is introduced into the bone to perform a 

bone marrow aspiration [7]. The aspiration is then 

typically followed by a bone marrow biopsy. A 

slightly larger needle that is inserted down into the 

bone to remove a little bit of bone and marrow [7]. 

Pressure will be provided to the area once the biopsy 

is completed to aid in stopping any bleeding.  

 

Stages of Progression 
 

Usually, the progression or stages of cancers are 

categorized by Stage I, II, III, or IV. This is determined 
by how far away the cancer cells moved from where it 

originally began. For example, in breast cancer, if the 

tumor is located only in the breast, this would mean 

the cancer is in Stage I. If the cancer cells travel into 

the brain or the liver, it would be identified as stage IV 

[8]. 

In the case of leukemia, the blood cells themselves are 

the malignant cells. The production of blood cells goes 

out of control causing the cancer to spread throughout 

your body. These new cells that are produced are 

abnormal and won’t efficiently function as they were 

meant to do. Healthy cells will be caught by the 

crossfire causing buildup and crowds will start to form 

[9]. At the time of a diagnosis, leukemia cells are 

present in the blood and in the bone marrow. Using 

this information, it is either an active disease or it’s in 

remission [8]. 

 

DNA Mutations and Genetics  
 

Acute Lymphocytic Leukemia (ALL) is the most 

common cancer found in pediatrics. While there is no 

found direct cause of this disease it has been linked 

mainly to both genetic alterations and a phenomenon 

of DNA mutations. ALL arises from the malignant 

transformation of progenitor B- and T-cells in the bone 

marrow into leukemic cells. Genes that help keep cell 

division under control or cause cells to die at the right 

time are called tumor suppressor genes. A 

translocation seen in mostly all cases of childhood 

https://www.sciencedirect.com/topics/biochemistry-genetics-and-molecular-biology/malignant-transformation
https://www.sciencedirect.com/topics/biochemistry-genetics-and-molecular-biology/malignant-transformation


Canales, et al. Pediatric Acute Lymphocytic Leukemia 

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ALL is the swap between chromosomes 9 and 22 also 

known as the Philadelphia Chromosome [3]. The swap 

between the chromosomes causes the oncogenes to 

help the leukemic cells grow within the body. 

Intensive treatment due to a poor prognosis illustrates 

that there is a complex intrachromosomal 

amplification of chromosome 21 that is most common 

to pediatric ALL patients. Secondary deletions or 

mutations may cause alterations in lymphoid 

transcription factors, cell cycle regulations, and tumor 

suppression [10]. Studies have indicated that many 

ALL mutations are present at low variant allele 

frequency and therefore become subclonal [11]. In 

Acute Lymphocytic Leukemia, Hyperdiploidy is 

defined as the non-random gain of chromosomes, 

increasing the modal chromosome number of 

leukemic blasts from 46 to between 51 and 65 or 67. 

Leukemic cells experiencing near or low hypodiploid 

tend to undergo a process that causes the hyperdiploid 

clone to double causing the drastic increase in number 

of chromosomes found in ALL patients predominantly 

in children [12]. The increase of hyperdiploid clones 

leads to what is called masked hyperdiploidy which is 

found in 60-65% of ALL patients, 25-30% being 

children [13].  Masked hyperdiploidy is clinically 

challenging for patients battling with ALL and serves 

as one of many DNA abnormalities contained in this 

disease. In addition, genetics has led to some of the 

world’s most underlying diseases and disorders. 

Inherited genes play a key role in the growth and or 

demise of leukemic cells in pediatric ALL patients. 

Several genetic conditions have taken a severe part in 

the development of Acute Lymphocytic Leukemia, 

these conditions include but not limited to Down 

syndrome, Neurofibromatosis type 1, Bloom 

syndrome, Fanconi anemia, Ataxia-telangiectasia, and 

Li-Fraumeni syndrome [14].  Although these 

conditions can contribute to ALL, Down syndrome 

has played the predominant contribution to this 

disease. Down syndrome is defined as a genetic 

disorder caused by the presence of all or part of a third 

copy of chromosome 21. Down syndrome affects 1 in 

every 700 infants which allows for an increased risk of 

developing leukemia. Since children with Down 

syndrome have an extra copy of chromosome 21 they 

are more likely to have faulty genes; these children are 

33 times more likely to develop ALL [15]. Children 

with down syndrome not only have an increased risk 

of developing ALL, but they have an increased 2.1% 

cumulative risk of developing the disease before the 

age of 5 [14]. 

 

 

 

 

Treatment Options 
 

Chemotherapy 
Chemotherapy is one of the main treatments 

for cancerous patients. This treatment is used to reduce 

the number of cancer cells in the body. Although very 

helpful, chemotherapy can decrease health through the 

removal of healthy cells. Depending on the patient, 

they are capable of feeling fatigue, hair loss, and 

having several infections [16]. Chemotherapy can 

differ depending on a patient's health status and the 

type of cancer they are experiencing.  

 

Radiation Therapy 
 

Radiation Therapy is a form of treatment that 

focuses on the removal of cancerous cells. This 

therapy can be a very laborious process, so it requires 

a lot of patience. Radiation therapy can be very similar 

to chemotherapy in the fact that it requires an immense 

number of time. External radiation therapy is a form 

of treatment associated with radiation therapy. This 

treatment heals places where acute leukemia has 

expanded in a child's system [14].  

 

Chemotherapy With Stem Cell Transplant 
 

Chemotherapy with stem cell transplant is 

similar to chemotherapy, but it is not the primary 

treatment for children. Children aren’t able to take 

large doses of chemotherapy because of their 

development [17]. With stem cell transplant, children 

are able to have a greater outcome. This means that 

children are able to have a higher intake of 

chemotherapy.  

 

Targeted Therapy 

 
Targeted therapies are forms of treatments 

that specifically target a certain type of cancer cells, 

while avoiding healthy tissues [14]. This is a preferred 

treatment route due to the fact that standard treatments 

like chemotherapy and radiation therapy destroy 

normal, non-cancer cells. This is partially 

counterintuitive because in killing healthy cells, the 

body loses important stationary cells that continue 

growth. 

 

Tyrosine Kinase Inhibitor (TKIs) Therapy 

This form of treatment is specific to blocking 

the enzyme, tyrosine kinase, that causes an 

overproduction of white blood cells within 

the body. Three of the most common TKI 

medications are: imatinib mesylate, 

dasatinib, and ruxolitinib. These three drugs 



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are used in several other cancers and 

conditions; they can help stop the growth of 

cancerous cells and may even help in killing 

malignant cells [14].  

 

Monoclonal Antibodies 

Moving on, monoclonal antibodies are 

laboratory-developed proteins that help fight 

specific diseases, such as cancer. This type of 

treatment is usually thought of as an option 

for patients with acute lymphocytic leukemia 

that doesn’t respond to other common 

treatments. One monoclonal antibiotic 

infusion being studied and used in pediatrics 

is blinatumomab. Blinatumomab is more 

specifically used to treat B-cell ALL that is in 

remission, has recently come back, or when 

an ALL patient doesn’t respond to other 

treatment options [14]. 

 

Immunotherapy 
 

Immunotherapy is an innovative type of 

treatment that focuses on assisting the body in its own 

natural defense mechanisms. This form of therapy 

effectively utilizes the substances created by the body 

or those made in a laboratory to direct more attention 

to a given disease, in this case, acute lymphocytic 

leukemia [14]. 

 

CAR T-cell Therapy 

This form of treatment is a procedure in 

which some T cells are removed from the 

patient and given a special receptor. The new 

cells are known as chimeric antigen receptor 

(CAR) T cells. The CAR T cells are given via 

infusion and multiply in the patient’s blood - 

attacking the cancerous cells. This treatment 

is also being studied in other cancers, as well 

as recurring childhood acute lymphocytic 

leukemia [14].  

 

Relapses 
 

Relapsed Acute Lymphocytic Leukemia refers to 

when lymphoblastic stem cells become immature 

white blood cells or blasts. Instead of becoming 

healthy white blood cells they build up in the bone 

marrow, resulting in less room for healthy white blood 

cells, red blood cells, and platelets. Furthermore, 

resulting in these abnormal cells the inability to fight 

off infection [18]. After children’s first treatment for 

acute lymphocytic leukemia about 85%-90% are 

cured; however, 10% to 15% of patients with pediatric 

acute leukemia experience relapse or have a slight 

chance of getting the disease again [19]. Acute 

lymphocytic leukemia is the most common fatal 

disease in children, which consists of 25% of all 

childhood cancers [20]. 

 

Studies show that most relapsed events occurred 

during the maintenance phase and after the finalization 

of chemotherapy [20]. Stem cell transplant is rarely 

used as initial treatment for children and adolescents 

with ALL, however It is used more often as part of 

treatment for ALL that relapses. Occasionally 

treatment for relapsed ALL is more intensive and 

critical than newly diagnosed ALL. Reinduction 

therapy is received at the time of the first relapse. If 

the second complete remission is a success, treatment 

options include: chemotherapy with or without 

radiation therapy and stem cell (bone marrow) 

transplantation.  

 

Prognosis 
 

A prognosis is the likely course of an illness after a 

diagnosis. When it comes to the prognosis of children 

with acute lymphocytic leukemia, there are numerous 

crucial determinants. The white blood cell count of a 
child and their age are prime examples of the many 

important influential factors. White blood cells, also 

known as leukocytes, are located in the circulatory 

system to fight off infections. Children with ALL who 

have very high white blood cell counts (greater than 

50,000 cells per cubic millimeter) when they are 

diagnosed are at higher risk and need more intensive 

treatment [21]. An overproduction in white blood cells 

is a main indicator for certain blood cancers or bone 

marrow diseases, such as ALL. In continuation, a 

pediatric patient’s age is essential to determining their 

prognosis because of their B-cell count. B-cells, also 

known as B-lymphocytes, are located in the immune 

system to produce tumor-specific antigens that stop 

the development of cancer, such as ALL. B-cell counts 

are found by blood tests. Children between the ages of 

1 and 9 with B-cell ALL tend to have better cure rates 

[21]. Physicians can plan their pediatric patients' 

future treatments once they have pediatric patients 

who have been diagnosed with B-cell ALL, a rare 

subtype of ALL, and know their B-cell count. When 

pediatric patients’ white blood cell counts and/or their 

age are reported to clinicians, they are often divided 

into risk categories classified as low risk to extremely 

high risk, with higher risk kids receiving more 

intensive treatment. 

 

 

 

 



Canales, et al. Pediatric Acute Lymphocytic Leukemia 

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Mortality Rate 
 

What is a mortality rate? A mortality rate is the 

measure of the frequency of occurrence of death in a 

defined population during a specified interval. Acute 

lymphocytic leukemia has been found to be the most 

common form of childhood cancer. It is usually found 

in children from ages 3 to 5 and it affects boys slightly 

more than girls [22]. Approximately 6,000 cases of 

Acute Lymphocytic Leukemia (ALL) cases are 

diagnosed in the US each year. More than 50% of 

these cases are in pediatric patients. The five-year 

mortality rate for pediatric patients diagnosed with 

ALL is 10%. Even though childhood cancer rates have 

been increasing, death rates have been drastically 

decreasing [16]. 

 

Survival Rate  

 

A survival rate refers to the percentage of people in a 

study or treatment group who are still alive for a 

certain period of time after they were diagnosed with 

or started treatment for a disease. Each year roughly 

about 6,000 ALL cases are diagnosed. More than half 

of these cases are diagnosed in children. 90% of 

pediatric cases found can be cured [16]. St. Jude 

patients diagnosed with ALL have a 94% survival rate, 

which is the best worldwide outcome for ALL  

patients. 

 

Conclusion  

 

In closing, acute lymphocytic leukemia (ALL) is a 

type of cancer that affects the blood and bone marrow 

of the body [9]. ALL is the most common pediatric 

leukemia, with approximately over 3,000 cases 

diagnosed in children. Even with being the most 

prevalent leukemia diagnosed in the pediatric group, 

only about 10% of patients succumb to ALL [16].  

Unfortunately, a cure has not been found for this 

disease. Doctors, patients, and all corresponding 

parties await for more research to stop the progression 

and cure acute lymphocytic leukemia in all children. 

 

Acknowledgments 

 

Dr. Monica Betancourt-Garcia, MD, Scientific 

Director; Melissa Eddie, MS, Program Manager; 

Xochitl Lopez, BS, Program Coordinator 

 

Funding 

 

Funded by DHR Health Institute for Research & 

Development; DHR Health; Region One ESC 

GEARUP College Ready, Career Set! Region One 

ESC GEARUP College Now, Career Connected and 

Region One ESC PATHS 

 

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