• Relapsed Acute Lymphoblastic Leukemia (ALL)

    Relapsed acute lymphoblastic leukemia, or relapsed ALL, refers to the return of acute lymphoblastic leukemia (ALL) in patients who have already undergone treatment for the disease. Between 15 and 20 percent of children who are treated for ALL and achieve an initial complete remission will have the disease return.

    Relapsed ALL Treatment at Dana-Farber/Boston Children's

    Children and adolescents with relapsed acute lymphoblastic leukemia (ALL) are treated at Dana-Farber/Boston Children’s Cancer and Blood Disorders Center through the Leukemia Program, one of the top pediatric leukemia treatment programs in the world. Our Leukemia Program has played a leading role in refining treatment for childhood leukemia, resulting in today’s cure rates of more than 90 percent for ALL—and we continue to lead clinical trials designed to increase cure rates, decrease treatment-related side effects, and improve care for long-term survivors.

    What are the symptoms of relapsed ALL?

    In relapsed ALL—as with newly diagnosed ALL—lymphocyte stem cells (a type of blood stem cell) become immature white blood cells called lymphoblasts or “blasts.” These blasts do not become healthy white blood cells. Instead, they build up in the bone marrow, so there is less room for healthy white blood cells, red blood cells and platelets. In addition, these abnormal cells are unable to fight off infection.

    The symptoms of relapsed ALL are the same as those for newly diagnosed ALL, including:

    • anemia
    • bone and joint pain
    • bruising or petechiae (small red spots on the skin)
    • fever
    • recurrent infections
    • abdominal pain
    • swollen lymph nodes
    • dyspnea, or difficulty breathing

    How is relapsed ALL diagnosed?

    To make a diagnosis of pediatric relapsed ALL, a doctor may order a variety of different tests, including:

    • complete blood count
    • bone marrow aspiration and biopsy
    • lumbar puncture (spinal tap)
    • x-ray
    • chromosomal analysis, which may help determine the way the leukemia is treated 

    After all tests are completed, doctors will be able to outline the best treatment options.

    What are the relapsed ALL treatment and care options?

    Treatment of relapsed ALL is much more intensive than for newly diagnosed ALL. Every child or adolescent who experiences a relapse of ALL undergoes reinduction therapy—a treatment course intended to achieve another complete remission. Reinduction therapy typically consists of chemotherapy given by vein (intravenous), by mouth (oral) and into the spinal fluid (intrathecal).

    After achieving another complete remission, treatment options include 1) chemotherapy with or without radiation and 2) stem cell (bone marrow) transplantation. The treatment strategy recommended for your child will depend on several factors, including:

    • the site of relapse (i.e., bone marrow, central nervous system, testicles)
    • the length of time between initial diagnosis and relapse
    • the type of ALL for which your child was initially treated (B-cell versus T-cell)
    • how many relapses your child has experienced (first, second, etc.)

    Patients who relapse in their marrow during or just after completing initial treatment may benefit from a stem cell transplant. Patients who relapse six months or more after initial treatment can often be re-treated with more intensive chemotherapy without a transplant.

    Relapses most often occur in the bone marrow. Less commonly, ALL will relapse in the central nervous system (CNS; the brain and spinal fluid) or, in boys, in the testicles, without any bone marrow involvement. As with bone marrow relapses, such cases are treated with aggressive chemotherapy—including, in CNS relapses, intrathecal chemotherapy (treatment delivered to the spinal canal)—but with the addition of radiation therapy targeted to the site of relapse.

    Sometimes relapsed ALL does not respond to standard chemotherapy agents. For patients whose leukemia persists despite aggressive chemotherapy, the Hematologic Malignancy Center offers clinical trials of many new agents and treatment approaches.

    These treatment approaches include:

    • New chemotherapy drugs
    • Novel combinations of chemotherapy drugs, or combinations incorporating new agents to other known active agents
    • Antibodies directed against the leukemia
    • Drugs that stimulate the body’s immune system to attack the leukemia

    What relapsed ALL clinical trials are available?

    See our list of open pediatric leukemia clinical trials, which includes trials for relapsed ALL. We also have a clinical trial for relapsed B-cell ALL testing the safety of giving patients special cells made from their own blood called "modified T-cells." The goal is to find a safe dose of modified T-cells for patients whose leukemia has returned.

    Should you have questions or need advice on whether a particular trial would be appropriate for your child, email our clinical trials team at clinicaltrials@danafarberbostonchildrens.org. We can help you navigate your options.

    What is the long-term outlook for children with relapsed ALL?

    The prognosis for children with relapsed ALL depends on a number of factors, including:

    • the site of relapse (i.e., bone marrow, central nervous system, testicles)
    • the length of time between initial diagnosis and relapse
    • age of child at initial diagnosis
    • response after the first month of reinduction treatment
    • biological features of the relapsed cells