Investigations for the New Patient With CLL

Asymptomatic, elderly patients with early stage, uncomplicated CLL do not require extensive investigation beyond confirmation of the diagnosis by CBC, film, and immunophenotyping. A younger patient who may be eligible for an allograft will need detailed work up. The following is a guide and further investigations should be directed by the clinical presentation:

Note: Additional tests may be required if a patient is enlisted into a CLL trial. Consult with trial document.

Monoclonal B-cell lymphocytosis

In the absence of lymphadenopathy or organomegaly (defined by physical examination or CT scan), cytopenias or B symptoms the presence of <5 x 10⁹/l clonal B-cells with the immunophenotype of CLL (weak CD5+, CD19+, weak CD20+, CD23+, weak Ig+) is defined as Monoclonal B-cell lymphocytosis (MBL).

It is not uncommon to find a bone marrow infiltrate, median 20% lymphocytes, in patients with MBL. The percentage involvement has not been linked to the risk of progression to CLL. In the absence of other criteria for CLL, the finding of BM infiltration does not change the diagnosis from MBL to CLL or SLL.

MBL is a newly described entity that should not be considered a clinical disease. MBL carries a different risk of progression to CLL depending on the number of lymphocytes.

Further reading


About this Canterbury DHB document (5509):
Document Owner:	Blake Hsu (see Who's Who)
Last Reviewed:	September 2018
Next Review:	September 2021
Keywords:
Note: Only the electronic version is controlled. Once printed, this is no longer a controlled document. Disclaimer The Haematology Department Protocols and Guidelines (the Red Book) are intended as a guide for registered health professionals to communicate guidelines and share best practices with supporting health professionals within New Zealand district health boards. They are not intended to be provided to or used as a reference for patients or non-registered health professionals. All health professionals must exercise their own clinical judgement and use pertinent clinical data when treating patients. The authors and editors of this publication have checked with sources believed to be reliable in their effort to provide information that is complete and in accord with the standards accepted at the time of publication. However, in view of the possibility of human error or changes in medical science, neither the authors, editors, publisher, nor any other party who has been involved in preparing or publishing this work warrants that the information contained in it is accurate or complete in every respect. They therefore have no liability (whether in tort (including negligence) or otherwise) for any loss or damage arising out of any reliance on this information. This publication has been compiled by the staff and contractors of Canterbury District Health Board (CDHB) and as such CDHB has copyright for this book. Amendments must be authorised in accordance with the documented process. No release of part of, or all of, this publication to any other party or organisation is permissible without the prior approval of the designated document owner.
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History, physical examination, performance status		All patients
CBC, differential and film	3 x 5 EDTA (mauve top). 1 x 5 mL citrate, 1 x 5 mL plain.	All patients
Immunophenotyping of peripheral blood lymphocytes	2 x 5 mL EDTA (mauve top), send to surface markers lab (ext: 80917)	All patients
ONCO profile, SPE, Ig levels	1 x 5 mL heparin, 1 x 5 mL plain	All patients
Direct antiglobulin test	1 x 7.5 mL EDTA (pink top)	All patients
Hepatitis B and C		All patients undergoing intensive therapy, e.g. FCR
HLA Typing	Contact SCT Coordinator. 4 x 10 mL CPDA, 1 x 10 mL plain, 1 x 5 mL EDTA.	Transplant-eligible patients only
Chromosome analysis and FISH DNA samples	20 mL in heparin	Screen for TP53 in patients receiving intensive therapy
Bone marrow aspirate and trephine	Arrange with Haematology registrar	Not routinely required for diagnosis (see above) but may be desirable pre-treatment
Chest X-Ray		If clinically indicated
CT chest/abdomen/pelvis		Consider pre- and post-treatment CT in patients receiving intensive therapy
Lymph node biopsy		Consider in patients with bulky or progressive lymphadenopathy, high LDH, and/or extranodal lesions to exclude Richter’s transformation