Case Presentation: Chronic Lymphocytic Leukemia

Susan O’Brien, MD, University of California Irvine Medical Center, California, provides background on a patient with chronic lymphocytic leukemia (CLL) with a deletion of 13q, following 4 years of observation for disease progression.

In this case, the patient is a 66-year-old man who was referred to an oncologist after his complete blood count (CBC) panel, which was ordered as part of pre-operative work for a knee replacement, showed he had lymphocytosis. It was noted that the patient was asymptomatic. His physical exam revealed shoddy cervical and axillary nodes, and no palpable hepatosplenomegaly. His white blood count was about 32,000, with mostly lymphocytes. His hemoglobin was 12.6, and platelets 120,000.

Flow cytometry was done on the peripheral blood and was found to be consistent with CLL, CD38 negative. At that time, he had a fluorescence in situ hybridization [FISH] panel that showed a 13q deletion, and his immunoglobulin heavy-chain variable region gene [IGHV] status was IGHV-mutated. The patient’s past medical history was positive for kidney stones and well-controlled hypertension, and he had not had any labs done in many years. Because the patient was asymptomatic and didn't have much disease, he was followed on a regular basis.

Approximately 2 years later, the patient presented with some mild fatigue, and occasional night sweats. His nodes were now bigger, but still presented with no palpable hepatosplenomegaly. His white blood count was about 56,000, and his hemoglobin was 11.8, which showed an increase in anemia. His platelets were 113. At that time, the plan was also to continue observation.

About 4 years from diagnosis, the patient presented with increasing fatigue and night sweats almost continuously. It was observed that he had 2-to-3-centimeter cervical nodes, 4-centimeter axillary nodes, and a 3-centimeter palpable spleen. His lymphocyte count increased to 74,000, and he measured a hemoglobin of 10.9 and platelets of 101.

Due to the patient becoming symptomatic with fatigue and night sweats, along with increasing anemia, the hematologists decided to begin treatment. They repeated the FISH panel, as there can be clonal evolution over time. The FISH [panel] showed a 13q deletion, which had not changed from earlier testing. They also did a p53 mutation status, which showed [wild] types rather than a p53 mutation.