Oncology Chronic Lymphocytic Leukemia: Review Questions Eric Jacobsen, MD, and David C. Fisher, MD Dr. Jacobsen is a hematologic malignancies fellow and Dr. Fisher is an instructor in medicine; both are at the Dana-Farger Cancer Institute and Harvard Medical School, Boston, MA. Choose the single best answer for each question.
	1. A 75-year-old woman is referred from her primary care physician with a leukocyte count of 34× 103/mm3 with 80% lymphocytes, hemoglobin concentration of 13 g/dL, hematocrit of 40%, and platelet count of 220× 103/mm3. A physical examination and computed tomography (CT) scan show no evidence of lymphadenopathy, splenomegaly, or hepatomegaly. She is asymptomatic. What is the most appropriate treatment for this patient at this time? Bone marrow transplantation Chlorambucil Chlorambucil and fludarabine in combination Hydroxyurea to eliminate the risk of leukostasis No treatment is indicated at this time Click here to compare your answer. 2. A 57-year-old man with a history of untreated stage I chronic lymphocytic leukemia (CLL) presents to the emergency department (ED) with a 1-week history of fatigue. He denies any trauma, melena, or hematemesis. His hematocrit is 14%, with a platelet count of 175 × 103/mm3 and leukocyte count of 22 × 103/mm3 with 68% lymphocytes. His chemistry profile is normal except for an elevated indirect bilirubin. A peripheral blood smear shows numerous spherocytes. His physical examination is unremarkable except for pallor. His most recent complete blood count (2 weeks earlier) revealed a hematocrit of 38%, a leukocyte count of 19 ×103/mm3 with 70% lymphocytes, and a platelet count of 190 × 103/mm3. What is this patient’s most likely diagnosis? Close follow-up with mammography, chest radiography, complete blood count, and tumor marker analysis every 6 months Autoimmune hemolytic anemia Progression to stage IV CLL with subsequent anemia from bone marrow replacement Pure erythrocyte aplasia Splenomegaly with splenic sequestration of erythrocytes Thrombotic thrombocytopenic purpura Click here to compare your answer.		3. A 65-year-old man has stage IV CLL, which was previously treated. Most recently, he was treated with alemtuzumab. One month after receiving alemtuzumab, he presents to the ED with a 1-week history of nonproductive cough, low-grade fevers, and progressive shortness of breath without prodromal symptoms. He lives in New Hampshire and has not traveled recently. He is tachypneic with an oxygen saturation of 85% on room air, hemodynamically stable, and has a temperature of 101.8°F. A chest radiograph shows a faint bilateral interstitial infiltrate. What is this patientıs most likely diagnosis? Histoplasmosis Hypersensitivity pneumonitis from alemtuzumab Pneumocystis carinii pneumonia Pneumococcal pneumonia Pulmonary infiltration with CLL Click here to compare your answer. 4. A 56-year-old woman has stage I CLL characterized by cervical and axillary lymphadenopathy. She has never been treated. She presents to clinic complaining of a 2-week history of worsening fatigue but no other symptoms. On physical examination, a markedly enlarged right cervical lymph node is noted, while the remainder of her lymph nodes are unchanged from a previous examination. The oropharynx is slightly red, but the tonsils are normal and without exudate. Which of the following is the most appropriate diagnostic test? Cervical lymph node biopsy CT of the neck Laryngoscopy Monospot Rapid test for streptococci Click here to compare your answer.
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