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Chronic Lymphocytic Leukemia (CLL)

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Topic updated on 06/09/17 10:08pm

Snapshot
  • A 62-year-old Caucasian man complains of months of fatigue. He notices that his skin seems abnormally yellow. On physical exam, he has notable tender lymphadenopathy. Peripheral smear reveals some spherocytes and lymphocytosis. His leukocyte count is 35,000/μL with 95% lymphocytes and a Hb of 7 g/dL. His direct Coombs test is positive with anti-IgG. He is started on fludarabine.
Introduction

  • Clonal proliferation of incompetent B-cells
    • small lymphocytic lymphoma (SLL)
      • disease is mainly in lymph nodes
    • chronic lymphocytic lymphoma (CLL)
      • disease in blood and bone marrow
  • Epidemiology
    • > 60 years of age
    • most common form of leukemia in adults in Western countries
    • more common in Caucasian males
  • Many are diagnosed incidentally with markedly elevated WBC
  • Insidious onset of symptoms
  • Associated conditions
    • warm autoimmune hemolytic anemia (IgG)

 

Presentation
  • Symptoms
    • many are asymptomatic at presentation
    • most common symptom is fatigue
    • recurring infections from incompetent lymphocytes
      • pneumonia
      • zoster
    • early satiety
    • mucocutaneous bleeding from thrombocytopenia
  • Physical exam
    • painful lymphadenopathy
    • hepatosplenomegaly
Evaluation
  • Labs – CBC
    • ↑ WBC (> 20,000/μL) with > 80% lymphocytes
    • ↓ RBCs (attacked by CLL cells)
    • ↓ PLTs (attacked by CLL cells)
  • ↓ IgG in half of patients
  • Most accurate test
    • flow cytometry – CD5, CD19, CD20, and CD23+ B-cells
  • Peripheral blood smear
    • smudge cells = hallmark
      • artifact of lab, from cover slip crushing the nucleus
Differential Diagnosis
  • AIHA
  • Mantle cell lymphoma
  • ALL
  • Hairy cell lymphoma
Treatment
  • Treatment only for symptomatic or rapid progression
    • fludarabine – first-line
    • fludarabine plus rituximab for symptomatic patients
  • Curative therapy
    • allogeneic stem cell transplant
Prognosis, Prevention, and Complications
  • Prognosis
    • most live 5-10 years after diagnosis
    • some die rapidly, within 2-3 years
  • Complications
    • Richter syndrome/transformation
      • transformation of CLL into aggressive large B-cell lymphoma
      • 3-10% of cases
      • weight loss, fevers, night sweats, cachexia, and lymphadenopathy
      • poor prognosis
    • infections secondary to hypogammaglobulinemia


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Qbank (1 Questions)

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(M2.ON.17) A 79-year-old man presents to clinic for a routine evaluation. He has had intermittent night sweats for the past several months and also complains of feeling “run down.” He has a past medical history of hypertension and hyperlipidemia. He smoked one half of a pack of cigarettes for ten years but quit 30 years ago. He drinks two glasses of wine on the weekend. Vital signs are within normal limits and he is afebrile. Physical examination is notable for painless anterior and posterior cervical lymphadenopathy. A complete blood count reveals a WBC of 44,000, which is predominately lymphocytic. A peripheral smear is obtained (Figure A). The diagnosis in this patient should be confirmed by what modality? Topic Review Topic
FIGURES: A          

1. Bone marrow biopsy
2. CT of the head and neck
3. MRI of the head and neck
4. Flow cytometry
5. Heterophile antibody test

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