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Textbook/Haematology and transfusion/Acute lymphoblastic leukaemia/Rapid
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Acute lymphoblastic leukaemia

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2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
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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.

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.

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.

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.
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.
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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.

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom