Chronic Lymphocytic Leukemia (CLL)
Diagnosis & Staging
Updated: February 2011
Diagnosis
See Publications for IWCLL reference.
A. CLL (Chronic Lymphocytic Leukemia)
B. SLL (Small Lymphocytic Leukemia)
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lymphocytes in peripheral blood not greater than 5 x 109/L
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lymphadenopathy and / or splenomegaly
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confirmation of dx by marrow and / or histopathologic exam of node biopsy
C. MBL (Monoclonal B-cell Lymphocytosis)
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absolute B-cell lymphocytye count < 5 x 109/L
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absence of lymphadenopaty, organomegaly, cytopenias, or disease related symptoms
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all lymph nodes < 1.5 cm
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no cytopenias
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no symptoms
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progression to CLL at a rate of 1 to 2% per year
Recommended at Diagnosis
1. Immunophenotyping (can be done at VGH, BCCA or SPH)
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typical is co-expression of CD5+ and B-cell antigens CD19+, CD20 dim, CD23+, sIg dim+, and cyclin D1-, with kappa or lambda light chain restriction
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FISH for t(11:14) should be done in all cases with atypical immunophenotype – i.e., CD23 dim or negative, CD20 bright, sIg bright
2. History with attention to:
3. Physical with attention to:
4. Blood work:
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CBC Diff plats retic count and peripheral blood smear
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Lytes, BUN, CR, LFTs including LDH, uric acid, calcium
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Direct antiglobulin test
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B2 microglobulin
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SPEP and quantitative Igs
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Hepatitis serologies to include HIV, HCV, HBsAg, Anti-HBc, Anti-HBs
Staging
Document clinical stage at diagnosis and at progression. In BC, the Rai stage is most commonly used:
Rai stage table:
| Modified Rai Stage | Classical Rai Stage | Findings |
| Low risk | 0 | Lymphocyte count > 5.0 x 109/L. Bone marrow contains > 40% lymphocytes |
| Intermediate risk | 1 | Stage 0 + lymphadenopathy |
| | 2 | Stage 0 + hepatomegaly and splenomegaly |
| High risk | 3 | Stage 0 + anemia (Hgb < 110 g/L) |
| 4 | Stage 0 + thrombocytopenia (Platelets < 100 x 109/L) |
Recommended Prior to Treatment
1. As per diagnosis but also:
- Hepatitis panel including Hep B/C, HIV, MCV, HSV, VZV
- FISH for: Del 17p, Dep 11q, Del 13q, +12
- At VGH or RCH, FISH testing is also done to look for IgH abnormalities
2. FISH should be repeated prior to each major change in treatment and for change in disease behaviour, i.e., for more aggressive disease behaviour
3. Chest x-ray
4. Prior to treatment it may be helpful depending upon clinical circumstances to consider imaging (CT scans) and marrow aspirate and biopsy if appropriate
5. Marrow aspirate and biopsy should always be done in the situation of unexplained cytopenias, evaluation of possible transformation, and prior to SCT
Prognosis & Risk Stratification
Prognostic factors in CLL include:
1. Stage - advanced 3 or 4 shorter overall survival
2. Bulky disease
3. B-symptoms
4. Transformation of CLL
5. B2 microglobulin
6. FISH:
| Unfavourable | 17p del | Short time to progression / time to therapy and overall survival
Refer for consideration of allo SCT once 17p- is found and therapy is required |
| | 11q del | Suboptimal TTP, TTT, OS
Early consideration for allo SCT - likely around first progression |
| Neutral | normal | |
| | +12 | |
| Favourable | 13q del as sole abnormality | |
7. IgVH mutation status
- Mutated IgVH has better prognosis, however it is not clear how this may impact on therapeutic decisions, and not widely available, not currently available in BC
8. Flow cytometry
- CD 38+ less favourable than CD 38-
| The information contained in these guidelines is a statement of consensus of Leukemia/BMT Program of BC professionals regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult these documents is expected to use independent medical judgment in the context of individual clinical circumstances to determine any patient’s care or treatment. Use of these guidelines and documents is at your own risk and is subject to the Leukemia/BMT Program of BC’s terms of use available at Terms of Use. |