A 70-year-old woman comes to the office for evaluation before an elective left knee replacement. Except for chronic left knee pain due to long-standing osteoarthritis, she has no other symptoms. The patient underwent an uncomplicated right knee replacement 4 years ago. Her only other medical problem is hypertension, for which she takes hydrochlorothiazide and amlodipine. She does not use tobacco or alcohol.
Vital signs are within normal limits. Her BMI is 24 kg/m². Physical examination shows spotty submandibular lymph nodes and crepitus in her left knee. Cardiovascular and abdominal examinations are unremarkable.
Laboratory results are as follows:

Peripheral blood smear shows small mature lymphocytes and a few smudge cells. Flow cytometry shows a population of cells that are CD5⁺, CD19⁺, CD23⁺, and CD38⁺.
Which of the following is the most appropriate next step in management of this patient?

Question

A 70-year-old woman comes to the office for evaluation before an elective left knee replacement. Except for chronic left knee pain due to long-standing osteoarthritis, she has no other symptoms. The patient underwent an uncomplicated right knee replacement 4 years ago. Her only other medical problem is hypertension, for which she takes hydrochlorothiazide and amlodipine. She does not use tobacco or alcohol.
Vital signs are within normal limits. Her BMI is 24 kg/m². Physical examination shows spotty submandibular lymph nodes and crepitus in her left knee. Cardiovascular and abdominal examinations are unremarkable.
Laboratory results are as follows:

Peripheral blood smear shows small mature lymphocytes and a few smudge cells. Flow cytometry shows a population of cells that are CD5⁺, CD19⁺, CD23⁺, and CD38⁺.
Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_982b_1325_853d_69e10a90ef60_MD0002_00 This patient's presentation is consistent with chronic lymphocytic leukemia (CLL), which accounts for nearly 30% of adult leukemias in the United States and has a median age of 70 at diagnosis. Patients typically present with "B symptoms" (eg, recurrent fever, night sweats, weight loss), painless lymphadenopathy, hepatosplenomegaly, anemia, and thrombocytopenia. Diagnosis is confirmed by peripheral smear showing >5000/mm³ mature-appearing small B lymphocytes and flow cytometry showing monoclonal B-cell characteristics (eg, CD19, CD20, CD23). ³ CLL is usually an indolent disease with a median survival of >10 years in asymptomatic patients with early-stage disease (Rai stage 0-I, Binet stage A). As a result, asymptomatic patients do not need treatment and can be observed for possible disease progression. Treatment should be initiated in patients with disease progression and advanced-stage CLL as they have a median survival time of 18 months to 3 years without therapy. This patient is asymptomatic and can undergo knee surgery without CLL treatment. If her disease progresses, she may require chemotherapy in the future (Choice A). early-stage disease (Choice B) Bone marrow aspirate and biopsy in CLL can show normal to increased cellularity, with lymphocytes accounting for >30% of all nucleated cells. However, these studies are not required for diagnosing or staging CLL. (Choice C) A lymph node biopsy in CLL will show malignant lymphoma containing morphologically mature-appearing small lymphocytes. However, it is indicated only if there is doubt regarding the etiology of the lymphadenopathy or concern for transformation into an aggressive large-cell lymphoma (ie, Richter transformation). (Choice D) CD38 and ZAP-70 positivity, VH gene mutation status, and other molecular and genetic studies are sometimes used as prognostic indicators for CLL. However, these studies are not necessary for the diagnosis and would likely not change management for this patient's knee surgery. Educational objective: Chronic lymphocytic leukemia (CLL) diagnosis requires >5000 B lymphocytes/mm³ in the peripheral blood and flow cytometry confirmation of circulating B lymphocyte clonality. CLL is usually an indolent disease, and asymptomatic patients do not need treatment. ³ __________ References: 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. (http://www.ncbi.nlm.nih.gov/pubmed/18216293)

A 70-Year-Old Woman Comes to the Office for Evaluation Before