HEMATOLOGY

THE CHRONIC LYMPHOCYTIC LEUKEMIAS

AND LYMPHOMA

The Chronic Lymphocytic Leukemias are characterised by mature lymphoid cells, B-cell and T-cell
types.
CHRONIC LEUKEMIA OF B-CELL LINEAGE
These leukemias (leukaemias) are characterised by surface membrane immunoglobulin (SMIg)
which is monoclonal. This can be proved by immunophenotyping using antibodies to both Light
chains, Kappa and Lambda. Positivity in a monoclonal disorder will be restricted to only one of the
light chains. The other will be negative.(Light chain restriction.) There may be more than one type
of Heavy chain.
CHRONIC LYMPHOCYTIC LEUKEMIA (CLL)
Pathogenesis:
Slow proliferating; long survival.
CLL is a clonal proliferation of B-cells at an intermediate stage of development. They are
immunologically defective and have a longer life-span than normal.
They infiltrate the bone marrow and circulate in the peripheral blood.
Clinical findings:
Seen in older individuals. (> 50)
Usually discovered accidentally.
Some patients have: lymph nodes, fatigue, weakness.
Occasionally: enlarged spleen,
antibody mediated hemolytic anemia.
Laboratory features:
FBC:
White cells increased: 20 200 X 109 /l.
Hemoglobin and platelets usually normal but can decrease later on in disease.
Peripheral blood:
Increase of small round lymphocytes.
Nuclear chromatin dense and clumped. (coarse chromatin.)
Cells are fragile and smear cells are often seen. Must comment when present.
Occasional nucleoli seen prolymphocytes (< 10 % of cells).
Bone marrow:
Infiltrated with small round mature lymphocytes similar to those in the blood.
Erythroid and myeloid cells are reduced.

Trephine:
Pattern of infiltration can be:
1. Interstitial: lymphocytes among other cells.
2. Nodular: nodules of small lymphocytes.
3. Diffuse: Entire bone marrow taken over by lymphocytes.
Immunophenotyping:
B-cell antigens: CD19+, CD20+
Surface immunoglobulin: Positive with Light chain restriction and dim fluorescence.
T-cell antigens: CD5+ usually co-expressed with a B-cell antigen. CD2 and CD3 negative.
Note: CD5 not positive in any other chronic leukemia.
Mature B-cell antigens: CD22 weak or negative.
FMC-7 weak or negative.
Mouse red cells: Positive.
Chronic Lymphocytic Leukemia / Prolymphocytic Leukemia (CLL / PLL)
CLL subtype.
There is increased (> 10 %) prolymphocytes which have nucleoli.

Treatment and staging:

The RAI system is used to stage patients. It correlates with prognosis.

Hb > 11 g/dl.
Platelets > 100 X 109 /l.

Stage 0 plus lymph nodes.

II

Stage 0 and nodes plus spleen and liver.

III

Stage II or I and Hb < 11 g/dl.

IV

Stage I or II and Platelets < 100 X 109 /l.

There is no cure.(2002)
Various drugs have been used. The newest (as at 2002) is fludarabine.
Patients tend to become resistant after 4 to 5 years.
Course:
Patients can transform to:
1. Richters Syndrome: Large cell lymphoma which is usually fatal.
2. Prolymphocytic Leukemia: Prolymphocytes become dominant.
3. Acute leukemia.

PROLYMPHOCYTIC LEUKEMIA (PLL)

Clinical:
Usually seen in elderly patients.
Patients have massive splenomegaly with few lymph nodes.
Laboratory:
FBC: White cells very high +_ 100 500 X 109 /l.
Peripheral smear: > 55 % of cells are prolymphocytes. Cells are large and less mature looking.
They have condensed nuclear chromatin, prominent nucleolus and abundant cytoplasm.
Immunophenotyping:
B-cell antigens:
CD19+, CD20+
SMIg:
Positive with bright fluorescence.
T-cell antigens:
Negative for CD5, CD2 and CD3.
Mature B-cell antigens: FMC-7+, CD22+
Mouse Rosettes:
Decreased.
Cytogenetics: Abnormalities of chromosome 14.
Treatment:
Usually resistant to all forms of therapy.(2002)
Prognosis is very poor.
HAIRY CELL LEUKEMIA
Clinical:
Can appear throughout adult life but predominates in elderly males.
Symptoms include: infections, lethargy and bruising.
Characterised by massive splenomegaly and minimal lymphadenopathy.
Laboratory:
FBC: Pancytopaenia. Low Hb, WCC and platelets.
Blood smear: Increased presence of Hairy cells:
Nucleus: eccentric, round or oval. Nuclear chromatin is finely dispersed.
Nucleoli are small and inconspicuous.
Cytoplasm: Abundant, weakly basophilic, irregular Hairy projections. Ill defined
cell outline. May see azurophilic granules.
Bone marrow: Similar cells are seen. The trephine has a diffuse infiltration with nuclei appearing
spaced apart, i.e. surrounded by a clear zone.
Reticulin is increased.
Cytochemistry:
Acid phosphatase: Positive. Hairy cells are tartrate resistant.(TRAP positive). Most other cells
are sensitive and loose their positivity.
Non Specific Esterase: Typical crescent positivity in cytoplasm.
Immunophenotyping:
B-cell antigens:
CD19+, CD20+, FMC-7+, CD22+.
T-cell antigens:
Negative for CD5, CD2, CD3.
SMIg:
Positive with bright fluorescence.
Mouse rosettes:
Decreased.

Other positive antigens: CD11c+, CD25+

Treatment:
Splenectomy: Half of cases do not need further treatment.
nterferon: 90 % of cases respond very well.
Other drugs: Prednisone and cyclophosphamide. (as at 2002.)
Prognosis:
Good; can live for many years. Patients can however die from infections due to the pancytopenia.
HAIRY CELL VARIANT
FBC: Usually high WCC.
Peripheral blood:
Leukaemic cells are numerous. They differ from hairy cells in that they have high nuclearcytoplasmic ratios.(Scanty cytoplasm still with projections.) The nucleus is condensed and they
have prominent nucleoli.
Cytochemistry: TRAP negative.
Immunophenotyping: CD25 negative.
Therapy:
Patients do not respond to interferon. Bad prognosis.
SPLENIC LYMPHOMA WITH VILLOUS LYMPHOCYTES
This disorder is a splenic lymphoma with minimal lymphadenopathy. Can be confused
(morphologically) with Hairy cell.
Laboratory:
White cells are variable.
Peripheral smear: Predominantly lymphocytes abnormal with round nucleus.
Nucleolus distinct but small.
Cytoplasm: moderately basophilic with short villous projections.
Cytochemistry: TRAP negative.
Immunophenotyping: Similar to prolymphocytic leukemia.
CD25 and CD11c negative.
NON-HODGKINS LYMPHOMA IN LEUKAEMIC PHASE
When the cells of a lymphoma spill over from the lymph nodes into the peripheral blood the
lymphoma enters a leukaemic phase. Certain lymphomas such as small-cell lymphoma tend to have
a high incidence of spill over.
Laboratory:
Periph. Blood:
Cells are small but more pleomorphic than CLL.
Nuclei have condensed chromatin and often have clefts. Nucleoli: not visible.

NB: The appearance of the cells can vary depending on the type of Lymphoma.
Immunophenotyping:
B-cell markers:
CD19+, CD20+, CD22+, FMC-7+
T-cell markers:
Negative for CD5, CD2, CD3.
Note: Patients with mantle cell lymphoma will express CD5.
Immunophenotyping can vary depending on type of lymphoma.
SMIg:
Positive with strong fluorescence.
Mouse rosettes:
low.
Treatment:
Clinically the small-cell lymphomas behave similarly to CLL.
MEMBRANE MARKERS IN CHRONIC B-CELL LEUKAEMIA
CLL

PLL

HCL

++

++

++

++

++

CD19
+
& CD20

CD22
+/_ weak
& FMC-7

Mouse
+
Rosettes

CD25

++

+/_

+/_

CD11c

++

+/_

+/_

SMIg
CD5

+/_ weak

HCL-V

CLL: Chronic Lymphocytic Leukemia

PLL: Prolymphocytic Leukemia
HCL: Hairy Cell Leukemia
HCL-V: Hairy Cell Variant
SLVL: Splenic Lymphoma with Villous Lymphocytes

SLVL

Lymphoma with
spillover

CHRONIC T-CELL LEUKEMIA

Rare disorder comprising +/_ 2 % of chronic leukemia.
It is a clonal disorder. Clonality can only be proved by doing molecular studies.
T-CELL CHRONIC LYMPHOCYTIC LEUKAEMIA
This disorder can also be called T lymphoproliferative disorder or Large granular lymphocytic
leukaemia.
Clinical:
Median age: +/_ 58 years.
Usually symptoms appear gradually.
Recurrent infections.
Splenomegaly.
Laboratory:
FBC and Smear:
Lymphocytosis and granulocytopaenia.
Lymphocytes are large with abundant weakly basophilic cytoplasm.
Cytoplasm contains small numbers of azurophilic granules.
Nucleus: Round / oval with clumped chromatin.
Immunophenotyping:
T-cell antigens:
CD2+, CD3+/_, CD7+
Cytotoxic T-cell:
CD8+
Helper T-cell:
CD4Natural Killer cells: CD56+, CD57+, CD16- (although normal NK cells are CD16+; note NK cells
do not have CD3)
Interleukin 2 receptor: CD25B-cell antigens:
CD19-, CD20Thus, the malignant cells are thought to be either T-cytotoxic cells or NK cells.
Course and treatment:
Chronic, non progressive course.
Chemotherapy is usually not indicated. Splenectomy can be performed to relieve symptoms.
T-CELL PROLYMPHOCYTIC LEUKAEMIA (T-PLL)
Clinical:
Splenomegaly (similar to B-cell PLL).
Patients also have lymphadenopathy and skin lesions.
Laboratory:
Peripheral blood smear:
Morphology is similar to B-cell PLL.
Cytoplasm is usually deeply basophilic. The nucleus can be more irregular but also has a prominent
nucleolus.
Immunophenotyping:
T-cell markers:
CD2+, CD3+, CD7+
Cytotoxic T-cells:
CD8-

Helper T-cells:
CD4+
Interleukin 2 receptor: CD25B-cell markers:
Negative for CD19 and CD20.
Cytogenetics:
2/3 have inversion 14.
Course and prognosis:
Aggressive disease with very bad prognosis.
SEZARY SYNDROME / LEUKEMIA
Sezary syndrome / leukemia is the leukaemic phase of Mycosis Fungoides. Mycosis Fungoides is a
lymphoma of the skin which is characterised by a generalized exfoliative erythroderma.
Clinical:
Mycosis Fungoides may be present for many years before Sezary syndrome develops.
Itchy skin lesions are present.
Lymphadenopathy.
Can have splenomegaly.
Laboratory:
FBC: Often normal.
Peripheral smear:
Sezary cells are seen.
The cells have a high nuclear cytoplasmic ratio.
A dense nucleus with a grooved surface.
No visible nucleolus.
Electron microscopy: Can be useful in revealing the deeply convoluted nucleus.
Immunophenotyping:
T-cell markers:
CD2+, CD3+, CD7Cytotoxic T-cell:
CD8Helper T-cell:
CD4+
Interleukin 2 receptor: CD25B-cell markers:
Negative CD19 and CD20.
ADULT T-CELL LEUKAEMIA / LYMPHOMA (ATLL)
ATLL occurs in adults who are carriers of the retrovirus HTLV-1. This virus is seen in the following
areas: Japan, The Caribbean, pockets of the U.S.A.
This is one of the few leukaemias which are directly associated with a virus. (as at 2002.)
Clinical:
Rapid onset.
Lymphadenopathy.
Skin lesions.
Hypercalcaemia.
Life threatening infections.
Laboratory:

The number of circulating lymphocytes are variable. They have a very distinctive morphology.
Condensed clumped nuclear chromatin. Nucleoli are infrequent.
Nucleus is convoluted and polylobated, often resembling a clover leaf.
Immunophenotyping:
T-cell markers:
CD2+, CD3+, CD7Cytotoxic T-cells:
CD8Helper T-cells:
CD4+
Interleukin 2 receptor: CD25+
B-cell antigens:
CD19-, CD20HTLV-1 virus: Always positive.
Trephine: +/_ 50 % of cases are involved.
Course and prognosis:
Aggressive disease with short survival (+/_ 13 months). Patients are prone to infection and have a
very short response to therapy. (as at 2002)
CELL MARKERS IN CHRONIC T-CELL LEUKAEMIA
LGLL(T-CLL)

T-PLL

ATLL

Sezary Syndrome

CD2

CD3

CD7

--

--

CD8

--

--

--

CD4

--

CD25 (Il 2)

--

--

--

CD56

--

--

--

--

--

--

--

--

--

--

NK

CD57

markers

CD16

LGLL(T-CLL): Large Granulocytic Leukemia/ Lymphoma (T-cell CLL)

T-PLL:
T-cell Prolymphocytic Leukemia
ATLL:
Adult T-cell Leukemia / Lymphoma.

LYMPHOMA
Definition: A malignant disorder which originates in the lymph nodes or other lymphatic tissue.
Divided into two groups: Hodgkins Disease and Non-Hodgkins Lymphoma.
The diagnosis is made in Histology.
HODGKINS DISEASE
Pathogenesis:
Malignant neoplasm which arises in a single group of lymph nodes and spreads to other nodes, and
eventually infiltrating non-lymphoid tissue.
Hodgkins disease is characterised by the Reed-Sternberg cell:

Cause:
Unknown.(2002)
Increased incidence after hydantoin anticonvulsant drug.
? viral e.g. Epstein Barr virus.
Familial: e.g. increased incidence in twins.
Clinical:
Lymphadenopathy nodes are usually painless except after alcohol intake.
Fever, night sweats, loss of weight.
Laboratory:
Diagnosis is made on the Lymph node biopsy. The lymph node is usually taken over by an infiltrate
of reactive and malignant cells.
1. Malignant cells:
- Reed-Sternberg cell,
- Hodgkins Mononuclear cell,
- Lacunar cells.
These cells are thought to originate from the monocyte-macrophage lineage.
2. Reactive cells:
Lymphocytes, plasma cells, eosinophils, fibroblasts and histiocytes.
Hodgkins Mononuclear cell (Hodgkin cell):

Lacunar cell:

Classification:
1. Nodular sclerosis: Most common. The node is divided up by bands of collagen. Increased
lacunar cells. Has a good prognosis.
2. Lymphocyte predominant: Node infiltrated by large and small lymphocytes. Occasional
Reed-sternberg cell is seen. Good prognosis.
3. Mixed cellularity: Very pleomorphic infiltrate : eosinophils, histiocytes, plasma cells,
lymphocytes and fibroblasts. (All non-malignant reactive cells.) There are also many Reedsterberg cells and Hodgkins mononuclear cells. Intermediate prognosis.
4. Lymphocyte depleted: Hodgkins mononuclear cells and R/S cells. Few lymphocytes.
Extensive fibrosis. Poor prognosis.
Therapy (as at 2002):
Aim to cure.
Radiotherapy and chemotherapy.
Prognosis:
+/_ 60 % survive at 10 years post-diagnosis.
+/_ 90 % survive at 5 years post-diagnosis.
Complications:
Develop other conditions e.g. MDS.
Prognostic indicators:
Classification.
Elderly patients do worse.
NON-HODGKINS LYMPHOMA
Pathogenesis:
Malignant disorder which arises in lymph node. They comprise mainly of lymphocytic cells and,
rarely histiocytes.
Possible causes: Immunodeficiency states e.g. HIV.
Viral, e.g. Epstein Barr virus.
Epileptic drugs.
Radiation: increase after Hiroshima.
Clinical:
Lymphadenopathy: main symptom.
Splenomegaly and hepatomegaly due to spread of disease.
Loss of weight, fever, malaise.
Laboratory:
Diagnosis is made on the lymph node.
Classification system:
REAL (Revised European-American Lymphoma) classification is based on both the histological
appearance of the cells and immunophenotyping.
Now the WHO classification is used (as at 2002).
Staging system:
Ann Arbor system can be used for staging of both Hodgkins disease and Non-Hodgkins Lymphoma.
I
Single lymph node involved.
II
2 or more lymph nodes on the same side of the diaphragm.
III
Nodes on both sides of diaphragm.
IV
Involvement of one or more organs other than lymph nodes, e.g. bone marrow.

Treatment:
Varies according to type of lymphoma. (WHO)
Usually a combination of radiotherapy and chemotherapy.
Up to 50 % of High-grade lymphomas are cured.
Lower grades can survive up to +_ 7 years (as at 2002).
Notes from Cape Peninsula University of Technology (Fmr. Cape Technikon), 2002, ND., B.Tech.
Biomedical Technology.
More Notes at:
http://www.scribd.com/people/documents/2135965/folder/83622