A 73-year-old man presents complaining of lumps on his neck. On examination, you note the presence of several large, non-tender cervical lymph nodes. You organise for some blood tests to be performed, and the results show that he has a lymphocytosis of 16 x 109/l.

1. What is the most likely diagnosis?
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Chronic lymphocytic leukaemia (CLL) is the most common type of adult leukaemia. It arises as a consequence of the clonal proliferation of relatively mature lymphocytes. Approximately 95% of cases are of B-cell lineage. It is predominantly a disease of adult men, with >75% of patients that present with CLL being men over the age of 50.

It is the most indolent of the chronic leukaemia and is often discovered as an incidental finding when blood counts are performed for other reasons, such as ‘well man’ screening tests. As the disease advances, the patient may develop lymphadenopathy, hepatosplenomegaly, anaemia and infections.

2. What other laboratory findings may be present?

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Laboratory findings in CLL include:

  • Clonal B cell lymphocytosis (greater than 5 x 109/l for diagnosis, but may be as high as 300 x 109/l)
  • Smear cells are classically seen on the blood film
  • Normocytic, normochromic anaemia present in advanced disease
  • Positive direct antiglobulin test (DAT) in patients with autoimmune-related haemolytic anaemias.

Bone marrow aspiration is not necessary in all cases but can assist with making a diagnosis of CLL. Lymph node biopsy is needed if there has been rapid lymph node enlargement, to assess for the possibility of Richter’s syndrome. This is a transformation to a high-grade lymphoma, accompanied by fever, weight loss, and pain.

3. How should this patient be treated?
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There is no curative treatment available for CLL, but the disease is treatable with chemotherapy regimens that prolong survival. There is no benefit to early treatment, and the standard treatment of early disease is a ‘watch and wait’ strategy, with examination and blood counts performed every 3-12 months. Chemotherapy is generally reserved for patients with active, symptomatic disease. 

The overall prognosis of CLL is as follows:

  • 1/3 will not require any treatment and have a long survival
  • 1/3 will have an initial indolent phase followed by disease progression
  • 1/3 will present with aggressive disease requiring immediate treatment.



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