Pediatric patients who undergo chemotherapy for ALL are at higher risks for fractures and decreased bone mineral density. This is due to the leukemia cells triggering osteoclast mediated bone resorption and this reduces bone growth and density.

Acute Lymphoblastic Leukemia (ALL) is a cancer of the blood and bone marrow. It is the most common type of cancer in children and most often occurs in ages 2-5. The most common treatment for ALL is chemotherapy and due to advancements in treatment, the overall cure rate in children is around 90%. With ALL, the cancer cells grow rapidly in the bone marrow. They are called blasts, which are immature white blood cells. Patients with ALL have too many blasts in their bone marrow. These cells don’t work normally, and they crowd out normal white blood cells, red blood cells, and platelets. The blast cells reduce hematopoiesis (red blood cell synthesis) and cause anemia, thrombocytopenia, and neutropenia. They attack the white blood cells that fight infection and protect the body from disease. This increases the risk of developing infections that can be fatal. (

There are two types of lymphocytes: B-lymphocytes and T-lymphocytes. ALL can be known as B-cell or T-cell ALL. B-cell ALL is the most common fom of ALL. Most cases of ALL have no known cause.

Symptoms of ALL are anemia with weakness and fatigue, low white blood cell count (Leukopenia) with frequent infections, thrombocytopenia with bruising and bleeding, and bone and joint pain. Some children will present with an unwillingness to walk because of this bone pain, which is caused by leukemia penetrating the periosteum, bone, or joint or because of expansion of the marrow cavity by leukemia cells. Children with significant bone pain can often have almost normal blood counts, which can contribute to delayed diagnosis and treatment. (Angsubhakorn et al., 2018)

Other reasons for low bone density in ALL survivors are the disease process, damage to endocrine organs that control bone growth, poor nutrition, genetic predisposition, inactivity, and puberty. After completing therapy, the bone mineral depletion may predispose survivors to osteoporosis with greater severity and earlier onset. Osteoporosis is a disease in which bone resorption exceeds deposit. The cell matrix remains normal, but bone mass declines. The most susceptible are the spongy bone of the spine and the head and neck of the femur. Low peak bone mass is a risk factor for osteoporosis later in life. (Ahn et al., 2020)

Overall, low bone mass density became more common with increasing time after the diagnosis of ALL. (Mostoufi-Moab et al, 2019)

Kaste, S.C., Rai, S.N., Fleming, K., McCammon, E.A., Tylavsky, F.A., Danish, R.K., Rose, S.R., Sitter, C.D., Pui, C.-H. and Hudson, M.M. (2006), Changes in bone mineral density in survivors of childhood acute lymphoblastic leukemia. Pediatr. Blood Cancer, 46: 77-87.

Ahn, M. B., & Suh, B. K. (2020). Bone morbidity in pediatric acute lymphoblastic leukemia. Annals of pediatric endocrinology & metabolism, 25(1), 1–9.

Mostoufi-Moab, S., & Ward, L. M. (2019). Skeletal Morbidity in Children and Adolescents during and following Cancer Therapy. Hormone research in paediatrics, 91(2), 137–151.

Angsubhakorn, N., & Suvannasankha, A. (2018). Acute lymphoblastic leukaemia with osteolytic bone lesions: diagnostic dilemma. BMJ case reports, 2018, bcr2018225008.

One Comment

  1. This project is about Acute Lymphoblastic Leukemia, which is a type of cancer, and how its advancement affects bone health. The objectives covered are “Identify the 4 cells that comprise bone tissue”, “Know the stages of bone development and repair”, and “Know the parts of the bone and their shape”. Acute Lymphoblastic Leukemia affects the blood and bone marrow. Those suffering from this disease have an overabundance of immature white blood cells, called blasts, in their bone marrow. This abundance leaves less room for the cells that should be occupying that space: white blood cells, red blood cells, and platelets; in addition, this crowding results in lack of sufficient space for proper hematopoiesis. This off-balanced blood cell count can cause a number of symptoms, including anemia and lowered immune function. The source of this illness is usually unknown, however, it is very curable. Chemotherapy and other treatments result in a mortality rate of only 10%, as long as treatment is given early in the course of the illness. Delays in treatment can be a result of misleadingly normal blood counts in children despite bone pain characteristic of disease advancement. After successful treatment, survivors of Acute Lymphoblastic Leukemia may experience higher rates of osteoporosis than the general population.
    The art aspect of this project involves a color coded illustration of two blood samples, one showing typical healthy blood and the other showing blood from someone with Acute Lymphoblastic Leukemia. Red blood cells, white blood cells, platelets, and leukemia cells are clearly labeled in a key. The cancerous sample is dominated by the leukemia cells, leaving little room for the other types of cells.

    Daisy Balavage

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