Acute Lymphoblastic Leukemia (ALL) Workup

Updated: Sep 02, 2017
  • Author: Karen Seiter, MD; Chief Editor: Emmanuel C Besa, MD  more...
  • Print

Approach Considerations

The following studies and procedures are used in the workup for acute lymphoblastic leukemia (ALL):

  • Complete blood count (CBC) with peripheral smear
  • Coagulation studies
  • Chemistry profile, including liver and renal function studies
  • Bone marrow aspiration and biopsy – Definitive diagnostic tests
  • Cultures, in particular blood cultures
  • Chest radiography
  • Chest computed tomography (CT) scan
  • Multiple-gated acquisition (MUGA) scan or electrocardiogram (ECG)

National Comprehensive Cancer Network (NCCN) guidelines note that diagnosis of ALL generally requires the following [6] :

  • Demonstration of ≥20% bone marrow lymphoblasts
  • Morphologic assessment of Wright/Giemsa–stained bone marrow aspirate smears
  • Hematoxylin and eosin (H&E)–stained bone marrow core biopsy and clot sections
  • Comprehensive flow cytometric immunophenotyping
  • Baseline characterization of the leukemic clone, to facilitate subsequent minimal residual disease (MRD) analysis

For optimal risk stratification and treatment planning in patients with ALL, the NCCN advises that bone marrow or peripheral blood lymphoblasts must be tested for specific recurrent genetic abnormalities, as follows [6] :

  • Cytogenetics – Karyotyping of G-banded metaphase chromosomes
  • Interphase fluorescence in situ hybridization (FISH)
  • Reverse transcriptase polymerase chain reaction (RT-PCR) for fusion genes (eg, BCR-ABL1), including determination of transcript size; in BCR-ABL1–negative cases, testing for other fusions that are associated with Ph-like ALL may be considered
  • Additional assessment (array cGH) may be considered in cases of aneuploidy or failed karyotype

See also Acute Lymphoblastic Leukemia Staging.


Routine Laboratory Studies

A complete blood cell (CBC) count with differential demonstrates anemia and thrombocytopenia to varying degrees in individuals with acute lymphoblastic leukemia (ALL). Patients with ALL can have a high, normal, or low white blood cell (WBC) count, but they usually exhibit neutropenia. The prevalence and severity of infections are inversely correlated with the absolute neutrophil count (ANC); infections are common when the absolute neutrophil count is less than 500/µL, and they are especially severe when it is less than 100/µL. See the Absolute Neutrophil Count calculator.

Coagulation studies and chemistry profiles

Abnormalities in the prothrombin time (PT) / activated partial thromboplastin time (aPTT) / fibrinogen / fibrin degradation products may suggest concomitant disseminated intravascular coagulation (DIC), which results in an elevated PT, decreased fibrinogen levels, and the presence of fibrin split products.

A review of the peripheral blood smear confirms the findings of the CBC count. Circulating blasts are usually seen. Schistocytes are sometimes seen if DIC is present.

A chemistry profile is recommended. Most patients with ALL have an elevated lactic dehydrogenase level (LDH), and they frequently have an elevated uric acid level. In addition, liver function tests and blood urea nitrogen (BUN)/creatinine determinations are necessary before the initiation of therapy.


Appropriate cultures, in particular blood cultures, should be obtained in patients with fever or with other signs of infection without fever.


Radiologic Studies

Chest x-ray films may reveal signs of pneumonia and/or a prominent mediastinal mass in some cases of T-cell acute lymphoblastic leukemia (ALL).

Computed tomography (CT) scans can further define the degree of lymphadenopathy in some patients, including those with mediastinal masses.


MUGA Scanning and Electrocardiography

Multiple-gated acquisition (MUGA) scans or electrocardiograms (ECGs) are needed when the diagnosis of acute lymphoblastic leukemia (ALL) is confirmed, because many chemotherapeutic agents used in the treatment of acute leukemia are cardiotoxic.

An ECG is recommended before the initiation of treatment.


Bone Marrow Aspiration and Biopsy

Bone marrow aspiration and biopsy are the definitive diagnostic tests to confirm the diagnosis of leukemia. Immunophenotyping helps to elucidate the subtype.

Aspiration slides should be stained for morphology with either Wright or Giemsa stain. The diagnosis of acute lymphoblastic leukemia (ALL) is made when at least 30% lymphoblasts (French-American-British [FAB] classification) or 20% lymphoblasts (World Health Organization [WHO] classification) are present in the bone marrow and/or peripheral blood.

In addition, slides should be stained with myeloperoxidase (MPO) (or Sudan black) and terminal deoxynucleotidyl transferase (TdT), unless another method is used, such as flow cytometry.

Bone marrow samples should also be sent for flow cytometry and cytogenetics. Approximately 15% of patients with ALL have a t(9;22) translocation (ie, Philadelphia [Ph] chromosome), but other chromosomal abnormalities may also occur, such as t(4;11), t(2;8), and t(8;14).


Histologic Features

The older, traditional classification of acute lymphoblastic leukemia (ALL) is the French-American-British (FAB) classification. This has now been replaced by the newer World Health Organization (WHO) classification but the FAB system is listed for historical purposes, as follows:

  • L1 – Small cells with homogeneous chromatin, regular nuclear shape, small or absent nucleolus, and scanty cytoplasm; subtype represents 25-30% of adult cases
  • L2 – Large and heterogeneous cells, heterogeneous chromatin, irregular nuclear shape, and nucleolus often large; subtype represents 70% of cases (most common)
  • L3 – Large and homogeneous cells with multiple nucleoli, moderate deep blue cytoplasm, and cytoplasmic vacuolization that often overlies the nucleus (most prominent feature); subtype represents 1-2% of adult cases

The WHO classifies the L1 and L2 subtypes of ALL as either precursor B lymphoblastic leukemia/lymphoblastic lymphoma (see the following image) or precursor T lymphoblastic leukemia/lymphoblastic lymphoma depending on the cell of origin. The L3 subtype of ALL is included in the group of mature B-cell neoplasms, as the subtype Burkitt lymphoma/leukemia.

Diagnostic workup of a patient with pre–B-cell acu Diagnostic workup of a patient with pre–B-cell acute lymphoblastic leukemia. Bone marrow aspiration revealed French-American-British L2 morphology.


A negative myeloperoxidase (MPO) stain and a positive and terminal deoxynucleotidyl transferase (TdT) is the hallmark of the diagnosis of most cases of acute lymphoblastic leukemia (ALL). However, positive confirmation of lymphoid (and not myeloid) lineage should be sought by flow cytometric demonstration of lymphoid antigens, such as CD3 (T-lineage ALL) or CD19 (B-lineage ALL), in order to avoid confusion with some types of myeloid leukemia (eg, M0), which also stain negative with myeloperoxidase.


Flow Cytometry and Cytogenetics

Although more than 95% of cases of the L1 or L2 subtype of acute lymphoblastic leukemia (ALL) are positive for Terminal deoxynucleotidyl transferase (TdT), TdT is not specific for ALL; TdT is absent in L3 (mature B-cell) ALL. However, TdT helps to distinguish ALL from malignancies of more mature lymphocytes (ie, non-Hodgkin lymphoma [NHL]).

In cases of acute leukemia that are myeloperoxidase (MPO) negative and TdT positive, the distinction between acute myelogenous leukemia (AML) and ALL is made on the basis of flow cytometry results. Patients with AML demonstrate myeloid markers such as CD33, whereas patients with ALL demonstrate lymphoid markers. Further confusion arises because some patients with ALL have aberrant expression of myeloid markers, such as CD13. However, if the cells are TdT positive, MPO negative, CD33 negative, and demonstrate lymphoid markers, the leukemia is considered ALL. See an example of a flow cytometry study below.

Diagnostic workup of a patient with pre–B-cell acu Diagnostic workup of a patient with pre–B-cell acute lymphoblastic leukemia. Flow cytometry shows that the cells were positive for CD10, CD19, CD22, CD34, and terminal deoxynucleotidyl transferase.

Cytogenetic abnormalities occur in approximately 70% of cases of ALL in adults (see Table 2, below). These abnormalities include balanced translocations as occur in cases of AML. However, abnormalities of chromosome number (hypodiploidy, hyperdiploidy) are more common in ALL than in AML.

Table 2. Common Cytogenetic Abnormalities in ALL (Open Table in a new window)

Abnormality Genes Involved 3-Year Event-Free Survival
t(10;14)(q24;q11) HOX11/TCRA 75%
6q Unknown 47%
14q11 TCRA/TCRD 42%
11q23 MLL 18-26%
9p Unknown 22%
12 TEL 20%
t(1;19)(q23;p13) PBX1/E2A 20%








t(9;22)(q34;q11) bcr-abl 5-10%*


t(4;11)(q21;q23) AF4-MLL 0-10%
* Traditional regimens.

Hyper-CVAD (cyclophosphamide, vincristine, doxorubicin [Adriamycin], dexamethasone) with rituxan.

Hyper-CVAD with imatinib.

Eighty-five percent of cases of ALL are derived from B cells. The primary distinction is among the following (see also Table 3, below):

  • Early (pro-B) ALL, which is TDT positive, CD10 (CALLA) negative, surface immunoglobulin (Ig) negative
  • Precursor B ALL, which is TDT positive, CD10 (CALLA) positive, surface Ig negative
  • Mature B cell (Burkitt) ALL, which is TdT negative, surface Ig positive. Fifteen percent of these cases are derived from T cells.

Table 3. Immunophenotyping of ALL Cells – ALL of B-Cell Lineage (85% of cases of adult ALL) (Open Table in a new window)

ALL Cells TdT CD19 CD10 CyIg SIg
Early B-precursor ALL + + - - -
Pre–B-cell ALL + + + + -
B-cell ALL - + +/- +/- +
ALL = acute lymphoblastic leukemia; Cylg = Cytoplasmic immunoglobulin; SIg =Surface immunoglobulin; TdT = terminal deoxynucleotidyl transferase.

These cases are subclassified into different stages corresponding to the phases of normal thymocyte development. The early subtype is surface CD3 negative, cytoplasmic CD3 positive, and either double negative (CD4-, CD8-) or double positive (CD4+, CD8+). The latter subtype is surface CD3 positive, CD1a negative, and positive for either CD4 or CD8, but not both. See Table 4, below.

Table 4. Immunophenotyping of ALL Cells – ALL of T-Cell Lineage (15% of cases of adult ALL) (Open Table in a new window)

ALL Cells TdT Surface CD3 CD4/CD8
Early T-precursor ALL + - +/+ or -/-
T-cell ALL + + +/- or -/+

Polymerase Chain Reaction or Cytogenics

Studies for bcr-abl analysis by polymerase chain reaction (PCR) or cytogenetics may help distinguish patients with Philadelphia chromosome–positive acute lymphoblastic leukemia (Ph+ ALL) from those with the lymphoid blastic phase of chronic myelogenous leukemia (CML). Most patients with Ph+ ALL have the p190 type of bcr-abl, whereas patients with lymphoid blastic CML have the p210 type of bcr-abl.