CLINICAL PRESENTATION:

CLL has a wide range of symptoms and physical and laboratory abnormalities at the time of its initial discovery in an individual patient.       Lymphadenopathy — 87 percent

     Splenomegaly — 54 percent

     Hepatomegaly — 14 percent

     Total white blood cell count >100,000/µL 30%

     Hemoglobin concentration <11.0 g/dL 31% .

     Platelet count <100,000/µL — 16 percent

Symptoms :

Approximately 25 percent with no symptoms lymphocytosis, leading to a diagnosis of CLL. Approximately 5 to 10 percent of patients present with typical "B" symptoms of lymphoma, formally defined one or more of the following .  - Unintentional weight loss   -Fevers of >38؛C for  2 weeks -Night sweats

-Extreme fatigue

Symptoms : Approximately 25 percent with no symptoms lymphocytosis, leading to a diagnosis of CLL. Approximately 5 to 10 percent of patients present with typical "B" symptoms of lymphoma, formally defined one or more of the following .  - Unintentional weight loss   -Fevers of >38؛C for  2 weeks -Night sweats

-Extreme fatigue

Most patients have painless swelling of lymph nodes

Most often in the cervical area, which spontaneously wax and wane, but do not altogether disappear.

Infections, autoimmune complications such as hemolytic anemia, thrombocytopenia, or pure red cell aplasia, or exaggerated reactions to insect bites.

Symptoms :

Most patients have painless swelling of lymph nodes.

Most often in the cervical area,which spontaneously wax and wane , but do not altogether disappear.

Symptoms : Approximately 25 percent with no symptoms lymphocytosis, leading to a diagnosis of CLL. Approximately 5 to 10 percent of patients present with typical "B" symptoms of lymphoma, formally defined one or more of the following .  - Unintentional weight loss   -Fevers of >38؛C for  2 weeks -Night sweats

-Extreme fatigue

Most patients have painless swelling of lymph nodes

Most often in the cervical area, which spontaneously wax and wane, but do not altogether disappear.

Infections, autoimmune complications such as hemolytic anemia, thrombocytopenia, or pure red cell aplasia, or exaggerated reactions to insect bites.

                                                                               

                         

Physical findings:  Lymphadenopathy : present in 50 to 90 percent of patients among various series. Lymph node enlargement may be generalized or localized - Splenomegaly :The spleen is the second most frequently enlarged lymphoid organ. It may be palpably enlarged in 25 to 55 percent of cases.   -Hepatomegaly : Enlargement of the liver may be noted at the time of initial diagnosis of CLL in 15 to 25 percent of cases.   -Other organ involvement: other lymphoid tissue in the body may be enlarged at diagnosis, such as Waldeyer's ring or the tonsils.Skin Infiltration lesions are the most commonly involved non-lymphoid organ, and are seen in fewer than 5 percent of cases., gastrointestinal mucosal involvement and meningeal leukemia is rarely seen in CLL. Membranoproliferative glomerulonephritis:appears to be a paraneoplastic phenomenon mediated by deposition and possibly processing of cryoprecipitating : Mechanisms: 1-mixed cryoglobulinemia, 2- classic type 1 MPGN, 3-immunotactoid glomerulopathy.

Physical findings:

  Lymphadenopathy : present in 50 to 90 percent of patients among various series. Lymph node enlargement may be generalized or localized

 Splenomegaly :The spleen is the second most frequently enlarged lymphoid organ. It may be palpably enlarged in 25 to 55 percent of cases.

Physical findings: Hepatomegaly : Enlargement of the liver may be noted at the time of initial diagnosis of CLL in 15 to 25 percent of cases. Other organ involvement: other lymphoid tissue in the body may be enlarged at diagnosis, such as Waldeyer's ring or the tonsils.Skin Infiltration lesions are the most commonly involved non-lymphoid organ, and are seen in fewer than 5 percent of cases., gastrointestinal mucosal involvement and meningeal leukemia is rarely seen in CLL.

Physical findings:

 Membranoproliferative glomerulonephritis:appears to be a paraneoplastic phenomenon mediated by deposition and possibly processing of cryoprecipitating :

Mechanisms: 1-mixed cryoglobulinemia, 2- classic type 1 MPGN, 3-immunotactoid glomerulopathy.

                                                                                      

                          

Lymph node biopsy :

B-cell CLL and small lymphocytic lymphoma (SLL) are considered to be the same disease at different stages .

-The diagnosis of SLL was made via a lymph node biopsy in a patient presenting with lymphadenopathy but without peripheral lymphocytosis.

Lymph node biopsy :

The histopathologic lymph node findings in SLL and CLL are identical , and consist of a diffusely effaced nodal architecture with occasional residual naked germinal centers.

The infiltrate is mostly mature-appearing, small lymphocytes, with an admixture of prolymphocytes and para - immunoblasts. Mitotic activity is usually very low.

CLL was diagnosed CLL was diagnosed through examination through examination

of the peripheral blood of the peripheral blood and bone marrow in and bone marrow in

patients with patients with lymphocytosis.lymphocytosis.

  Other abnormalities :

*Anemia

*Thrombocytopenia :

*The direct antiglobulin (Coombs') test positive

  Other abnormalities :Other abnormalities :

Anemia and thrombocytopenia hemoglobin (<11 g/dL) and platelet levels (<100,000/µL), are observed at the time of diagnosis in about 20 percent of patients. 

 The direct antiglobulin (Coombs') test may be positive at some time during the course of the disease in up to 35 percent of cases; overt autoimmune hemolytic anemia (AIHA) occurs in 11 percent whose antibody was an IgM had significantly shorter survival following diagnosis of the AIHA than those with an IgG antibody.

Autoimmune thrombocytopenia is most often diagnosed on the basis of the presence of adequate numbers of megakaryocytes in the bone marrow with an abnormally low platelet count in the peripheral blood.

Agranulocytosis:Agranulocytosis: may be encountered in CLL, but is rare (approximately 0.5 percent).

Hypogammaglobulinemia may be present at the time of initial diagnosis.

Pure red cell aplasia (PRCA) is rare, AIHA,

PRCA may occur early in the course of CLL.

Elevated levels of serum lactate dehydrogenase

(LDH) and beta-2 microglobulin

were found in 60 percent of patients. Elevations of uric acid, hepatic

enzymes (ALT or AST) and, rarely, calcium may also be observed.

                                                                               

                            

                                                                    

                       

  Chromosomal changes in CLL :

There is no one chromosomal change that is specific for CLL, although certain patterns are frequently seen. These include:     Trisomy of chromosomes 12, 3, or 16

     del(13q14)

     del(11q)

     del(17p)

     t(11;14)(q13;q32).

DIAGNOSTIC CRITERIA :

Absolute lymphocytosis in the peripheral blood occurs

in an adult.

Blood lymphocytosis may also occur with viral or other

infections

DIAGNOSTIC CRITERIA :Infection: (eg, infectious mononucleosis, pertussis, toxoplasmosis ) as well as in neoplastic conditions other than CLL: (eg, the leukemic phase of lymphomas, hairy cell leukemia, prolymphocytic leukemia, and large granular cell lymphocyte leukemia).

DIAGNOSTIC CRITERIA : The task is therefore to distinguish between reactive causes of lymphocytosis and clonal (malignant) causes, and, for the latter, to distinguish CLL from the other malignant lymphoproliferative disorders.

                                                                                                        

                           

DIFFERENTIAL DIAGNOSISin CLL :-Small lymphocytic lymphoma :

-Mantle cell lymphoma :The small lymphocytes with irregular or cleaved nuclei seen in mantle cell lymphoma (MCL) share with B-CLL positivity for CD5 and CD20.

-Lymphoplasmacytic lymphoma :Lymphoplasmacytic lymphoma, which is indistinguishable from Waldenstrom's macroglobulinemia. -Hairy cell leukemia : (HCL) is associated with an elevated lymphocyte, cytochemically, a moderately strong TRAP+-Large granular lymphocyte leukemia :(LGL) leukemia, lymphocytes are T-cells and express a mature post-thymic phenotype, CD3+, CD4-, CD8+, CD57.-Mycosis fungoides :cutaneous T-cell lymphoma (CTCL), the lymphocytes have a cerebriform nucleus (Sezary cells, which are usually CD4+, CD8-.

-Adult T cell lymphoma/leukemia

-Prolymphocytic leukemia :

-T cell CLL :A series of twenty-five cases of T-cell CLL (T-CLL) has been reported;

DIFFERENTIAL DIAGNOSISin CLL :

-Small lymphocytic lymphoma :

-Mantle cell lymphoma :The small lymphocytes with irregular or cleaved nuclei seen in mantle cell lymphoma (MCL) share with B-CLL positivity for CD5 and CD20.

-Lymphoplasmacytic lymphoma: Lymphoplasmacytic lymphoma, which is indistinguishable from Waldenstrom's macroglobulinemia.

DIFFERENTIAL DIAGNOSISin CLL :

-Hairy cell leukemia : (HCL) is associated with an elevated lymphocyte, cytochemically, a moderately strong TRAP+

-Large granular lymphocyte leukemia :(LGL) leukemia, lymphocytes are T-cells and express a mature post-thymic phenotype, CD3+, CD4-, CD8+, CD57.

DIFFERENTIAL DIAGNOSISin CLL :

-Mycosis fungoides :cutaneous T-cell lymphoma (CTCL), the lymphocytes have a cerebriform nucleus (Sezary cells, which are usually CD4+, CD8-.

-Adult T cell lymphoma/leukemia

DIFFERENTIAL DIAGNOSISin CLL :

-Prolymphocytic leukemia :

-T cell CLL :A series of twenty-five cases of T-cell CLL (T-CLL) has been reported;

                                                                                                     

                            

  Partial response : A partial response (PR) is defined (NCI criteria) as presence of all of the following for two or more months:    - A reduction in previously enlarged nodes, spleen, and liver by at least 50 percent and

 -Absolute neutrophil count   1,500/µL or

 -Platelet count   100,000/µL or

 -Hemoglobin concentration   11 g/dL or

     50 percent improvement over pretherapy reductions in hemoglobin concentration and/or platelet count

Complete remission :

A complete remission in CLL requires all of the following to be present for two or more months      -Absence of symptoms attributable to CLL.

  -Normal findings on physical examination.

  -Absolute lymphocyte count <4,000/µL.   -Absolute neutrophil count >1,500/µL.

  -Platelet count >100,000/µL.

  -Hemoglobin concentration >11 g/dL (untransfused).

  -Bone marrow lymphocytosis <30 percent.

  -No nodules (lymphoid aggregates) on BM biopsy.

CHEMOTHERAPY:  

Cyclophosphamide Corticosteroids

Nucleoside (purine) analogs Fludarabine &  Cladribine Pentostatin —

Chlorambucil

  High dose steroid salvage therapy

Total body irradiation LEUKAPHERESIS SPLENECTOMY BONE MARROW TRANSPLANTATION IMMUNOTHERAPY MONOCLONAL ANTIBODIES Anti-CD20 (rituximab)

Other antibodies — Infusions of a T101 antibody Anti-CD52 (alemtuzumab, Campath-1H) — Alemtuzumab,

CHEMOTHERAPY:

  

Cyclophosphamide Corticosteroids

Nucleoside (purine) analogs Fludarabine &  Cladribine

Pentostatin —

Chlorambucil

CHEMOTHERAPY:  

 High dose steroid salvage therapy

Total body irradiation

LEUKAPHERESIS

SPLENECTOMY BONE MARROW TRANSPLANTATION

Chemotherapy:

IMMUNOTHERAPY MONOCLONAL ANTIBODIES

Anti-CD20 (rituximab)

Other antibodies — Infusions of a T101 antibody

Anti-CD52 (alemtuzumab, Campath-1H) — Alemtuzumab,

Infection in CLL :

       Mycobacteria

     Listeria monocytogenes

     Pneumocystis carinii

     Cytomegalovirus

     Herpes simplex virus

                                               

  Survival of untreated patients with chronic lymphocytic leukemia by time period.

                                               

  Survival of untreated patients with chronic lymphocytic leukemia by Rai stage.