Patient Resources

Chronic Lymphocytic Leukemia

 

 

OVERVIEW

Leukemia is a cancer that begins in the hematopoietic (blood-forming) cells of the bone marrow, the soft, spongy inner part of such bones as the skull, pelvis, and backbones. The hematopoietic cells produce three types of blood cells: red, white, and platelets. Red cells carry oxygen to the muscles and provide the body with energy. Platelets are the clotting cells that prevent bleeding. White blood cells are the cells of the immune system. Leukemia occurs when abnormal blood cells reproduce and crowd out normal cells in the bone marrow. Most leukemias are cancers of the white blood cells. Abnormal leukemic cells can spread the cancer to other parts of the body including the lymph nodes, liver, spleen, skin, and central nervous system. (When cancer starts elsewhere and spreads to the bone marrow, it is not leukemia.)

Leukemia can be acute or chronic (such as chronic lymphocytic leukemia), depending on whether the abnormal cells are mature or immature. In chronic leukemia, bone marrow cells mature but they do not function properly and do not fight infections as would normal white blood cells. Because chronic leukemic cells can live much longer than normal white blood cells, chronic leukemia is a slower-forming disease that usually worsens gradually.

Chronic lymphocytic leukemia (CLL) forms in the lymphoid cells of the bone marrow. The disease most commonly affects adults over age 65, but sometimes occurs in younger adults. It almost never affects children. In 2007, the American Cancer Society estimates that 15,000 new cases of CLL will be diagnosed in the United States.

At The Cancer Center, our chief of the Division of Leukemia, Stuart L. Goldberg, M.D., is one of the nation's foremost authorities and researchers of all types of leukemia. He also serves as the medical advisor to the Northern NJ Chapter of the Leukemia and Lymphoma Society. He leads an active leukemia research team that is conducting about 30 clinical trials for new treatments for leukemia. Many patients with leukemia at The Cancer Center are enrolled in a clinical trial. National Cancer Institute research groups, pharmaceutical companies, and independent research agencies frequently turn to Dr. Goldberg to collaborate on clinical research studies because of his successful accruals (enrollments) and his ability to attract new patients to The Cancer Center.

A hematologist/oncologist, Dr. Goldberg also specializes in the use of stem cell transplantation to treat patients with leukemia. He and his colleagues at The Cancer Center's Adult Blood and Marrow Stem Cell Transplantation Program pioneered the use of reduced-intensity "mini&quot: transplants for older patients and those who are too frail to undergo the rigors of a standard stem cell transplant. Our stem cell transplantation program is one of the nation's 10 largest; each year more than 200 stem cell transplants are performed here.

A crucial component to the accurate diagnosis of leukemia is The Cancer Center's Special Diagnostic Immunology Laboratory, one of only several sites in New Jersey where comprehensive tests are available to detect cancer at the molecular level and to stage and classify it.

 

DIAGNOSTIC SERVICES

A diagnosis of leukemia is made after several tests have been completed. Samples of cells are taken from a patient's blood and bone marrow. Other tissue and cell samples (possibly from the lymph nodes and cerebrospinal fluid) may be taken in order to guide treatment. A crucial component to the accurate diagnosis of leukemia is The Cancer Center's Special Diagnostic Immunology Laboratory, one of only several sites in New Jersey where comprehensive tests are available to detect cancer at the molecular level and to stage and classify it.

Since many patients with CLL will live for many years and may not require therapy, the identification of prognostic characteristics in CLL has assumed a critical place in disease management. In addition to making a correct diagnosis, the hematologist is now charged with properly identifying those CLL patients with high risk disease so that therapy can be tailored, and separating them from the majority of patients with low risk CLL who only need infrequent monitoring (because of their excellent prognosis). The Special Immunology Laboratory at Hackensack University Medical Center performs blood analysis for CD38 on newly diagnosed patients with CLL. Patients who have less than <30percent CD38 positive cells in their leukemia samples have a longer time until needing treatment and a longer survival. Similarly, most patients are screened by FISH (fluorescent in-situ-hybridization) for genetic changes that can aid in determining prognosis.

Radiologic tests used to diagnose leukemia may include a chest X-ray, bone scan, CT scan, MRI, and/or ultrasound.

 

RISK FACTORS

CLL has not been associated with any environmental or external causes such as benzene or radiation. However genetic relationships may be important. First-degree relatives (parents, siblings, or children) of patients with chronic lymphocytic leukemia have a two-to-four-fold increased risk. Interestingly although the disease is common in the United States and Europe, it is rare in Asia.

 

SYMPTOMS

Symptoms of chronic leukemia emerge slowly and, when they do appear, they are generally mild at first then worsen gradually. About one out of five persons with chronic leukemia has no symptoms at the time that it is found. Some common symptoms for chronic lymphocytic leukemia include:

  • fever, chills, and other flu-like symptoms
  • frequent infections
  • weakness and fatigue (due to anemia)
  • loss of appetite and/or weight loss
  • swollen or tender lymph nodes, liver, or spleen
  • easy bruising or bleeding
  • tiny red spots (called petechiae) under the skin
  • swollen or bleeding gums
  • sweating, especially at night
  • bone or joint pain

 

TREATMENT SERVICES

For patients with low-risk and intermediate stage chronic lymphocytic leukemia (CLL) with no symptoms, no immediate treatment is usually given. Your doctor will have you visit for frequent follow-up exams. Patients with intermediate stage CLL with symptoms may be treated with chemotherapy, antibody therapy, radiation therapy, surgery, leukapheresis (removal of white blood cells and leukemic cells), or a combination of methods. Patients with high-risk CLL may be treated with a combination of chemotherapy, surgery/radiation therapy for an enlarged spleen, and stem cell transplantation. Your hematologist/oncologist will decide which treatment or combination of treatments is best for you based on the stage of the disease, your age, your overall health, and whether the leukemia is causing any symptoms. The decision to receive treatments can often be quite difficult but may be based on the patient's subtype of leukemia, general health, age, and overall desires. Shortly after diagnosis a comprehensive review of the type of leukemia is performed to determine the aggressiveness of the cancer and to provide prognostic information that may be helpful in chosing a treatment course.

Chemotherapy

Chemotherapy is used to destroy leukemic cells and to help control symptoms and side effects of the cancer. A combination of medications is often used. Drugs known as growth factors are sometimes given to increase white blood cell counts after chemotherapy and thus reduce the chance of infection. Many older patients are surprised at how well they tolerate chemotherapy for CLL. Since this is a slowly growing form of cancer with a generally good prognosis, types of chemotherapy have been developed to minimize toxicities. If you are diagnosed with intermediate stage chronic lymphocytic leukemia (CLL) or high-risk CLL, you may be treated with chemotherapy alone or combined with surgery to remove your spleen (if it is enlarged), radiation therapy, total body irradiation, and/or high-dose chemotherapy combined with total body irradiation and stem cell transplantation. A more complete discussion of the risks and benefits of chemotherapy will be provided during the extensive consultation process with members of the Division of Leukemia. Additional updates on current treatment approaches are available from the Leukemia and Lymphoma Society (www.LLS.org) and the National Cancer Institute (www.cancer.gov).

Antibody Therapies

One of the major advances in the past decade for CLL has been the use of antibodies which specifically target the cancer cells. Rituximab (Rituxan), either alone or in combination with chemotherapy, attacks a target (CD20) on the surface of most CLL cells. Recent studies have shown that Rituximab improves both the chances of entering remission and prolongs the remission in most patients. Alemtuzumab (Campath) is another antibody that targets CLL cells. It is very potent and is typically used after recurrences of cancer. It is administered in the Cancer Center allowing most patients to remain at home during their treatments.

Stem Cell Transplantation

Stem cell transplantation may be used to restore blood-producing stem cells that have been destroyed by leukemia or cancer treatment. Stem cell transplantation is a highly advanced type of treatment that is available at only several hospitals in New Jersey. Our Adult Blood and Marrow Stem Cell Transplantation Program is one of the nation's 10 largest. Each year more than 200 persons undergo stem cell transplantation here at The Cancer Center. The program is the only one in New Jersey where stem cell transplants using cells from unrelated donors are performed. Our chief of the Division of Leukemia, Stuart L. Goldberg, M.D., and other experts in stem cell transplantation at The Cancer Center are responsible for some of the major advances in the techniques used in stem cell transplantation, including the use of reduced-intensity "mini&quot: transplants. The role of transplantation for CLL is in evolution. The development of the reduced-intensity strategies is allowing this aggressive treatment to be offered to younger CLL patients in hopes of providing them with the chance at cure.

Immunosuppressive Therapy

Immunosuppressants are medications that are used to prevent the rejection of donor stem cells after transplantation.

Radiation Therapy

Patients with intermediate stage chronic lymphocytic leukemia (CLL) with symptoms may be treated with radiation therapy if their spleen or lymph nodes are enlarged. For patients with high-risk CLL, radiation therapy may be combined with surgery to remove an enlarged spleen. Total body irradiation may be combined with high-dose chemotherapy and stem cell transplantation for patients with high-risk CLL. Radiation therapy may also be used as a palliative treatment to treat pain due to bone destruction by leukemic cells and/or if enlarged internal organs are pressing against others.

Surgery

The only type of surgery used to treat leukemia is a splenectomy (removal of the spleen) if the organ is enlarged and pressing against other internal organs and causing pain.

Supportive Treatment

Whole blood transfusions or transfusions of platelets, white blood cells, and red blood cells may be given as supportive treatment.