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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Acute lymphoblastic leukaemia

Haematology and transfusion · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

RapidFull
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ALL with sepsis, lysis or mediastinal compromise

Neutropenic sepsis, spontaneous tumour lysis, severe bleeding, hyperleukocytic neurological or respiratory dysfunction and a T-ALL mediastinal mass with airway or superior vena cava obstruction require immediate treatment.

Action: Use ABCDE assessment, obtain FBC, film, lysis, coagulation, cultures, group and diagnostic blood or marrow material, give prompt empiric antibiotics for sepsis and lysis prevention, avoid sedation or supine procedures with airway compression and involve acute leukaemia, intensive care and anaesthetic teams before cytoreduction.

Synopsis

Recognise and classify adult acute lymphoblastic leukaemia, stabilise infection and tumour lysis, deliver lineage- and genotype-directed multi-phase therapy and use measurable residual disease to guide immunotherapy and transplantation.

  • Suspect ALL with unexplained cytopenias, circulating blasts, bone pain, lymphadenopathy, hepatosplenomegaly, testicular symptoms or a mediastinal mass; total WBC may be low, normal or high.
  • First-line confirmation is expert FBC and film followed urgently by marrow aspirate and trephine, multiparameter flow, cytogenetics or FISH and a comprehensive molecular panel.
  • Determine B- versus T-lineage and urgently test BCR::ABL1 because Philadelphia-positive ALL requires a tyrosine kinase inhibitor integrated into the systemic protocol.
  • Preserve diagnostic material before non-essential corticosteroids: even brief steroid exposure can reduce blasts, obscure immunophenotype and complicate risk stratification.
  • Adult treatment is multi-phase: prephase when used, induction, consolidation or intensification, CNS-directed intrathecal therapy and prolonged maintenance, with exact drugs and timing set by UKALL or centre protocol.
  • Measurable residual disease after induction and consolidation is the principal response measure and guides blinatumomab, allogeneic transplant and relapse-risk decisions.
  • NICE now supports blinatumomab with chemotherapy at the start of consolidation for eligible adults with Philadelphia-negative, CD19-positive B-cell precursor ALL that is MRD negative.
  • Blinatumomab is also commissioned for defined MRD-positive remission and relapsed or refractory B-ALL populations; monitor cytokine-release and neurological toxicity in a trained service.
  • Relapsed B-ALL is re-phenotyped before commissioned antibody, TKI, cellular or transplant treatment is selected.

Key red flags

Fever, hypotension, confusion or hypoxia with neutropenia needs immediate broad-spectrum antibiotics; do not wait for leukaemia confirmation or a positive culture.

Orthopnoea, stridor, facial swelling, venous distension or inability to lie flat with an anterior mediastinal mass suggests airway or superior vena cava compromise and makes sedation hazardous.

Hyperkalaemia, hyperphosphataemia, hypocalcaemia, rising urate or creatinine before treatment suggests spontaneous tumour lysis and requires cardiac monitoring and metabolic intervention.

Headache, cranial neuropathy, vomiting, focal deficit, testicular enlargement or pain can represent sanctuary-site involvement and changes staging and treatment.

T-lineage mediastinal mass

Cough, orthopnoea, facial swelling, stridor or inability to lie flat signals compressive anterior mediastinal disease and procedural risk.

Investigation priorities

01
First-line: FBC and expert filmFirst stepFirst line

Identify cytopenias, blast burden and an urgent acute-leukaemia pattern.

Management branches

Suspected ALLSecure samples and stabilise emergencies

Blasts, unexplained cytopenia, mediastinal mass or lymphoblastic tissue disease is found.

  1. Obtain blood and marrow flow, genetic and MRD-marker material before non-essential steroid exposure when physiology permits.
  2. Treat sepsis and lysis, assess airway and SVC compromise and use anaesthetic expertise before sedation or supine procedures.
  3. Classify B or T lineage, BCR::ABL1 and current risk genetics through the specialist MDT.

Key medicines

Protocol adult ALL chemotherapyUse the exact current UKALL or centre protocol for corticosteroid, vincristine, anthracycline, asparaginase, consolidation, intrathecal therapy and oral maintenance; doses are body-surface-area, age, phase and toxicity dependent and cannot be safely combined from a generic list.Independently verify every phase and intrathecal route. Monitor marrow, infection, neuropathy, thrombosis, fibrinogen, antithrombin, pancreas, liver, glucose and cardiac function; apply TPMT or NUDT15 and interaction rules where required. Provide fertility and pregnancy counselling.
Blinatumomab in MRD-positive remissionFor adults at least 45 kg give 28 micrograms/day by continuous IV infusion on days 1–28 followed by 14 treatment-free days per cycle, for up to four cycles within the commissioned MRD-positive remission pathway.Premedicate and use the exact indication-specific SmPC schedule. Monitor cytokine-release syndrome, encephalopathy, seizure, infection, lysis, pancreatitis and pump interruption; hospital observation is required for specified early days. Avoid pregnancy and breastfeeding.
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Sources and review status6 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • NICE TA1049 blinatumomab consolidation recommendationsCurrent 2025 NHS use in MRD-negative Philadelphia-negative CD19-positive adult B-ALL consolidation.
  • NICE TA589 blinatumomab for MRD-positive remissionCommissioned adult MRD-positive B-ALL population.
  • NICE TA541 inotuzumab recommendationsCommissioned relapsed or refractory CD22-positive B-ALL treatment.
  • Blincyto Summary of Product CharacteristicsIndication-specific continuous-infusion schedules and neurological, cytokine and reproductive precautions.
  • Besponsa Summary of Product CharacteristicsInotuzumab divided-cycle dose and sinusoidal obstruction risk.
  • NICE NG47 haematological cancers recommendationsUK diagnostic and haemato-oncology service standards.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting review
JurisdictionUnited Kingdom