A Case Study On

CHRONIC LYMPHOCYTIC LEUKEMIA

DIPLOMA IN MEDICAL LABORATORY TECHNOLOGY

UNIVERSITI TEKNOLOGI MARA

By:

Training Venue :
 1.0 Acknowledgement

Bissmillahirrahmanirrahim,

Alhamdulillah. Thanks to Allah SWT, whom with His willing giving me the opportunity
to complete my case study on Chronic lymphoid leukemia(CLL) and finish my practical
training for 14 weeks. This assignment would not have been possible without the support of
many people.

Firstly, I would like to express my deepest thanks to my parents and family for their
valuable guidance, understanding & endless love, and also gave me full of support through
the duration of my studies from beginning untill the end

Special thanks also to all my friends, especially group members who doing practical
at Pusat Perubatan Universiti Kebangsaan Malaysia (PPUKM) for sharing the information in
completing my case study and invaluable assistance.

Besides, i would like to thank the Head Programme of Diploma in Medical Laboratory
Technology, Dr. Roslinah bt Md Hassan and to all my beloved lecturers that give me
knowledge and exciting experiences during in UiTM Jalan Othman since first semester until
the practical session. En. Zed Zakari bin Abdul Hamid, En. Mohd Nazri bin Abu, En. Mohd
Fahmi bin Mastuki, En. Wan Shahriman Yushdie bin Wan Yusoff, Prof. Izham bin Abdul
Rahim, Sir Tengku Shahrul Anuar bin Tengku Basri,others lecturer. Thank you for all effort
taught to us and it is very useful during practical session.

Lastly, the very thanks to all the staff because give full attention and guide me during
practical session. The valuable experiences and knowledge that I gain, I will not forget and
apply in the future. Thank you for everything. Not forgetting to those who were involved,
either directly or indirectly in the completion of this assignment till it is fully completed.

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 2.0 Abstract

Leukemia is cancer of the white blood cells. The body produce a large number of
abnormal white blood cells. Leukemia disrupts the production of normal blood cells. Its lack
the ability to fight infections.Leukemia kills more children and it develops in about 4 in every
100 00 youngster. White blood cells are formed in bone marrow. The marrow is the soft,
spongy center of bones. Under normal circumstances, the white blood cells circulate to the
lymph nodes, the liver and the spleen. The cells stay until they are needed. In leukemia, the
marrow produces a large number of abnormal white blood cells which are immature or
young.they look different and do not function properly.

Leukemia can be acute or chronic. Acute leukemia gets worse rapidly.the number of
abnormal white cells multiplies quickly. Chronic leukemia develops more slowly.Leukemia
have four main type which is Acute lymphocytic leukemia (ALL), Acute myelocytic leukemia
(AML), Chronic myelocytic leukemia (CML) and Chronic lymphocytic leukemia (CLL).ALL is
most common in children,AML is affects both children and adults but it is most common in
adult,CML is most common in adults and small number in children and for CLL is only affects
adults age 55 and older,it is never appears in children.

In the chronic leukemias, the onset tends to be slow, and the cells generally
mature abnormally and often accumulate in various organs, often over long intervals. Their
ability to fight infections and assist in repairing injured tissues is impaired. However, unlike
the acute forms of leukemia, untreated, these disorders may persist for many months or as in
the chronic lymphocytic group can live for several years. A distinctive feature of the chronic
myelocytic type is its invariable conversion, if untreated, to a more rapidly fulminating acute
type, leading to rapid death.

In chronic lymphocytic leukemia (CLL), there are too many of a specific type of white
blood cell called a lymphocyte.CLL is the second most common form of leukemia in adults.
Usually CLL does not cause any symptoms at all. Tests that examine the blood, bone
marrow, and other else test are needed. To diagnose this disease,the blood sample will be
sent to several laboratory.

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 . DEPARTMENT OF MEDICAL LABORATORY TECHNOLOGY

FACULTY OF HEALTH SCIENCES

UNIVERSITY TECHNOLOGY MARA JALAN OTHMAN

LIST OF CONTENTS

1.0 Acknowledgement............................................................................................... 2

2.0 Abstract...........................................................................................3

3.0 Content............................................................................................4

4.0 Introduction .......................................................................................5

4.1 Definition...............................................................................5

5.0 Etiology............................................................................................6

5.1 High risk individual ....................................................................7

5.2 Symptoms...............................................................................7

5.3 Exams and test........................................................................8

5.3 Staging....................................................................................8

6.0 Treatment.........................................................................................11

7.0 Outlook (prognosis).............................................................................14

8.0 Possible complication..........................................................................14

9.0 Case Report

9.1 Patient History..........................................................................15

9.2 Laboratory Investigation.............................................................16

9.3 Patient results...........................................................................24

10.0 Discussion.........................................................................................30

11.0 Conclusion.........................................................................................32

12.0 References.........................................................................................33

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 4.0 Introduction

Chronic lymphocytic leukemia (CLL) is a lymphoproliferative disorder which is 30% of

adult leukemia and 25% of non-Hodgkin lymphoma (NHL). It is the most common form of
leukemia in the western world is about 5 in every 100 000 but fewer than 5% of the cases in
the eastern hemisphere. Elderly people are mainly affected with CLL, a small number of
people are diagnosed with CLL in their 30s and 40s. (Hallek, 2010)

CLL is difficult to detect early because does not cause any symptoms. Patients may
be asymptomatic prior to an incidental diagnosis. In the last 20 years, the number of cases of
CLL presenting in asymptomatic stages has doubled from 30% to 60%, likely due to an
increasing number of blood tests performed for other medical or surgical reasons. Moreover,
sensitive techniques to diagnose and differentiate CLL from other chronic lymphoproliferative
disorders have only recently become routinely available. (Kalil & Cheson, 1999)

4.1 Defination

First case that diagnosed as a Chronic Lymphocytic Leukemia is about 150 years ago
in 1841 by Craige that saw two patient having leukemia but unknown what type of leukemia
craige start published about this case in 1845 after futher reseached and post mortem that
has done after the patient died. (Polliack & Catovsky, 1988)

CLL is one of four main types of leukemia. It is slow growing cancer in which too
many immature or young lymphocytes are found mostly in the blood and bone marrow. The
next stage of this cancer, cells are found in the lymph nodes and the disease is called small
lymphocytic lymphoma. Also called chronic lymphocytic leukemia.

CLL starts with a change (mutation) to the DNA of a single cell called a lymphocyte.
In 95% of people with CLL, the change occurs in a B lymphocyte. In the other 5%, the cell
that transforms from normal to leukemic has the features of a T lymphocyte or an NK cell. B-
cells, T-cells and NK-cells are types of lymphocytes. The diagram below illustrates the
process of lymphocyte development.

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 CLL cells multiply and replace normal lymphocytes in the marrow and lymph nodes.
The high number of CLL cells in the marrow may crowd out normal blood forming cells and
CLL cells are not able to fight infection like normal lymphocytes do.

5.0 Etiology

The etiology of CLL is unknown . Several lines of evidence suggest a genetic

component, such as the increased prevalence of CLL among first-degree relatives, the
phenomenon of anticipation, where there is an increased of severity and earlier age of onset
with each generation and the increased frequency of autoimmune disorders in relatives of
CLL patients. Environmental factors, such as ionizing radiation, chemicals (benzene and
solvents from the rubber industry),and drugs have shown no apparent relationship. (Kalil &
Cheson, 1999)

CLL causes a slow increase in the number of white blood cells called B cells in the
bone marrow. The cancerous cells spread from the blood marrow to the blood and can also
affect the lymph nodes or other organs such as the liver and spleen. CLL eventually causes
the bone marrow to fail, resulting in low blood counts, and weakens the immune system.The
reason for this increase in B cells is unknown. There is no link to radiation, cancer-causing
chemicals, or viruses. (Hallek, 2010)

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 5.1 High risk individual
Few group are having high potential to get CLL.

1. Smoker because smoke will be develop cancerous cell but many people who have
leukemia have never smoked.

2. Who is being middle-aged or older. From 50 years old and above.

3. People who work using fomaldehyde or benzene and as x-ray or CT scan people .

4. People have done chemotherapy treatment for other cancer because it can linked to
develop leukemia later.

5. A family history of CLL or cancer of the lymph system.

6. Having relatives who are Russian Jews or Eastern European Jews.

5.2 Symptoms
Symptoms usually develop slowly over time. Many cases of CLL are detected by
blood tests done in people for other reasons or who do not have any symptoms.

Symptoms that can occur include:

1. Abnormal bruising (occurs late in the disease)

2. Enlarged lymph nodes, liver, or spleen

3. Excessive sweating, night sweats

4. Fatigue

5. Fever

6. Infections that keep coming back (recur)

7. Loss of appetite or becoming full too quickly and unintentional weight loss.

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 5.3 Exam and tests
The following tests and procedures may be used:

Physical exam and history: An exam of the body to check general signs of health, including

checking for signs of disease.

Full blood count (FBC): A procedure in which a sample of blood is drawn and checked for the

following:

-The number of red blood cells, white blood cells, and platelets.

-The amount of hemoglobin (the protein that carries oxygen) in

the red blood cells.

-The portion of the blood sample made up of red blood cells.

Cytogenetic analysis: A test in which cells in a sample of blood or bone marrow are viewed

under a microscope to look for changes in the structure or number

of chromosomes in the lymphocytes.

Immunophenotyping: A test in which the cells in a sample of blood or bone marrow are

looked at under a microscope to find out if malignant lymphocytes

(cancer) began from the B lymphocytes or the T lymphocytes.

Bone marrow aspiration and biopsy: The removal of bone marrow, blood, and a small piece

of bone by inserting a hollow needle into the hipbone.

A pathologist views the bone marrow, blood, and bone

under a microscope to look for abnormal cells.

CT scan of the chest, abdomen, and pelvis

Flow cytometry usually done on blood or bone marrow

Blood lactate dehydrogenase level

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 5.4 Staging
Staging is the way cancers are classified. Staging indicates the size or extent of the
cancer the degree to which other parts of the body are affected and other important details.
In general, leukemias are classified rather than staged in order to determine the most
appropriate therapy.

All leukemias are classified according to their genotypes, or their unique

chromosomal arrangements, which also enables the physicians to determine risk factors.

In addiction, chronic myelogenous leukemia is classified by phase. The 3 phases

are chronic phase, accelerated phase, and blast phase (or blast crisis) and are defined by
the number of blasts (leukemia cells) in the blood and bone marrow.

There are two systems used to stage CLL:

• The Rai system uses numbers to group CLL into low-, intermediate-, and high-risk
categories. Generally, the higher the stage number, the more advanced the cancer.
• The Binet system uses letters to stage CLL according to how many lymph node
groups are involved and whether you have a drop in the number of red blood cells or
platelets.

Stage 0

In stage 0 chronic lymphocytic leukemia, there are too many lymphocytes in the blood, but
there are no other symptoms of leukemia. Stage 0 chronic lymphocytic leukemia
is indolent (slow-growing).

Stage I

In stage I chronic lymphocytic leukemia, there are too many lymphocytes in the blood and
the lymph nodes are larger than normal.

Stage II

In stage II chronic lymphocytic leukemia, there are too many lymphocytes in the blood,
the liver or spleenis larger than normal, and the lymph nodes may be larger than normal.

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 Stage III

In stage III chronic lymphocytic leukemia, there are too many lymphocytes in the blood and
there are too few red blood cells. The lymph nodes, liver, or spleen may be larger than
normal.

Stage IV

In stage IV chronic lymphocytic leukemia, there are too many lymphocytes in the blood and
too fewplatelets.

CLL table staging (rai system)

Lymph node Spleen/Liver Hb Plt Survival

Rai Lymphocytosis
enlargement enlargement <11g/dL <100x10⁹/L (years)

0 Yes No No No No >13

Ⅰ Yes Yes No No No 8

Ⅱ yes - - No No 5

Ⅲ Yes - - Yes No 2

Ⅳ Yes - - - Yes 1

6.0 Treatment

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For most patients with early stage CLL, no treatment is started. However, these people must
be closely watched by their doctor.

Treatment may also be started if:

• Infections keep coming back

• Leukemia is growing rapidly.

• Low blood counts (anemia and thrombocytopenia (low platelet count) are present

• Fatigue, loss of appetite, weight loss, or night sweats occur

• Several chemotherapy drugs are commonly used to treat CLL.

• Fludarabine, chlorambucil, cyclophosphamide (Cytoxan), and rituximab (Rituxan) may

be used alone or in combination.

• Alemtuzumab (Campath) is approved for treatment of patients with CLL that have not
responded to fludarabine.

• Bendamustine is a newer drug recently approved for use in patients with CLL that has
come back after initial treatment.

• Radiation may be used for painfully enlarged lymph nodes. Blood transfusions or
platelet transfusions may be required if blood counts are low.

Five types of standard treatment are used:

Watchful waiting

Watchful waiting is closely monitoring a patient’s condition without giving any

treatment until symptomsappear or change. This is also called observation. During this time,
problems caused by the disease, such as infection, are treated.

Radiation therapy

Radiation therapy is a cancer treatment that uses high-energy x-rays or other types
of radiation to kill cancer cells or keep them from growing. There are two types of radiation
therapy. External radiation therapy uses a machine outside the body to send radiation toward
the cancer. Internal radiation therapyuses a radioactive substance sealed in needles, seeds,
wires, or catheters that are placed directly into or near the cancer. The way the radiation
therapy is given depends on the type and stage of the cancer being treated.

Chemotherapy

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 Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer
cells, either by killing the cells or by stopping them from dividing. When chemotherapy is
taken by mouth or injected into a veinor muscle, the drugs enter the bloodstream and can
reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is
placed directly into the spinal column, an organ, or a body cavitysuch as the abdomen, or the
drugs mainly affect cancer cells in those areas (regional chemotherapy). The way the
chemotherapy is given depends on the type and stage of the cancer being treated.

Surgery

Splenectomy is surgery to remove the spleen.

Targeted therapy

Targeted therapy is a type of treatment that uses drugs or other substances to identify
and attack specific cancer cells without harming normal cells. Monoclonal antibody therapy is
a type of targeted therapy used in the treatment of chronic lymphocytic leukemia.

Monoclonal antibody therapy is a cancer treatment that uses antibodies made in the
laboratory from a single type of immune system cell. These antibodies can identify
substances on cancer cells or normal substances in the body that may help cancer cells
grow. The antibodies attach to the substances and kill the cancer cells, block their growth, or
keep them from spreading. Monoclonal antibodies are given byinfusion. They may be used
alone or to carry drugs, toxins, or radioactive material directly to cancer cells.

Chemotherapy with stem cell transplant

Chemotherapy with stem cell transplant is a method of giving chemotherapy and

replacing blood-forming cells destroyed by the cancer treatment. Stem
cells (immature blood cells) are removed from the blood or bone marrow of the patient or a
donor and are frozen and stored. After the chemotherapy is completed, the stored stem cells
are thawed and given back to the patient through an infusion. These reinfused stem cells
grow into (and restore) the body’s blood cells.

Biologic therapy

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 Biologic therapy is a treatment that uses the patient's immune system to fight cancer.
Substances made by the body or made in a laboratory are used to boost, direct, or restore
the body's natural defenses against cancer. This type of cancer treatment is also called
biotherapy or immunotherapy.

Patients may want to think about taking part in a clinical trial.

For some patients, taking part in a clinical trial may be the best treatment choice.
Clinical trials are part of the cancer research process. Clinical trials are done to find out if
new cancer treatments are safe and effective or better than the standard treatment.

Many of today's standard treatments for cancer are based on earlier clinical trials.
Patients who take part in a clinical trial may receive the standard treatment or be among the
first to receive a new treatment.

Patients who take part in clinical trials also help improve the way cancer will be
treated in the future. Even when clinical trials do not lead to effective new treatments, they
often answer important questions and help move research forward.

Patients can enter clinical trials before, during, or after starting their cancer treatment.

Some clinical trials only include patients who have not yet received treatment. Other
trials test treatments for patients whose cancer has not gotten better. There are also clinical
trials that test new ways to stop cancer from recurring (coming back) or reduce the side
effects of cancer treatment.

Clinical trials are taking place in many parts of the country. See the Treatment
Options section that follows for links to current treatment clinical trials. These have been
retrieved from NCI's listing of clinical trials.

Follow-up tests may be needed.

Some of the tests that were done to diagnose the cancer or to find out the stage of
the cancer may be repeated. Some tests will be repeated in order to see how well the
treatment is working. Decisions about whether to continue, change, or stop treatment may be
based on the results of these tests. This is sometimes called re-staging.

Some of the tests will continue to be done from time to time after treatment has
ended. The results of these tests can show if your condition has changed or if the cancer
has recurred (come back). These tests are sometimes called follow-up tests or check-ups.

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 7.0 Outlook(prognosis)
The outlook depends on the stage and behavior of the disease. Half of patients
diagnosed in the earliest stages of the disease live more than 12 years. Some people may
not require any treatment at all, while others may have faster spreading disease that requires
aggressive therapy with multiple chemotherapy agents.

Newer tests that look at cell genetic changes may be done to help predict disease
behavior and thus guide treatment approaches.

8.0 Possible complication

• Autoimmune hemolytic anemia

• Bleeding from low platelet count
• Fatigue from anemia
• Hypogammaglobulinemia (reduced levels of antibodies) -- increases the risk of
infection
• Idiopathic thrombocytopenic purpura (ITP)
• Recurrent infections
• Other cancers, including transformation to a much more aggressive lymphoma
(Richter’s transformation)
• Side effects of chemotherapy

9.0 Case study

9.1 Patient history

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 A 57 years old chinese man came to the hospital for treatment on 9 may 2007. He
had fever for one and half week.he has complained that he loss his appetite and he loss
weight for a fews kilograms. Other than temperature of 38.5 °c, his vital sign are normal. His
blood sample is taken to diagnose. The blood was sent to the laboratory and the result have
shown the abnormality.

Family history

Family of this patient does not has any history of blood cancer or other cancer. Just
only his cousin done a small surgery on her breast because have a small lump.

Laboratory tests:

a) Haematology Laboratory
 Full Blood Count (FBC)

 Prothrombin Time (PT)

 International Normalize Ratio (INR)

 Bone marrow aspiration

 Immunophenotyping

b) Chemical Pathology Laboratory

 Lactate Dehydrogenese (LDH)

 Liver Function Test (LFT)

 Erythrocyte Sedimentation Rate (ESR)

 Urine FEME

c) Radiology Laboratory

 CT scan

d) Blood banking Laboratory

• Cross match platelet

e) Histology Laboratory
• Trephine biopsy

9.2 Laboratory investigation

Hematology laboratory

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Full Blood count (FBC)

Principle

Full blood count is to obtain a full hematological data of the patient in order to diagnose the
diseases and the patient’s conditions. This is a quantitative analysis of blood cells which
consists of hemoglobin estimation, total RBC, total WBC, packed cell volume, platelet count,
differential count, mean cell hemoglobin, mean cell volume and mean cell hemoglobin
concentration. Blood cells are detected using electro optical detectors.

Specimen

Blood samples in EDTA tube.

Specimen preparation

When taking specimen from patient, non fasting specimen is acceptable but avoid
from lipaemia and haemolysis. Make sure the condition of the patient are relax. Swab the
skin patient with alcohol before take the blood. After get the specimen, put the blood
specimen into tube that contain EDTA. Mix gently the blood with EDTA to make sure no clot
is present. If specimen is clotted, reject the sample as it can produce false positive result.

Analyzer
Beckman Coulter LH-750

Procedure
1. Start the analyzer and the pressure pump.
2. Press the select button and press the buttons ( ↓ ) and ( ↑ ) to abtain the AUTO
RINSE. AUTO RINSE until “0” several times.
3. Start the computer and get the LIS
4. Main menu, press the key →.
5. Then press F1.
6. Press F3- INTERFACE ACTIVITY
7. Firstly, place barcode in each sample and the forms.
8. Press ENTER in the machine to insert barcode and re-press ENTER again.
9. Insert the blood sample into the probe and press the START button and hold until the
green light disappears.
10. The blood will be processed within few seconds and the results will appear in the
computer.
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 11. Print out the result in analyzer.
12. Repeat the steps 8, 9 and 10 with the blood samples.
13. Insert the patients data into the computer and FBCS test and the barcode must tally
with the samples.
14. In the computer, press ESCAPE, then press F5 ( validate manually) to validate the
results.
15. Before shutting down the Sysmex, it has to be AUTO RINSE for washing purpose.

PT and INR test

Principle

Prothrombin time (PT) evaluates the ability of blood to clot properly, it can be used to
help diagnose bleeding. When used in this instance, it is often used in conjunction with
the PTT to evaluate the function of all coagulation factors. Occasionally, the test may be
used to screen patients for any previously undetected bleeding problems prior to surgical
procedures.
The International Normalized Ratio (INR) is used to monitor the effectiveness of blood
thinning drugs such as warfarin (Coumadin). These anti-coagulant drugs help inhibit the
formation of blood clots. They are prescribed on a long-term basis to patients who have
experienced recurrent inappropriate blood clotting. This includes those who have had heart
attacks, strokes, and deep vein thrombosis (DVT). Anti-coagulant therapy may also be given
as a preventative measure in patients who have artificial heart valves and on a short-term
basis to patients who have had surgeries, such as knee replacements. The anti-coagulant
drugs must be carefully monitored to maintain a balance between preventing clots and
causing excessive bleeding.

Specimen

Blood sample in sodium citrate

Bone marrow aspiration and biopsy

Principle

The bone marrow biopsy and aspiration procedure provides information about the
status of and capability for blood cell production. It is not routinely ordered and in fact the
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majority of people will never have one done. A bone marrow aspiration and/or biopsy may be
ordered to help evaluate blood cell production, to help diagnose leukemia, to help diagnose
a bone marrow disorder, to help diagnose and stage a variety of other types of cancer that
may have spread into the marrow, and to help determine whether a severe anemia is due to
decreased RBC production, increased loss, abnormal RBC production, and/or to a vitamin or
mineral deficiency or excess. Conditions that affect the marrow can affect the number,
mixture, and maturity of the cells, and can affect its fibrous structure.

Procedure

Posterior superior iliac crest: This is the most commonly employed site for reasons of safety,
a decreased risk of pain, and accessibility. The posterior superior iliac crest site is localized
to the central crest area.

Bone marrow aspiration

A marrow biopsy is generally performed before aspiration sampling due to the fact the biopsy
technique induces elevated thromboplastic substances. The consequence of this is a
reduction in the effectiveness of an aspiration sampling. However, as many clinical requests
are for an aspiration sample only, this technique is described first.

• The patient is placed in the lateral decubitus position, with the top leg flexed and the
lower leg straight.
• Palpate the iliac crest, and mark the preferred sampling site with a pen.
• Aseptic technique is employed, including sterile gloves and gown.
• The site is prepared with an antiseptic (eg, povidone-iodine or chlorhexidine
gluconate), scrubbed, and draped, exposing only the site to be sampled.
• The skin and the underlying tissue to the periosteum are infiltrated with a local
anesthetic (eg, approximately 10 mL of 1% Xylocaine [lidocaine]). A 10-mL syringe
with a 25-gauge needle is used to inject an initial 0.5 mL directly under the skin,
raising a wheal. A 22-gauge needle is used to penetrate deeper into the

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 subcutaneous tissue and the underlying periosteum, an area roughly 1 cm in
diameter

• Adequacy of the anesthesia is tested by gently prodding the periosteum with the tip of
the needle and questioning the patient for any painful sensation. It is important to be
aware of changes in the patient's comfort level throughout the procedure to not only
decrease the patient's anxiety level, but to minimize movements that may affect the
efficacy of the procedure. Having a family member present may help to alleviate the
patient's anxiety. To ensure sufficient pain control is being managed well, the person
performing the procedure should talk to the patient, discuss the steps taken
throughout the process, and listen to the manner as well as the content of the
patient's response.
• A skin incision is made with a small surgical blade, through which the bone marrow
aspiration needle, with a stylet locked in place, is inserted
• Once the needle contacts the bone, it is advanced by slowly rotating clockwise and
counterclockwise until the cortical bone is penetrated and the marrow cavity is
entered. Contact with the marrow cavity is usually noted by a sudden reduction in
pressure. The depth of the penetration should not extend beyond an initial 1 cm

• Once within the marrow cavity, the stylet is removed. Using a 20 mL syringe,
approximately 0.3 mL of bone marrow is aspirated. A volume greater than 0.3 mL
may dilute the sample with peripheral blood and thus is not recommended. The
material collected for bone marrow slides is generally not mixed with an
anticoagulant, and it is processed immediately by a technologist; this avoids any
cellular morphologic artifacts. If there is to be a delay in slide preparation, place the
sample in an EDTA (ethylenediaminetetraacetic acid) anticoagulant-containing tube,
preferably a pediatric-sized tube to avoid exposure to excess anticoagulant.
• If additional marrow is needed for ancillary studies, subsequent specimens are
obtained by attaching a separate syringe, collecting 5 mL at a time. The samples are
then transferred into an anticoagulant-containing tube that is appropriate to the
requested study: heparin for cytogenetic analysis; either heparin or EDTA for
immunophenotyping; formalin for a Cytoblock preparation; and, gluaraldehyde for
ultrastructural examination.
• The marrow needle is removed, and pressure is applied to the aspiration site with
gauze until any bleeding has stopped.

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 • Once the aspiration is completed, the specimen is processed by the hematopathology
technician.

Bone marrow biopsy

Any of several needle models can be utilized; however, the Jamshidi needle is considered
the most popular. This disposable needle is tapered at the distal end to help retain the
specimen for improved extraction.

• Patient preparation is to be followed in the manner previously described for bone

marrow aspiration.
• The needle, with stylet locked in place, is held with the palm and index finger and
repositioned so that a new insertion site is created for biopsy sampling. Once the
needle touches the bone surface, the stylet is removed..
• Using firm pressure, slowly rotate the needle in an alternating clockwise-
counterclockwise motion, and advance it into the bone marrow cavity to obtain an
adequate bone marrow specimen measuring approximately 1.6-3 cm in length.
• Rotate the needle along its axis to help loosen the sample, pull back approximately 2-
3 mm, and advance the needle again slightly, at a different angle, to help secure the
specimen.
• Following this procedure, slowly pull the needle out, while rotating in an alternating
clockwise and counterclockwise motion.
• Remove the specimen from the needle and introduce a probe through the distal
cutting end. If the aspirate was unsuccessful (ie, a "dry tap"), the core biopsy may be
used to make touch preparations.This must be performed before placing the
specimen in formalin.
• Place the specimen in formalin solution for histologic processing.
• The marrow needle is removed, and pressure is applied to the site with gauze until
any bleeding has stopped

Chemical pathology laboratory

Lactate dehydrogenese (LDH)

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Principle

LDH is as a general indicator of the existence and severity of acute orchronic tissue
damage and, sometimes, as a monitor of progressive conditions. LDH isoenzymes may also
be used in differential diagnosis to help determine which organs are likely to be involved.

Specimen

Should come in ice.

ESR

The erythrocyte sedimentation rate is a non-specific test. It is raised in a wide range

of infectious, inflammatory, degenerative, and malignant conditions associated with changes
in plasma proteins, particularly increases in fibrinogen, immunoglobulins, and C-reactive
protein. It is also affected by many other factors including anemia, pregnancy,
hemoglobinopathies, hemoconcentration and treatment with anti-inflammatory drugs.
Moderately raised sedimentation rates can sometimes be found in healthy people,
particularly those living in tropical countries and a ‘normal’ ESR cannot exclude disease.

Principle

When citrated blood in a vertically positioned Westergen pipette is left undisturbed,

red cells aggregate, stack together to form rouleaux, and sediment through the plasma. The
ESR is the rate at which this sedimentation occurs in 1 hour as indicated by the length of the
column of clear plasma above the red cell, measured in mm. Fibrinogen, immunoglobulins,
and C reactive protein increase red cell aggregation. Sedimentation is increased when the
ratio of red cells to plasma is altered

Urine FEME

Principle

Urine is produced by the kidneys from blood flowing through it. It therefore reflects
conditions in the blood, kidneys and urinary tract. The finding in the urine is also influenced
by the things we eat and drink.

Liver funtion test

Principle

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 Liver Function Test is a liist of test that is used to monitor function of the liver. The list
of tests includes albumin, total protein, total bilirubin, globulin, alanine transaminase (ALT),
aspartate transaminase (AST) and alkaline phosphatase (ALP).

Albumin test

Principle:
Bromocresol green (BCG) is an indicator which is yellow between pH 3.5 – 4.2. When it
binds to albumin, the colour of the indicator changes from yellow to blue-green. The
absorbance of the colour produced is measured in a colorimeter using an orange filter or in a
spectrophotometer at 632 nm wavelength.

Bilirubin test

Principle :

Bilirubin reacts with diazotized sulfanilic acid to produce azobilirubin, which has an
absorbance maximum at 560 nm in the dimethyl sulfoxide (DMSO) solvent. The intensity of
the color produced is directly proportional to the amount of total bilirubin concentration
present in the sample.Direct bilirubin consists of glucoronic acid conjugated derivates, is
water soluble and its react directly. Indirect bilirubin can be calculated by minus the total
bilirubin with direct bilirubin.

ALT test :

Principle :

L-Alanine + a-ketoglutarate -------------------> pyruvate + Glutamate

H+
pyruvate + 2 4 - DNPH-ine ----------> pyruvate + 2 4-DNPH-one

The method used here is a modification of the classical Reitman-Frankel colorimetric

endpoint reaction.4 In this procedure ALT (SGPT) catalyzes L-alanine and a-ketoglutarate to
form pyruvate and glutamate. The pyruvate is then reacted with 2 4-dinitrophenylhydrazine (2
4-DNPH-one) to form 2 4-DNPH-one. The addition of sodium hydroxide dissolves this
complex allows 2 4-DNPH-one to be measured at 505 nm

ALP test

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Principle:

Alkaline phosphatase (ALP) catalyses the hydrolysis of p-nitrophenyl phosphate at pH 10.4,

liberating p-nitrophenol and phosphate, according to the following reaction

ALP
p-itrophenylphosphate + H2O p-Nitrophenol + phosphate

the rate of p-nitrophenol formation, measured photometrically, is proportional to the catalytic

concentration of alkaline phosphatase present in the sample.

Radiology laboratory

X-ray

X-rays for medical diagnostic procedures or for research purposes are produced in a
standard way: by accelerating electrons with a high voltage and allowing them to collide with
a metal target. X-rays are produced when the electrons are suddenly decelerated upon
collision with the metal target; these x-rays are commonly called brehmsstrahlung or "braking
radiation". If the bombarding electrons have sufficient energy, they can knock an electron out
of an inner shell of the target metal atoms. Then electrons from higher states drop down to fill
the vacancy, emitting x-ray photons with precise energies determined by the electron energy
levels. These x-rays are called characteristic x-rays

9.3 Patient results

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Haematology Laboratory:

Full Blood Count

Flag Test % Result Units Range

- White Cell Count 3-6 x10^9/L (4.0-10.0)

-- Red Cell Count 3.01 x10^12/L (4.5-6.3)

-- Hemoglobin 8.5 g/dL (14.0-17.0)

-- Hematocrit 25.3 % (39.0-52.0)

Mean Cell Volume 84.1 fl (77.0-91.0)

Mean Cell Hemoglobin 28.4 pg (26.0-32.0)

MCHC 33.8 g/dL (32.0-36.0)

++ Red Cell Distribution Width 16.1 % (11.3-14.6)

Mean Platelet Volume 8.2 fl (6.3-10.2)

--- Platelet 7 x10^9/L (150-400)

- Neutrophils 2.9 0.1 x10^9/L (2.0-7.0)

- Eosinophils 0.1 0.0 x10^9/L (0.02-0.5)

- Basophils 0.8 0.0 x10^9/L (0.02-0.1)

+ Lymphocytes 95.5 8.4 x10^9/L (1.0-3.0)

- Monocytes 0.7 0.0 x10^9/L (0.2-1.0)

FBC comment

Hb is severely reduced,normochromic normocytic cells, some atypical lymphocytes seen.

Platelet mildly reduced.

PT/INR/APTT

Flag Test Result Units Range

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 PT (Patient) 14.1 Seconds (11.4-14.2)

PT (Control) 14.2 seconds (12.2-16.2)

-- INR 0.99 ratio (2.4-4.0)

THERAPEUTIC
RANGE

APTT (Patient) 35.8 seconds (31.3-46.1)

APTT (Control) 38.7 seconds (31.3-46.1)

APTT Ratio 0.93 ratio (0.89-1.32)

Bone marrow aspiration

BMA is hypercellular with prodominantly lymphocytes cells

seen (>90%).the lymphocytes are heterogenous in size,some
with clump chromatin and appear to be maturs looking and
Other cells appear to be immature with open chromatin,inconspicuous
nucleoli and with more cytoplasm.

Other cells lines are markedly deppressed. Many smudge cells

seen.

Perl’s stain Iron stain is increase.

BMA is suggestive of lymphoproliferative disease. See also

Conclusion
immunophenotyping result to confirm.

Immunophenotyping

Flag test Result Units

CD3 intracellular/ surface - %

CD19 - %

Chemical pathology laboratory

Lactate dehydrogenese

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Flag Test Result Units Range

+ LDH 455 U/L (211-423)

Erythrocyte Sedimentation Rate (ESR)

Flag Test Result Units Range

++ ESR 50 mm/hr (1-15)

Liver Function Test

Flag Test Result Units Range

Albumin 43 g/L (35-50)

Total Protein 72 g/L (67-88)

+ Bilirubin Total 37 umol/L (< 23)

ALT 31 U/L (< 44)

ALP 80 U/L (32-104)

Urine FEME
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 Flag test Result

Urine colour Yellow

Urine clarity Clear

Specefic gravity 1.015

Urine Ph 6

+++ Leucocyte 500/ul

Urine nitrite Negative

++ Urine protein 1.5g/l

Urine glucose Normal

Urine ketone negative

Urine bilirubin Negative

Urine urobilirubin Normal

+++ Urine blood 250/ul

++ Urine rbc >50

++ Urine pus cells >50

Radiology laboratory

CT scan

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CECT NECK, THORAX, ABDOMEN AND PELVIS

CT for staging

Findings :
There are multiple lobulated non enhancing soft tissue mass seen at the coeliac, porta
hepatis, para-aortic, paracaval and in the mesentery in keeping with enlarged lymph nodes.
The largest measurement is 4.8 x 9.7 x 14.0 cm at the mesenteric region which extending
to pelvic region at the level of bifurcation of aorta. However, the major vessels appear not
compressed. Enlarged lymph nodes are also seen in the pelvic wall and inguinal region
bilaterally.

The liver is normal in density. No focal lesion seen.

The GB, pancreas, spleen and both kidneys are normal.
No hydronephrosis seen bilaterally.
No bowel wall thickening or bowel related mass.
No ascites.

Multiple cervical lymphadenopathies noted involving the all levels and supraclavicular
region.
The largest 1.4 x 2 cm at the right submandibular region and level III.

Bilateral enlarged axillary lymph nodes. No hilar or mediastinal lymphadenopathy.

No focal lung nodule seen.
No pleural effusion.

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Blood bank laboratory

Cross match packed cells

Blood Group Test Bag Number Result Date

O positive Cross match packed cell PC11180888 Compatible 09/08/2008

Cross match packed cell PC11180623 Compatible 09/08/2008

Cross match packed cell PC11176838 Compatible 09/08/2008

Cross match packed cell PC11177950 Compatible 09/08/2008

Histology laboratory

Specimen : Trephine biopsy

Microscopic: Section shows bony trabeculae with marrow spaces. There are 2 marrow
spaces filled with monomorphic population of cells with reduction in other cell lineage. Other
marrow spaces show heamodiluted marrow tissue.

Diagnosis : Bone marrow: consistent with lymphoma infiltration.

10.0 Discusion

Patient first came in for a medical examination in may 2007. The patient is a chinese
man with aged 57years old. The patient having a long period fever is about more than one
week. His weight loss a few kilogram because he loss his appetite. He doesn’t feel to eat
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anything. His do not have any family members who had any cancer. He look pale and low of
energy. Doctor was taken his blood sample to test the abnormality. One in EDTA tube for
FBC and FBP test. One in sodium citrate tube for INR,PT and APTT test. One in palin tube
for sent to chemical patology laboratory.

On the next day,he came to know the result. Most of them are out of the range. The
patient white blood cell count is 3.6x10^9/L,.this is slightly lower than normal range.This is
shows that something present in the body. White blood cell (WBC) count is monitored
routinely as part of a complete blood count. It is sometimes monitored by itself to monitor
recovery from illness. Certain conditions and medications weaken the immune system and
cause a decrease in white blood cells, while infections and disease can cause very high
numbers of white blood cells. The WBC count detects dangerously low and high numbers of
these cells. Differential count lymphocytes is slightly increase with 8.4x10^9/L. This can due
to this patient had lymphoid or lymphocytic leukemia.

Hb and RBC are severely reduced with result 8.5 g/dL and 3.01x10^12/L. Who had
this cancer is always get anemia too because low level of RBC produces. From the result
shows that RBC is normochromic normocytic cells. Mean cell volume (MCV), MCH, and
MCHC shows normal result with the result are on the normal range. In report of FBC shows
that level of platelet is severely low. It is called thrombocytopenia. If the bone marrow does
not produces enough platelet will change the level of platelet count. Leukemia, lymphomas or
other bone marrow disorder can have this effect.

In heamatology laboratory finding for this case, the result shows that APTT and PT is
normal and stil aroud the range but for INR is slightly low. INR is show for how long for a
person’s blood will be clots. The higher of INR is the longer it takes to clot. This patient had
low level of INR,so his blood clots faster than other normal person. A tumor present in the
body can have this effect.

In bone marrow aspiration result shows the abnormalities of white blood cells
morphology. Resul BMA is hypercellular with prodominantly lymphocytes cells seen (>90%).
The lymphocytes are heterogenous in size,some with clump chromatin and appear to be
maturs looking and appear to be immature with open chromatin,inconspicuous nucleoli and
with more cytoplasm. In a chronic cases, the observation shows of hypercellular. For
immunophenotyphing results show the gated cells to be positive for CD19,CD20,CD5,CD23,
anti-Kappa,anti HLA-DR and negative for CD 34,intra TdT,CD 10 and T markers. The above
features are consistent with B lymphoproliferative.

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 ALT,ALP,albumin and total protein still in normal range for test was done in chemical
pathology laboratory.LDH, ESR and total billirubin is increase or high from the range. LDH
with result 455 from range 211- 423,ESR with result 42 from range 1-15 and lastly total
bilirubin with result 37 more than 23. ESR is high if the blood has inflammation or tumor
marker. It also high because of anemia. Most of leukemia patient have anemia. Elevated
levels of LDH and changes in the ratio of the LDH isoenzymes usually indicate some type of
tissue damage. Usually LDH levels will rise as the cellular destruction begins.

In blood banking laboratory, cross match platelet and packed cell was made. The
patient has undergone platelet and packed cell transfusion. This is to cover the decreased of
platelet and replaced healthy RBC in patient.

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 12.0 References

Rodgers, G. P., & Young, N. S. (2009). Handbook of Clinical Hematology.

Philadelphia: Lippincott Williams and Wilkins.

Young, S. N., Gerson, S. L., & High, K. A. (2006). Clinical Hematology. Missouri:
Mosby Publishing.

Chabner, B. A., Lynch Jr, T. J., & Longo, D. L. (2008). Harrison's Manual of
Oncology. United States of America: The McGraw-Hill Companies.

Degos, L., Linch, D. C., & Lowenberg, B. (1999). Textbook of Malignant

Haematology. London: Martin dunitz Ltd.

Hallek, M. (2010). Chronic Lymphocytic Leukemia. Annals of Oncology , 154-164.

Kalil, N., & Cheson, B. D. (1999). Chronic Lymphocytic Leukemia. Bethesda,

Maryland, USA.

Peacock, J. (2000). Leukemia. Minnesota: Capstone Press.

Polliack, A., & Catovsky, D. (1988). Chronic Lymphocytic Leukemia. Poststrasse:

Harwood academy publisher.

Riccardo, D. F., & Federico, C. C. (2005). Chronic Lymphocytic Leukemia.

Heidelberg: Springer media.

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Terry, J. H. (2009). Chronic lymphocytic leukemia. The New England Journal of
Medicine , 2378-2379.

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