Chronic lymphocytic leukemia in general practice

Uvod. Hronična limfocitna leukemija (HLL) je najčešća leukemija kod odraslih, retko obolevaju deca. Češće se javlja kod osoba muškog pola starosti preko 60 godina. Etiopatogenetski, predstavlja nenormalno bujanje limfocita u koštanoj srži, koji su disfunkcionalni iako morfološki liče na zrele. Prikaz slučaja. Pacijentkinja, stara 66 godina, domaćica, dolazi na pregled zbog zamora koji traje oko mesec dana i gubitka 3 kg do 4 kg, ostale tegobe negira. Na pregledu svesna, orijentisana u vremenu, prostoru i prema ličnostima, eupnoična, limfadenopatija na vratu, aksilama i ingvinumu, odaje utisak lakšeg bolesnika. Klinički pregled: na plućima disanje vezikularno bez propratnih šušnjeva, srčana radnja ritmična, tonovi jasni, krvni pritisak (TA) 140/80 mmHg, abdomen u ravni grudnog koša, palpatorno bolno neosetljiv, jetra se ne palpira a slezina se palpira 2 cm ispod rebarnog luka. Krvna slika je pokazala povećan broj leukocita 181,30x109/L i limfocitozu 92,2%, ostali parametri su bili normalni. Upućena je hematologu Opšte bolnice u Kraljeva, gde je urađena dalja dijagnostika. Ponovljena je krvna slika, urađen radiološki pregled (RTG) pluća, ultrazvuk (EHO) abdomena, vrata, aksila, ingvinuma, srca, virusologija, pregled ORL. Ultrazvuk abdomena je pokazao patoloski nalaz sa uvećanom jetrom, slezinom, limfnim nodusima (LN). Pregled ORL: uvećane tonzile, ostali nalaz uredan. Pod sumnjom na hroničnu limfocitnu leukemiju, pacijentkinja je upućena u Klinički centar Srbije (KCS). Urađena je imunofenotipizacija (IF) i kompjuterizovana tomografija (CT) vrata, grudnog koša i abdomena. Potvrđena je dijagnoza HLL. Konzilijarno je odlučeno da se sprovede imunohemioterapijsko lečenje (IHT) sa Fludarabinom i Rituksimabom. Posle 6 primljenih ciklusa, bolesnica se subjektivno dobro oseća a nalazi krvne slike su normalni. Zaključak. Kod velikog broja pacijenata HLL može proticati asimptomatski ili sa nespecifičnim i blagim simptomima. Stoga su pregledi krvne slike i nalaz leukocitoze i apsolutne limfocitoze presudni da se posumnja na ovo oboljenje i da se sprovede dalja dijagnostika. Ključne reči. Hronična limfocitna leukemija, leukocitoza, limfocitoza. Abstract


Introduction
Leukemias are malignant blood diseases. In relation to the duration, they are divided into acute and chronic, and according to the type of leukocytes, which flourish malignantly, into granulocytic and lymphocytic. They represent an abnormal, generalized proliferation of one of the leukocyte lines, followed very often by an increased number of leukocytes in the peripheral blood 1 .
Chronic lymphocytic leukemia (CLL) is a malignant disease of the blood cells-lymphocytes, which are morphologically slightly different from normal cells but are nonfunctional, which consequently affects immunity. There are two types of CLL: B-cell, which is more common and occurs in 95% of patients, and T-cell, which is less common 1 . The etiology is unknown. The culprits are ionizing radiation, genetics, pathogenic agents, viruses, bacteria, pesticides and herbicides, stress. There is evidence that frequent exposure to pesticides and herbicides is a major external risk factor 1,2 . A family history of the disease can increase the risk by up to 3 times than in people who do not have a positive family history. Chronic lymphocytic leukemia is a disease mainly of older men, over 60. The risk of CLL increases significantly with age. There are about 13 new cases per 100,000 people over the age of 65 1,2 .
The clinical presentation is remarkable for enlarged lymph glands, liver, and spleen, but also many atypical signs such as fatigue, night sweats, weight loss, bloating, itching, and hyperpigmentation of the skin, herpes zoster, and others. Disease staging can be performed according to Rai and Binet classification. There are 4 disease stages: Zero, when only lymphocytosis is present, I when there is lymphadenopathy in addition to lymphocytosis, II lymphocytosis, lymphadenopathy, and enlarged liver and/or spleen. In stage III, in addition to the above, there is also anemia, and in stage IV there is also thrombocytopenia 1,2 . The onset of the disease is usually insidious and CLL is often diagnosed accidentally during a routine blood check or treatment of asymptomatic lymphadenopathy 2 . CBC reveals leukocytosis with pronounced lymphocytosis. Leukocyte formula initially shows lymphocyte percentages ranging from 60%-75%, and later up to 90%. Although mature, these lymphocytes are atypical, dysfunctional with consequences for the immune system. In most cases, the patient with an increased number of leukocytes feels well. In rare cases, clinical symptoms and signs accompany the onset of the disease. Normally, the bone marrow is made up of stem cells, which become mature blood cells over time. In CLL, too many blood stem cells become abnormal lymphocytes that do not reach a certain maturity and thus lose function. As the number of leukemic cells increases in the peripheral blood, there is a consequent increase in the number of cells in the bone marrow, thereby reducing the space for normal cells 1 . Over time, abnormal leukocytes accumulate in the

Case report
A 66-year-old female patient, a housewife, comes for an examination due to fatigue that lasts for about a month. She lost 3-4 kg in the last two months, denies other health problems. She is treated for high blood pressure, rarely visits her GP, long-term smoker, 20 cigarettes a day, does not drink alcohol, had more stressful situations in recent months. She has got a family history of cardiovascular disease and diabetes.
She is alert, oriented to time, space, and persons, afebrile, eupnoeic, mobile, well-fed, with pale skin, lymphadenopathy on the neck, axillae, and groins up to 4 cm, in conglomerates. She gives away the impression of a patient with mild clinical symptoms.
Physical examination revealed: head of normal configuration, nose passable, tongue moist and uncoated, tonsils enlarged, eyeballs moving in all directions, pupils reacting to light and accommodation, neck movable in all directions, thyroid gland within physiological limits, chest symmetrical, respiratory bilaterally mobile, clear breath sounds in all lung fields, regular heartbeat, clear tones, without pathological noises, BP 140/80 mmHg. Abdomen in the plane of the chest, painless to palpation, the liver is not palpable, the spleen is palpated by 2 cm, firm, smooth edges, painless. Renal lodges are insensitive to rough percussion. Limbs without edema and deformity, preserved peripheral arterial pulsations on UE (upper extremities), and LE (lower extremities). No visible neurological deficits.
A CBC showed high values of leukocytes 181.30x10 9 /L in peripheral blood with a high percentage of lymphocytes 92.2%. Other findings were within the reference range. She was immediately referred to a hematologist at the Kraljevo General Hospital, where she was hospitalized on October 15, 2019, and further diagnostics were performed: chest X-ray, ultrasound (US) of the abdomen, neck, axillae, groins, and heart, complete biochemistry and ELISA test (ELISA enzymelinked immunosorbent assay). ENT examination was performed. Abdomen US findings: the size of the liver is within the physiological limits; two vaguely defined, hyperechoic formations of 14 mm and 15 mm in diameter can be observed, which might be hemangiomas, but they also might be lesions of secondary etiology. The size of the spleen is at the upper limit of physiological values (120 mm x 55 mm) with a distinctly heterogeneous structure, it is infiltratively altered with visible diffusely distributed hypoechoic micro areas with a diameter of 3 mm to 12 mm. In the retroperitoneum, a larger number of altered lymph nodes (LN) with a diameter mandibularno se uočava par uvećaih LN, od kojih su neki izmenjene strukture, zbrisanog hilusa, promera 10 mm i 7 mm. Obostrano parajugularno uočava se više pojedinačnih LN u nizu, izmenjene strukture, zbrisanih hilusa, očuvanog L/W indeksa, najveći promer do 14 mm. Obostrano aksilarno uočava se više grupisanih uvećanih LN, ali očuvane strukture i hiperehogenog hilusa, očuvanog L/W indeksa, promera do 20 mm. Obostrano ingvinalno uočava se više grupisanih uvećanih LN, očuvane strukture i hiperehogenog hilusa, očuvanog L/W indeksa promera do 23 mm. Nalaz RTG pluća u granicama normale, nalaz EHO srca uredan. Virusologija of 15 mm to 27 mm are observed, which are of hypoechoic structures, the rest is unremarkable. Neck, axillary and groin regions US: The size of the thyroid gland is within normal limits, symmetrical with regular contours and homogeneous structure; in the right lobe, heterogeneous cystically degenerated nodule 7.5 mm x 4.5 mm and in the left lobe isoechoic nodule 5 mm x 6 mm. In submandibular area, there is a pair of enlarged LNs, some of which are of altered structure, with a deleted hilus, 10 and 7 mm in diameter. On both sides, parajugularly, several individual LNs are observed in a row, altered structures, erased hili, of preserved L/W index, maximum diameter up to 14 mm. On both sides, in axillae, several grouped enlarged LNs are observed, but with preserved structure and hyperechoic hili, of the preserved L/W index, up to 20 mm in diameter. In both groins, several grouped enlarged LNs, of preserved structure and hyperechoic hili, with preserved L/W index, up to 23 mm in diameter are observed. Chest X-ray findings are within normal limits. Heart US findings are normal. Virology tests (ELISA test) for HepB, HepC and HIV Ag are negative. Coombs dir. and ind. tests are negative. CT examination of the neck, chest, and abdomen findings: in the neck region there were enlarged lymph nodes on all levels, on the right-hand side ranging from 12 to 24 mm in diameter, mostly in the upper third. Supraclavicular enlarged lymph nodes were up to 12 mm. On the left-hand side of the neck, there were enlarged and changed lymph nodes with a diameter of 14 to 35 mm, and supraclavicular left up to 14 mm. Axillary bilaterally enlarged and pathologically altered lymph nodes were up to 20 mm. There was a subpleural node in the basal part of the right lung up to 9 mm in diameter, with banded adhesive changes. Spleen was of heterodense structure, regular contours, 143 mm x 59 mm. Liver of regular contours, in AP diameter in MCL 160 mm, with a formation in VII segment, 13 mm in diameter, which 300 mg/dan, Aciklovir i Bactrim 2 x 2 u dane vikenda. Kontrola krvne slike jednom nedeljno. Primenu II cy rituksimaba imala je preko dnevne bolnice KCS 13.01.2020, Primena II cy FC na hematologiji Opšte bolnice u Kraljevu. Primila je na opisani način ukupno 6 cy. Sada se subjektivno dobro oseća, kontrole hematologa na tri meseca. Sadašnja biohemija je u normalnim granicama WBC 4,19 x10 9 /L, RBC 4,12x10 12 /L, HGB 135 g/L.
During the hospital stay, the Medical Council decided to start immunochemotherapeutic treatment (ICT) according to the RFC protocol, D1 I cy on December 3, 2019: Fludarabine, amp. 38 mg D1-3, Cyclophosphamide, amp. 380 mg D1-3, Rituximab, amp. 500mg D4. There were no complications during the treatment. She was discharged home with the advice to take the Allopurinol tab. 300mg /day, Acyclovir and Bactrim, tab. 2x2 on weekends. CBC check was advised once a week. The application of II cy of rituximab was performed in the daily clinic of CCS on January 13, 2020, and the application of II cy of FC at Hematology Ward of the General Hospital in Kraljevo. She received a total of 6 cy, as described. Now she feels well and has got regular check-ups with a hematologist every three months. Current CBC is within normal limits WBC 4.19 x10 9 /L, RBC 4.12x10 12 /L, HGB 135 g/L.

Discussion
CLL is one of the most common leukemias in adults. The incidence reaches 13 cases per 100,000 people, over the age of 65. Since in the initial phase it can have very mild and nonspecific symptoms or even be asymptomatic, routine blood counts and preventive examinations are needed, and they are crucial for early diagnosis and timely treatment. The finding of leukocytosis with lymphocytosis is an alarm, and a patient should be referred to a hematologist for further diagnostic evaluation. Anemia and/or thrombocytopenia or hypogammaglobulinemia may also be present in the blood count.
In order to confirm the diagnosis of CLL, it is necessary to prove that all lymphocytes are of the same origin (monoclonal lymphocytosis). Therefore, their immunophenotyping (IF) is performed, ie. determination of lymphocyte characteristics in peripheral blood 3,4 . In the CLL cells, the presence of markers CD5, CD19, CD23, CD20 was mainly proven. If it is proven that the lymphocytes are of the same origin, and there are more than 5,000 of them in the peripheral blood sample, a diagnosis of CLL can be confirmed. So, invasive tests such as puncture and bone marrow biopsy are not needed for early diagnosis 5 .
Given the slow progression of the disease in most patients, it is necessary to determine the stage of the disease according to Binet and Rai, perform immunophenotyping (IF), as well as the risk of progression and prognosis (FISH -Fluorescence in situ hybridization)., before starting treatment.
to serious bacterial, viral, fungal infections. Chromosomal abnormalities are very common in CLL, so it is important to perform a FISH analysis to determine the presence of specific chromosomes before starting treatment. Del (13g) -the most common genetic change on chromosome 13, is detected in 40-60%, and they have a more favorable prognosis, while Del (17p) (deletion of chromosome 17) has about 5% of patients and they have the worst prognosis because they do not respond to standard treatment 1,6 .
The treatment methods are multiple, and the patient approach is individual. Chemotherapy, immunochemotherapy, biological therapy, radiological, palliative, bone marrow transplantation, general measures are used in the treatment 5,6 . Chemotherapy usually consists of a combination of several drugs. The most commonly used are Fludarabine, Cyclophosphamide, Chlorambucil, Bendamustine. Cytostatics can be administered alone or in combination with targeted therapy or monoclonal antibodies. Neutropenia, allergic reactions, fever, nausea, vomiting are the most common side effects.
Immunochemotherapy is a combination of cytostatics and an antibody that binds to a specific protein on a malignant cell. This therapy represents an improvement in the treatment, unlike chemotherapy which is less specific. Monoclonal antibody therapy aims to destroy only CLL cells. Rituximab, Obinuturumab and Ofatumumab are used 5,6 .
Biological therapy is used in the disease relapses, or when the patient does not respond to conventional therapy, but also in patients with high-risk CLL. The most commonly used drug is Ibritunib, which blocks Bruton's tyrosine kinase 7,8,9 . Palliative therapy includes transfusions of erythrocytes and/or platelets, use of antibiotics, corticosteroids, possible surgical removal of the spleen. Bone marrow transplantation involves the use of donor stem cells. General recommendations include avoiding risk factors for malignant diseases, avoiding stress, regular sleep, enough fluids intake, avoiding infections and insect bites because these patients have intense reactions at the site of the bite.
Patients with B-cell CLL or its complications live an average of 7-10 years. Patients in Rai grade of 0-II can live from 5-20 years. Grade III or IV patients die within 3-4 years. Progression to bone marrow failure indicates short survival. Patients with CLL are prone to other malignant tumors, especially skin cancer. As CLL is a progressive disease, some patients remain asymptomatic for years, so treatment is not necessary before symptoms or progression occurs. Healing is usually impossible, so treatment is aimed at suppressing symptoms and prolonging life 2 .