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Relapsed Childhood Acute Lymphoblastic Leukemia (ALL) Overview

  • Children and adolescents with relapsed acute lymphoblastic leukemia (ALL) are treated at Dana-Farber/Boston Children's Cancer and Blood Disorders Center through the Childhood Leukemia Program, one of the top pediatric leukemia treatment programs in the world. Our 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.

    We are also a certified treatment center for providing KYMRIAH, the FDA-approved CAR T-cell therapy for relapsed B-cell ALL for patients who are up to 25 years old.


  • CAR T-Cell Therapy for Children with Relapsed ALL

  • About Childhood Relapsed 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.

    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

    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
    • How many relapses your child has experienced (first, second, etc.)

    How We Diagnose Childhood Relapsed ALL

    To make a diagnosis of pediatric relapsed acute lymphoblastic leukemia, 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.

    How We Treat Childhood Relapsed ALL

    Treatment of relapsed acute lymphoblastic leukemia is typically more intensive than for newly diagnosed ALL. At the time of first relapse, children and adolescents receive 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). Often, it is similar to treatment that was given when the ALL was first diagnosed.

    After achieving a second complete remission, treatment options include 1) chemotherapy with or without radiation therapy 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 well the leukemia responded to the first month of treatment (reinduction therapy)

    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 (does not go into remission) despite standard treatment approaches, or relapses again (second or greater relapse), the Childhood 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
    • Chimeric antigen receptor (CAR) T-cell therapy, which involves genetically engineering a child's own immune cells (T-cells) to target and kill leukemia cells

    Learn more about clinical trials for pediatric cancer.