Chronic lymphocytic leukemia

Background

• Most common leukemia in adults in developed world
• Typically occurs in adults >55 yo
• Usually indolent disease, slow progression over up to 10 years

Clinical Features

• Nonspecific systemic symptoms: fever, malaise, fatigue, weight loss
• Lymphadenopathy, hepatosplenomegaly
• Recurrent and/or opportunistic infections: pneumonia, herpes simplex, zoster
• Signs/symptoms of anemia
• Signs/symptoms of thrombocytopenia

Differential Diagnosis

Oncologic Emergencies

Related to Local Tumor Effects

• Malignant airway obstruction
• Bone metastases and pathologic fractures
• Malignant spinal cord compression
• Malignant Pericardial Effusion and Tamponade
• Superior vena cava syndrome

Related to Biochemical Derangement

• Hypercalcemia of malignancy
• Hyponatremia due to SIADH
• Adrenal insufficiency
• Tumor lysis syndrome
• Carcinoid syndrome

Related to Hematologic Derangement

• Neutropenic fever
  • Neutropenic enterocolitis (typhlitis)
• Leukostasis and hyperleukocytosis
• Hyperviscosity syndrome
• Thromboembolism

Related to Therapy

• Chemotherapy-induced nausea and vomiting
• Cytokine release syndrome
• Chemotherapeutic drug extravasation
• Differentiation syndrome (retinoic acid syndrome) in APML
• Stem cell transplant complications
• Catheter-related complications
  • Tunnel infection
  • Exit site infection
  • CVC obstruction (intraluminal or catheter tip thrombosis)
  • Catheter-related venous thrombosis
  • Fracture of catheter lumen
  • Oncologic therapy related adverse events

Leukocytosis

• Normally responding bone marrow
  • Infection
  • Inflammation: tissue necrosis, infarction, burns, arthritis
  • Stress: overexertion, seizures, anxiety, anesthesia
  • Drugs: corticosteroids, lithium, beta agonists
  • Trauma: splenectomy
  • Hemolytic anemia
  • Leukemoid malignancy
• Abnormal bone marrow
  • Acute leukemia
    • Acute myeloid leukemia
    • Acute lymphocytic leukemia
  • Chronic leukemia
    • Chronic myeloid leukemia
  • Myeloproliferative disorders

Evaluation

• CBC, peripheral smear
  • absolute B-lymphocyte count > 5000 cells/μL
  • mature lymphocytes with a dense nucleus and a narrow cytoplasmic border on smear
• Evaluate for complications/oncologic emergencies
  • Neutropenic fever
  • DIC
  • Tumor lysis syndrome
  • Leukostasis and hyperleukocytosis
  • Hyperviscosity syndrome
  • Thromboembolism
  • Anemia
  • Thrombocytopenia
  • Stem cell transplant complications

Management

• Treat complications: see Neutropenic fever, DIC, Tumor lysis syndrome, Leukostasis and hyperleukocytosis, Hyperviscosity syndrome, Thromboembolism, Anemia, Thrombocytopenia, Stem cell transplant complications
• Consider heme/onc consult if new diagnosis or unfamiliar complication

Disposition

• If incidental finding or only very mild symptoms, discharge with close outpatient follow up
• Admit if complication

See Also

• Leukemia
• Oncologic emergencies