- What is the predominant white blood cell type present?
Most of the white blood cells are small to medium-sized lymphocytes. A WBC differential count is likely to show that more than 85% of the WBCs on the peripheral smear are lymphocytes. There are also many smudged lymphocytes present. In addition, one may see some larger lymphocytes, with abundant cytoplasm and a prominent nucleolus, which are prolymphocytes.
- What is the diagnosis?
The only real diagnostic consideration in this case is chronic lymphocytic leukemia (CLL). A lymphocytosis from infection or inflammation is unlikely to be this pronounced. CLL is the peripheral blood manifestation of a small lymphocytic lymphoma (SLL) which is a systemic B cell disease that typically affects not only bone marrow but also lymph nodes, liver, and spleen. These cells mark with the typical B cell markers CD19 and CD20, but in addition mark with CD23 and CD5 (a T cell marker).
- In view of the prognosis for this disease, what are treatment options?
Though most patients live for at least 5 years without therapy, many will live over 10 years, remaining mostly asymptomatic during that time, or bothered only by chronic anemia. However, 15 to 30% of patients have a "prolymphocytic" transformation of their CLL to a high-grade B cell lymphoma, with survival after that less than a year.
Thus, these issues just mentioned above become especially difficult for this chronic, indolent, but fatal disease. Can one plan for a remaining 10-15 year lifespan? Is a bone marrow transplant (BMT) worth the chance that you will lose those 10-15 years? How would you present the options without bias to a patient with this diagnosis?
