Chronic Lymphocytic Leukemia Workup
- Author: Muhammad A Mir, MD, FACP; Chief Editor: Emmanuel C Besa, MD more...
In patients with chronic lymphocytic leukemia (chronic lymphoid leukemia, CLL), the complete blood count (CBC) with differential shows absolute lymphocytosis, with more than 5000 B-lymphocytes/µL. Lymphocytosis must persist for longer than 3 months. Clonality must be confirmed by flow cytometry. The presence of a cytopenia caused by clonal bone marrow involvement establishes the diagnosis of CLL regardless of the peripheral B-lymphocyte count.
Patients with fewer than 5000 B-lymphocytes/µL with lymphadenopathy and without cytopenias more likely have small lymphocytic lymphoma (SLL), although this diagnosis should be confirmed by lymph node biopsy.
Patients with a clonal B-cell population less than 5000/µL without lymphadenopathy or organomegaly, cytopenia, or other disease-related symptoms have monoclonal B-lymphocytosis (MBL). MBL will progress to CLL at a rate of 1-2% per year.
Microscopic examination of the peripheral blood smear is indicated to confirm lymphocytosis. It usually shows the presence of smudge cells, depicted in the image below, which are artifacts from lymphocytes damaged during the slide preparation.
Large atypical cells, cleaved cells, and prolymphocytes are also often seen on the peripheral smear and may account for up to 55% of peripheral lymphocytes. If this percentage is exceeded, prolymphocytic leukemia (B-cell PLL) is a more likely diagnosis.
Peripheral blood flow cytometry is the most valuable test to confirm a diagnosis of chronic lymphocytic leukemia (chronic lymphoid leukemia, CLL). It confirms the presence of circulating clonal B-lymphocytes expressing CD5, CD19, CD20(dim), CD 23, and an absence of FMC-7 staining.
Consider obtaining serum quantitative immunoglobulin levels in patients developing repeated infections, because monthly intravenous immunoglobulin administration in patients with low levels of immunoglobulin G (IgG) (<500 mg) may be beneficial in reducing the frequency of infectious episodes.
The differential diagnosis (see DDx) of CLL includes several other entities, such as hairy cell leukemia, which is moderately positive for surface membrane immunoglobulins of multiple heavy-chain classes and is typically negative for CD5 and CD21.
Prolymphocytic leukemia has a typical phenotype that is positive for CD19, CD20, and surface membrane immunoglobulin; one half will be negative for CD5. Large granular lymphocytic leukemia has a natural killer (NK) cell phenotype (CD2, CD16, and CD56) or a T-cell immunotype (CD2, CD3, and CD8). The pattern of positivity for CD19, CD20, and the T-cell antigen CD5 is shared only by mantle cell lymphoma; these cells generally do not express CD23.
Splenic lymphoma with villous lymphocytes is strongly positive for surface immunoglobulin, and positive for FMC-7, CD22, CD79b, and DBA-44. Follicular lymphoma is also strongly positive for surface immunoglobulin, positive for FMC-7, CD22, CD10, CD79b, and weak CD23.
Bone marrow aspiration and biopsy with flow cytometry is not required in all cases of CLL. However, it may be necessary in selected cases to establish the diagnosis and to assess other complicating features such as anemia and thrombocytopenia.
Liver/spleen ultrasonographic studies may demonstrate splenomegaly in patients with CLL. CT scanning of the chest, abdomen, or pelvis is generally not required for staging purposes in CLL. However, be careful to not miss lesions such as obstructive uropathy or airway obstruction that are caused by lymph node compression on organs or internal structures.
Serum free light chain (FLC) assays remain a research tool. Monoclonal and polyclonal abnormalities have been detected in half the patients and appear to be associated with poor time to first treatment.
Although not necessary for the diagnosis or staging of CLL, additional molecular testing now exists that may help predict prognosis or clinical course.[16, 17, 18, 19] The National Comprehensive Cancer Network regards the following tests as informative (but not essential) for determining prognosis, therapy, or both in CLL :
Fluorescence in situ hybridization (FISH) to detect +12; del(11q); del(13q); del(17p)
CpG-stimulated metaphase karyotype for complex karyotype
Molecular analysis to detect immunoglobulin heavy chain region (IgV H) mutation status
Determination of CD38 and ZAP-70 expression by flow cytometry, methylation, or immunohistochemistry
However, a systematic review and meta-analysis by Parikh and colleagues recommended that FISH and IGVH status be performed as standard clinical tests for all patients with newly diagnosed CLL patients in those countries with the resources to do so. These authors argue that use of these tests allows the application of powerful, recently developed prognostic indices to CLL cases.
Chromosomal evaluation using FISH can identify certain chromosomal abnormalities of CLL with prognostic significance. Patients with a deletion in the short arm of chromosome 17 [del(17p)] tend to have a worse prognosis, as well as resistance to therapy with alkylating agents and purine analogues. Patients with deletions in the long arm of chromosome 11 [del(11q)] also have a worse prognosis and bulky lymphadenopathy at presentation.
The poor prognosis seen with del(17p) and del (11q) are independent of the patient's stage at presentation. Patients with these abnormalities may benefit from treatment with the monoclonal antibody alemtuzumab.[22, 23, 24]
IgVH status has shown potential as a prognostic marker for CLLas well. ZAP-70 and CD38 expression tend to correlate with unmutated IgVH and a poorer prognosis; however, these associations are not absolute. Further clinical information is necessary to determine the role that testing for these markers should play in the management of chronic lymphocytic leukemia (chronic lymphoid leukemia, CLL).
None of the poor prognostic markers has been validated as an indication to initiate treatment in asymptomatic patients.
MicroRNA analysis remains a research tool. miR-181b levels appear to decrease in blood samples of patients whose disease is progressive.
Bone Marrow Aspiration and Biopsy
Bone marrow aspiration and biopsy with flow cytometry is not required in all cases of CLL, but it may be necessary in selected cases to establish the diagnosis and to assess other complicating features such as anemia and thrombocytopenia. For example, bone marrow examination may be necessary to distinguish between thrombocytopenia of peripheral destruction (in the spleen) and that due to marrow infiltration.
Consider a lymph node biopsy if lymph node(s) begin to enlarge rapidly in a patient with known CLL, to assess the possibility of transformation to a high-grade lymphoma. When such transformation is accompanied by fever, weight loss, and pain, it is termed Richter syndrome.
Two staging systems are in common use for CLL: the modified Rai staging in the United States and the Binet staging in Europe. Neither is completely satisfactory, and both have often been modified. Because of its historical precedent and wide use, the Rai-Sawitsky system is described first, followed by the Binet. See also Chronic Lymphocytic Leukemia Staging.
These CLL staging systems have been unable to provide information regarding disease progression due to its heterogeneity.
After successful treatment of immune cytopenias, CLL may be down-staged,
Rai-Sawitsky staging system
The original 5-stage Rai-Sawitsky staging system was revised in 1987 to a simpler 3-stage system. The revised Rai staging system divides patients into low-, intermediate-, and high-risk groups, as follows:
Low risk (formerly stage 0) – Lymphocytosis in the blood and marrow only (25% of presenting population) 
Intermediate risk (formerly stages I and II) – Lymphocytosis with enlarged nodes in any site or splenomegaly or hepatomegaly (50% of presentation)
High risk (formerly stages III and IV) – Lymphocytosis with disease-related anemia (hemoglobin <11 g/dL) or thrombocytopenia (platelets <100 x 10 9/L) (25% of all patients)
Binet staging system
The Binet stages are as follows:
Stage A – Hemoglobin greater than or equal to 10 g/dL, platelets greater than or equal to 100 × 10 9/L, and fewer than 3 lymph node areas involved.
Stage B – Hemoglobin and platelet levels as in stage A and 3 or more lymph node areas involved
Stage C – Hemoglobin less than 10 g/dL or platelets less than 100 × 10 9/L, or both
Elter T, Hallek M, Engert A. Fludarabine in chronic lymphocytic leukaemia. Expert Opin Pharmacother. 2006 Aug. 7(12):1641-51. [Medline].
PDQ Adult Treatment Editorial Board. Chronic Lymphocytic Leukemia Treatment (PDQ®): Health Professional Version. PDQ Cancer Information Summaries. Bethesda, MD: National Cancer Institute; January 29, 2016. [Full Text].
Klepfish A, Gilles L, Ioannis K, Eliezer R, Ami S. Enhancing the action of rituximab in chronic lymphocytic leukemia by adding fresh frozen plasma: complement/rituximab interactions & clinical results in refractory CLL. Ann N Y Acad Sci. 2009 Sep. 1173:865-73. [Medline].
Badoux XC, Keating MJ, Wang X, et al. Fludarabine, cyclophosphamide and rituximab chemoimmunotherapy is highly effective treatment for relapsed patients with CLL. Blood. 2011 Jan 18. [Medline].
Zenz T, Benner A, Duhrsen U, Durig J, Dohner H, Siffert W, et al. BCL2-938C>A polymorphism and disease progression in chronic lymphocytic leukemia. Leuk Lymphoma. 2009 Sep 11. 1-6. [Medline].
Fabbri M, Bottoni A, Shimizu M, et al. Association of a microRNA/TP53 feedback circuitry with pathogenesis and outcome of B-cell chronic lymphocytic leukemia. JAMA. 2011 Jan 5. 305(1):59-67. [Medline].
Wang L, Lawrence MS, Wan Y, et al. SF3B1 and other novel cancer genes in chronic lymphocytic leukemia. N Engl J Med. 2011 Dec 29. 365(26):2497-506. [Medline].
Slager SL, Kay NE. Familial Chronic Lymphocytic Leukemia: What Does it Mean to Me?. Clin Lymphoma Myeloma. 2009 Sep 1. 9:S194-S197. [Medline].
Berndt SI, Camp NJ, Skibola CF, Vijai J, Wang Z, et al. Meta-analysis of genome-wide association studies discovers multiple loci for chronic lymphocytic leukemia. Nat Commun. 2016 Mar 9. 7:10933. [Medline].
Cancer Facts & Figures 2016. American Cancer Society. Available at http://www.cancer.org/acs/groups/content/@research/documents/document/acspc-047079.pdf. Accessed: March 10, 2016.
Rai KR, Keating HJ. Chronic lymphocytic leukemia. Holland JF, Bast RC, Morton DL, et al, eds. Cancer Medicine. 4th ed. Baltimore, Md: Williams and Wilkins; 1997. Vol II: 2697-728.
Kristinsson SY, Dickman PW, Wilson WH, et al. Improved survival in chronic lymphocytic leukemia in the past decade: a population-based study including 11,179 patients diagnosed between 1973-2003 in Sweden. Haematologica. 2009 Sep. 94(9):1259-65. [Medline]. [Full Text].
Maurer MJ, Cerhan JR, Katzmann JA, et al. Monoclonal and polyclonal serum free light chains and clinical outcome in chronic lymphocytic leukemia. Blood. 2011 Sep 8. 118(10):2821-6. [Medline]. [Full Text].
Hallek M, Cheson BD, Catovsky D, et al. Guidelines for the diagnosis and treatment of chronic lymphocytic leukemia: a report from the International Workshop on Chronic Lymphocytic Leukemia updating the National Cancer Institute-Working Group 1996 guidelines. Blood. 2008 Jun 15. 111(12):5446-56. [Medline].
Bouley J, Deriano L, Delic J, Merle-Béral H. New molecular markers in resistant B-CLL. Leuk Lymphoma. 2006 May. 47(5):791-801. [Medline].
Zwiebel JA, Cheson BD. Chronic lymphocytic leukemia: staging and prognostic factors. Semin Oncol. 1998 Feb. 25(1):42-59. [Medline].
[Guideline] National Comprehensive Cancer Network. Non-Hodgkin's Lymphomas Version 2. 2016. NCCN. Available at http://www.nccn.org/professionals/physician_gls/pdf/nhl.pdf. Accessed: March 11, 2016.
Parikh SA, Strati P, Tsang M, West CP, Shanafelt TD. Should IGHV status and FISH testing be performed in all CLL patients at diagnosis? A systematic review and meta-analysis. Blood. 2016 Feb 3. 39 (8A):935-7. [Medline].
Hillmen P, Skotnicki AB, Robak T, et al. Alemtuzumab compared with chlorambucil as first-line therapy for chronic lymphocytic leukemia. J Clin Oncol. 2007 Dec 10. 25(35):5616-23. [Medline].
Montillo M, Tedeschi A, Miqueleiz S, et al. Alemtuzumab as consolidation after a response to fludarabine is effective in purging residual disease in patients with chronic lymphocytic leukemia. J Clin Oncol. 2006 May 20. 24(15):2337-42. [Medline]. [Full Text].
Moreton P, Kennedy B, Lucas G, et al. Eradication of minimal residual disease in B-cell chronic lymphocytic leukemia after alemtuzumab therapy is associated with prolonged survival. J Clin Oncol. 2005 May 1. 23(13):2971-9. [Medline]. [Full Text].
Bosch F, Ferrer A, Villamor N, et al. Fludarabine, cyclophosphamide, and mitoxantrone as initial therapy of chronic lymphocytic leukemia: high response rate and disease eradication. Clin Cancer Res. 2008 Jan 1. 14(1):155-61. [Medline].
Byrd JC, Gribben JG, Peterson BL, et al. Select high-risk genetic features predict earlier progression following chemoimmunotherapy with fludarabine and rituximab in chronic lymphocytic leukemia: justification for risk-adapted therapy. J Clin Oncol. 2006 Jan 20. 24(3):437-43. [Medline].
Wierda WG, O'Brien S, Wang X, et al. Multivariable model for time to first treatment in patients with chronic lymphocytic leukemia. J Clin Oncol. 2011 Nov 1. 29(31):4088-95. [Medline].
Eichhorst BF, Busch R, Stilgenbauer S, et al. First-line therapy with fludarabine compared with chlorambucil does not result in a major benefit for elderly patients with advanced chronic lymphocytic leukemia. Blood. 2009 Oct 15. 114(16):3382-91. [Medline].
Burger JA, Tedeschi A, Barr PM, Robak T, Owen C, Ghia P, et al. Ibrutinib as Initial Therapy for Patients with Chronic Lymphocytic Leukemia. N Engl J Med. 2015 Dec 17. 373 (25):2425-37. [Medline].
Robak T, Jamroziak K, Gora-Tybor J, et al. Comparison of cladribine plus cyclophosphamide with fludarabine plus cyclophosphamide as first-line therapy for chronic lymphocytic leukemia: a phase III randomized study by the Polish Adult Leukemia Group (PALG-CLL3 Study). J Clin Oncol. 2010 Apr 10. 28(11):1863-9. [Medline].
Fischer K, Cramer P, Busch R, et al. Bendamustine combined with rituximab in patients with relapsed and/or refractory chronic lymphocytic leukemia: a multicenter phase II trial of the German Chronic Lymphocytic Leukemia Study Group. J Clin Oncol. 2011 Sep 10. 29(26):3559-66. [Medline].
Knauf WU, Lissitchkov T, Aldaoud A, Liberati AM, Loscertales J, Herbrecht R, et al. Bendamustine compared with chlorambucil in previously untreated patients with chronic lymphocytic leukaemia: updated results of a randomized phase III trial. Br J Haematol. 2012 Oct. 159(1):67-77. [Medline].
Nabhan C, Coutré S, Hillmen P. Minimal residual disease in chronic lymphocytic leukaemia: is it ready for primetime?. Br J Haematol. 2007 Feb. 136(3):379-92. [Medline].
Sayala HA, Rawstron AC, Hillmen P. Minimal residual disease assessment in chronic lymphocytic leukaemia. Best Pract Res Clin Haematol. 2007 Sep. 20(3):499-512. [Medline].
Parikh SA, Keating MJ, O'Brien S, et al. Frontline chemoimmunotherapy with fludarabine, cyclophosphamide, alemtuzumab, and rituximab for high-risk chronic lymphocytic leukemia. Blood. 2011 Aug 25. 118(8):2062-8. [Medline].
Badoux XC, Keating MJ, Wang X, et al. Cyclophosphamide, fludarabine, alemtuzumab, and rituximab as salvage therapy for heavily pretreated patients with chronic lymphocytic leukemia. Blood. 2011 Aug 25. 118(8):2085-93. [Medline].
Skoetz N, Bauer K, Elter T, Monsef I, Roloff V, Hallek M, et al. Alemtuzumab for patients with chronic lymphocytic leukaemia. Cochrane Database of Systematic Reviews. 2012.
Lemery SJ, Zhang J, Rothmann MD, Yang J, Earp J, Zhao H. U.S. Food and Drug Administration approval: ofatumumab for the treatment of patients with chronic lymphocytic leukemia refractory to fludarabine and alemtuzumab. Clin Cancer Res. 2010 Sep 1. 16(17):4331-8. [Medline].
Nelson R. FDA Grants Full Approval to Ofatumumab (Arzerra) for CLL. Medscape Medical News. Available at http://www.medscape.com/viewarticle/823837. Accessed: March 10, 2016.
Furman RR, Sharman JP, Coutre SE, Cheson BD, Pagel JM, Hillmen P, et al. Idelalisib and rituximab in relapsed chronic lymphocytic leukemia. N Engl J Med. 2014 Mar 13. 370(11):997-1007. [Medline]. [Full Text].
van Oers MH, Kuliczkowski K, Smolej L, Petrini M, Offner F, Grosicki S, et al. Ofatumumab maintenance versus observation in relapsed chronic lymphocytic leukaemia (PROLONG): an open-label, multicentre, randomised phase 3 study. Lancet Oncol. 2015 Oct. 16 (13):1370-9. [Medline].
Goede V, Fischer K, Humphrey K, Asikanius E, Busch R, Engelke A, et al. Obinutuzumab (GA101) plus chlorambucil (Clb) or rituximab (R) plus Clb versus Clb alone in patients with chronic lymphocytic leukemia (CLL) and preexisting medical conditions (comorbidities): Final stage 1 results of the CLL11 (BO21004) phase III trial. J Clin Oncol 31, 2013 (suppl; abstr 7004).
B McCall. Obinutuzumab Active in Elderly Chronic Lymphocytic Leukemia. Medscape Medical News from the: 18th Congress of the European Hematology Association (EHA). June 21, 2013. Available at http://www.medscape.com/viewarticle/806700. Accessed: November 11, 2013.
Mougalian SS, O'Brien S. Adverse prognostic features in chronic lymphocytic leukemia. Oncology (Williston Park). 2011 Jul. 25(8):692-6, 699. [Medline].
Robak T, Dmoszynska A, Solal-Celigny P, et al. Rituximab plus fludarabine and cyclophosphamide prolongs progression-free survival compared with fludarabine and cyclophosphamide alone in previously treated chronic lymphocytic leukemia. J Clin Oncol. 2010 Apr 1. 28(10):1756-65. [Medline].
Woyach JA, Ruppert AS, Heerema NA, Peterson BL, Gribben JG, Morrison VA, et al. Chemoimmunotherapy With Fludarabine and Rituximab Produces Extended Overall Survival and Progression-Free Survival in Chronic Lymphocytic Leukemia: Long-Term Follow-Up of CALGB Study 9712. J Clin Oncol. 2011 Apr 1. 29(10):1349-55. [Medline].
Hallek M, Fischer K, Fingerle-Rowson G, et al. Addition of rituximab to fludarabine and cyclophosphamide in patients with chronic lymphocytic leukaemia: a randomised, open-label, phase 3 trial. Lancet. 2010 Oct 2. 376(9747):1164-74. [Medline].
Nelson R. New Drug Combo Potentially 'Practice Changing' in CLL. Medscape [serial online]. Available at http://www.medscape.com/viewarticle/817454. Accessed: December 16, 2013.
Byrd JC, Furman RR, Coutre SE, Flinn IW, Burger JA, Blum KA, et al. Targeting BTK with ibrutinib in relapsed chronic lymphocytic leukemia. N Engl J Med. 2013 Jul 4. 369(1):32-42. [Medline]. [Full Text].
Chustecka Z. Ibrutinib in CLL: indication expanded, benefit confirmed. July 28, 2014. [Full Text].
Byrd JC, Brown JR, O'Brien S, Barrientos JC, Kay NE, Reddy NM, et al. Ibrutinib versus ofatumumab in previously treated chronic lymphoid leukemia. N Engl J Med. 2014 Jul 17. 371 (3):213-23. [Medline]. [Full Text].
Chustecka Z. Idelalisib (Zydelig) approved for CLL and lymphoma. Medscape Medical News. July 23, 2014. [Full Text].
FDA news release: FDA approves Zydelig for three types of blood cancers. US Food and Drug Administration. July 23, 2014. Available at http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm406387.htm.
Molica S. Immunomodulatory drugs in chronic lymphocytic leukemia: a new treatment paradigm. Leuk Lymphoma. 2007 May. 48(5):866-9. [Medline].
Boggs W. Chlorambucil Effective for Chronic Lymphocytic Leukemia in Elderly. Medscape Medical News. December 13, 2012. [Full Text].
Woyach JA, Ruppert AS, Rai K, Lin TS, Geyer S, Kolitz J, et al. Impact of Age on Outcomes After Initial Therapy With Chemotherapy and Different Chemoimmunotherapy Regimens in Patients With Chronic Lymphocytic Leukemia: Results of Sequential Cancer and Leukemia Group B Studies. J Clin Oncol. 2012 Dec 10. [Medline].
Gribben JG, Hosing C, Maloney DG. Stem cell transplantation for indolent lymphoma and chronic lymphocytic leukemia. Biol Blood Marrow Transplant. 2011 Jan. 17(1 Suppl):S63-70. [Medline].
Michallet M, Dreger P, Sutton L, et al. Autologous hematopoietic stem cell transplantation in chronic lymphocytic leukemia: results of European intergroup randomized trial comparing autografting versus observation. Blood. 2011 Feb 3. 117(5):1516-1521. [Medline].
Raanani P, Gafter-Gvili A, Paul M, Ben-Bassat I, Leibovici L, Shpilberg O. Immunoglobulin prophylaxis in chronic lymphocytic leukemia and multiple myeloma: systematic review and meta-analysis. Leuk Lymphoma. 2009 May. 50(5):764-72. [Medline].
Koehrer S, Keating MJ, Wierda WG. Eltrombopag, a second-generation thrombopoietin receptor agonist, for chronic lymphocytic leukemia-associated ITP. Leukemia. 2010 May. 24(5):1096-8. [Medline].
Borthakur G, O'Brien S, Wierda WG, et al. Immune anaemias in patients with chronic lymphocytic leukaemia treated with fludarabine, cyclophosphamide and rituximab--incidence and predictors. Br J Haematol. 2007 Mar. 136(6):800-5. [Medline].
Moulin B, Ronco PM, Mougenot B, Francois A, Fillastre JP, Mignon F. Glomerulonephritis in chronic lymphocytic leukemia and related B-cell lymphomas. Kidney Int. 1992 Jul. 42(1):127-35. [Medline].
Chustecka Z. Ibrutinib (Imbruvica) Approved for CLL in US. Medscape [serial online]. Available at http://www.medscape.com/viewarticle/820537. Accessed: February 19, 2014.
FDA News Release. FDA approves Gazyva for chronic lymphocytic leukemia. Medscape [serial online]. Available at http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm373209.htm. Accessed: November 4, 2013.
FDA News Release. FDA approves Imbruvica to treat chronic lymphocytic leukemia. U.S. Food and Drug Administration. Available at http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm385764.htm. Accessed: February 19, 2014.
Nelson R. FDA Gives Arzerra Breakthrough Therapy Designation for CLL. Medscape Medical News. Available at http://www.medscape.com/viewarticle/811307. Accessed: September 24, 2013.
Shanafelt T, Lanasa MC, Call TG, et al. Ofatumumab-based chemoimmunotherapy is effective and well tolerated in patients with previously untreated chronic lymphocytic leukemia (CLL). Cancer. 2013 Aug 6. [Medline].
Venclexta (venetoclax) [package insert]. North Chicago, IL: AbbVie, Inc. April 2016. Available at [Full Text].