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Teachable Moment
May 2017

Staging CT Scans in Early-Stage Chronic Lymphocytic Leukemia

Author Affiliations
  • 1Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
  • 2Division of Hematology Oncology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
  • 3Division of Hematology Oncology, VA North Texas Health Care System, Dallas
JAMA Intern Med. 2017;177(5):719-720. doi:10.1001/jamainternmed.2017.0348

A man in his 60s with hypertension presented to his primary care physician for a routine visit. He reported feeling well without recent illness, weight loss, fevers, or night sweats. Medications included lisinopril and hydrochlorothiazide. Examination demonstrated normal vital signs without lymphadenopathy or hepatosplenomegaly. Routine laboratory studies revealed a white blood cell count of 36.8 × 109/L (reference, 3.5-10.5 × 109/L) with 82% lymphocytes, hemoglobin 13.8 g/dL (reference, 13.5-17.5) (to convert to g/L, multiply by 10), hematocrit 41.7% (reference, 38.8-50) and platelet count 212 × 109/L (reference, 150-450 × 109/L). A peripheral blood smear demonstrated a preponderance of small lymphocytes without blasts. Peripheral blood flow cytometry noted a clonal B-cell population positive for CD3, CD5, CD10, CD20, and CD23, consistent with chronic lymphocytic leukemia (CLL). Contrast-enhanced computed tomography (CT) scans of the chest, abdomen, and pelvis performed for staging did not reveal any masses and the patient was referred to the hematology oncology clinic. Based on the absence of clinical lymph node enlargement, hepatosplenomegaly, and absence of cytopenias, patient was diagnosed with modified Rai low-risk stage 0 CLL. The CT scan had been superfluous for diagnosis or staging purposes and did not alter treatment. The patient expressed disappointment that he had to undergo needless scans and contrast exposure, and anxiety regarding the findings. No specific therapy was administered and he was followed up every 6 months using medical history, examination, and complete blood cell counts without repeated imaging. He remains asymptomatic without clinically palpable lymphadenopathy or hepatosplenomegaly, worsening lymphocytosis, or cytopenias 4 years later.

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