What is the recommended long‑term surveillance plan for a child who has completed chemotherapy for acute lymphoblastic leukemia?

Surveillance of Childhood ALL After Chemotherapy

Children who have completed chemotherapy for acute lymphoblastic leukemia should undergo structured surveillance with physical examinations and CBC with differential every 1-4 months during year 1, every 3-6 months during year 2, and every 6-12 months from year 3 onward, with routine imaging NOT recommended unless clinically indicated. 1

Surveillance Schedule by Time Period

Year 1 Post-Treatment (Every 1-4 Months)

• Complete physical examination including testicular examination (for males) 1
• CBC with differential at each visit 1
• Liver function tests should continue until values normalize 1
• Bone marrow aspirate, cerebrospinal fluid analysis, and echocardiogram only as clinically indicated, not routinely 1

Year 2 Post-Treatment (Every 3-6 Months)

• Physical examination including testicular examination 1
• CBC with differential 1

Year 3 and Beyond (Every 6-12 Months or As Indicated)

• Physical examination including testicular examination 1
• CBC with differential 1
• Continue annual follow-up indefinitely due to late effects risk 1

Relapse Detection Strategy

Routine surveillance imaging is NOT recommended - imaging should only be performed when there is clinical suspicion of relapse 1. This is a critical pitfall to avoid, as unnecessary imaging increases radiation exposure and false-positive findings without improving outcomes.

When Relapse is Suspected Clinically:

• Bone marrow aspirate with flow cytometry 1
• Comprehensive cytogenetics, FISH, molecular tests, and MRD assessment 1
• Full workup including imaging as appropriate 1
• For Philadelphia chromosome-positive ALL specifically: periodic quantification of BCR-ABL1 transcript 1

Late Effects Monitoring

Cardiac Surveillance

Echocardiogram as clinically indicated to monitor for anthracycline-related cardiotoxicity 1, 2. The frequency depends on cumulative anthracycline dose received during treatment.

Neuropsychological Assessment

Neuropsychological testing as clinically indicated given the increased risk of neurotoxicity from ALL treatment 1, 2. This is particularly important for children who received cranial irradiation or high-dose methotrexate.

Metabolic Monitoring

Monitor for healthy weight and encourage healthy lifestyle choices as pediatric ALL survivors are at increased risk for obesity 1

Comprehensive Late Effects Surveillance

Follow Children's Oncology Group (COG) Long-Term Follow-Up Guidelines for comprehensive screening of late effects including growth abnormalities, cognitive dysfunction, emotional concerns, reproductive health issues, and secondary malignancies 1, 2

Critical Timing Considerations

Most relapses occur within the first 2-3 years after completing therapy, with the highest risk in the first year 3. Contemporary therapy without cranial irradiation shows approximately 6% post-treatment relapse risk, with nearly all relapses occurring within 4 years 3. Patients remaining in remission at 4 years post-treatment have less than 1% chance of relapse and may be considered cured 3.

Common Pitfalls to Avoid

• Do not perform routine bone marrow aspirates in asymptomatic patients - these should only be done when relapse is clinically suspected 1
• Do not order routine surveillance imaging (CT, PET, MRI) - this increases cost, radiation exposure, and anxiety without improving outcomes 1
• Do not neglect testicular examination in males, as isolated testicular relapse requires systemic therapy to prevent marrow relapse 1
• Do not forget to provide a treatment summary at completion of therapy including cumulative anthracycline dosage and radiation details for future providers 1