In previously untreated patients, lymphocytosis must be present. Lymphocytosis may be affected by treatment, and some patients may have prominent adenopathy with minimal lymphocytosis following treatment. The leukemic cells of patients with CLL are typically small-to-medium size, well differentiated, and have a thin rim of cytoplasm and a dense, homogenous, round nucleus that is slightly eccentrically located [Figure 23.2(a)].22 The chromatin is clumped and nucleoli are usually not prominent. Prolymphocytes are larger with dispersed chromatin, a single nucleolus, and more abundant cytoplasm [Figure 23.2(b)]. For typical CLL, there should be fewer than 10% prolymphocytes.23 CLL with increased prolymphocytes (CLL/PL) is defined by more than 10% but fewer than 55% prolymphocytes. Patients with greater than 55% prolymphocytes or greater than 15,000
prolymphocytes/^L meet the diagnostic criteria for PLL. Smudge cells may be present on the peripheral blood smear of patients with CLL [Figure 23.2(c)].24 These are leukemia cell artifacts that result from rupture of fragile lymphocytes with processing and preparation of the blood smear. Patients with CLL almost never experience leukostasis syndrome. With a rising absolute lymphocyte count, there is a relative reduction in the number of neu-trophils; previously untreated patients may develop neu-tropenia (<500 neutrophils/^L). This may be a dilution effect, but may also be due to reduced production as a result of CLL bone marrow infiltration.
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