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Chronic lymphocytic leukemia

Last revised by Joshua Yap on 9 May 2023

Chronic lymphocytic leukemia (CLL) is a hematological malignancy characterized by the proliferation of mostly mature but abnormal leukocytes. 

Chronic lymphocytic leukemia is considered the most common type of leukemia in the Western hemisphere; its prevalence in Europe and North America ranges from 29-38% of all leukaemias 1. It primarily affects adults 65-70 years of age 3.

The diagnosis is generally established by a bone marrow biopsy and immunophenotyping.

Up to half of the patients can be asymptomatic with the disease being incidentally discovered by routine blood workup 3. Patients may sometimes present with hepatomegaly, splenomegaly or both and/or hemolytic anemia.

It is a B-lineage neoplasm of prefollicular center cells that is usually associated with circulating neoplastic small lymphocytes. From a morphologic and immunophenotypic perspective, the malignant cells of chronic lymphocytic leukemia tend to be identical to those of nodal-based small lymphocytic lymphoma (SLL), and these two malignancies are thought to represent different manifestations of the same disease 1. This is reflected in the latest WHO classification of haematolymphoid tumors (5th edition).

There are two common staging systems in use which are:

Imaging may identify various features of the disease such as splenomegaly, hepatomegaly +/- lymphadenopathy, although these are not specific to the disease.

As with other types of bone marrow infiltrative disease, it is possible to see a diffusely hypointense signal of bone structures on T1, easier to see on spinal MRI.

Chronic lymphocytic leukemia treatment is offered in the presence of active disease, which is characterized by any of the listed below 7

  • presence of B symptoms

  • progressive bone marrow failure

  • extensive or rapidly progressing lymphadenopathy

  • massive or rapidly progressive splenomegaly

  • uncontrolled autoimmune cytopenias

  • rapid lymphocyte doubling time: either occurring in <6 months or when there is an increase of 50% in ≤2 months

About one-third of patients with chronic lymphocytic leukemia will never require treatment 7

Richter transformation: is defined as a diffuse large cell lymphoma, occurring by transformation of chronic lymphocytic leukemia 2,4.

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Cases and figures

  • Figure 1: splenic deposits in CLL
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  • Case 1: with spinal cord infiltration
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  • Case 2: widespread lymphadenopathy
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  • Case 3: marked splenomegaly
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