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Diagnosing Acute Lymphoblastic Leukemia


Bone marrow aspiration

A bone marrow aspiration or bone marrow biopsy if it is difficult to aspirate representative bone marrow, is necessary to diagnose ALL. A biopsy can in some cases also provide additional valuable information.

Examinations performed on the aspirate:

  • Microscopy, MGG staining, and possible cytochemical staining
  • Immunophenotyping (flow cytometry)
  • Cytogenetics with directed testing using FISH or molecular genetic techniques
  • If possible, a cell suspension which is frozen locally for later supplementary examinations.
  • RNA/DNA extraction for later molecular genetic analyses should be done, if possible.

In all patients, the bone marrow aspirate and blood are sent to PCR for BCR-ABL.

Blood tests


ABO typing, hemoglobin, leukocytes with differential counting, thrombocytes, blood smear, LD, albumin, creatinine, Na, K, Ca, phosphate, urea, glucose, CRP, CMV.

Special testing:

  • Blood tests at the start of treatment with emphasis on development of tumor lysis syndrome: urate, Ca, Mg, K+, phosphate, creatinine, and liver tests.  
  • HLA typing – taken if there is a need for HLA compatible blood components

Lumbar puncture

A lumbar puncture is performed when there is a clinical suspicion of CNS leukemia or for the first intraspinal prophylaxis treatment. 

Examinations performed on the aspirate:

  • Cell count - for an increase in cell count, cytospin with MGG staining is performed
  • Spinal protein

In some cases, a cytological examination of the spinal fluid is done and possibly with immunophenotyping.

Interpretations of findings in spinal fluid may be difficult when there are blasts in blood due to the risk of contamination by puncture bleeding.

Familial evaluation

In cases where an allogeneic stem cell transplant is considered, HLA typing of siblings and parents is done when remission is achieved. This means all patients under 60 who reach complete remission.


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