The state of the penultimate stage of chronic lymphocytic leukemia. Chronic b cell lymphocytic leukemia. Diet, nutrition for lymphocytic leukemia

RCHD (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical protocols MH RK - 2015

Chronic lymphocytic leukemia (C91.1)

Oncohematology

general information

Short description

Recommended
Expert Council
RSE on REM "Republican Center
health development"
Ministry of Health
And social development
Republic of Kazakhstan
dated July 9, 2015
Protocol #6

Chronic lymphocytic leukemia/small lymphocyte lymphoma- a tumor disease of the blood system, characterized by the proliferation and accumulation in the blood, bone marrow and lymphoid organs of morphologically mature and immunologically incompetent B-lymphocytes with a characteristic immunophenotype (co-expression of CD5 and CD23).
Chronic lymphocytic leukemia (CLL) and small lymphocyte lymphoma are different manifestations of the same disease. In both cases, clonal small B-lymphocytes are the main substrate. The only difference is that in CLL the bulk of tumor lymphocytes are concentrated in the bone marrow and peripheral blood, and in lymphoma from small lymphocytes in the lymph nodes.

Protocol code:

ICD code -10:
C91.1 - Chronic lymphocytic leukemia

Protocol development date: 2015

Abbreviations used in the protocol:
* - drugs purchased as part of a single import
CLL - chronic lymphocytic leukemia
NCCN - National Comprehensive Cancer Network
HSC - hematopoietic stem cells
MRD - minimal residual (residual) disease
PCT - polychemotherapy
TKI - tyrosine kinase inhibitors
TCM - bone marrow stem cell transplant
FISH - fluorescent in situ hybridization
HLA - human leukocyte antigen system
AH - arterial hypertension
BP - blood pressure
ALAT - alanine aminotransferase
ASAT - aspartate aminotransferase
HIV - human immunodeficiency virus
ELISA - enzyme immunoassay
CT - computed tomography
LDH - lactate dehydrogenase
MDS - myelodysplastic syndrome
MPO - myeloperoxidase
NE - naphthylesterase
UAC - general analysis blood
PCR - polymerase chain reaction
ESR - erythrocyte sedimentation rate
UZDG - ultrasonic dopplerography
ultrasound - ultrasound procedure
EF - ejection fraction
FGDS - fibrogastroduodenoscopy
RR - respiratory rate
HR - heart rate
ECG - electrocardiography
EchoCG - echocardiography
NMRI - nuclear magnetic resonance imaging
PET/CT - positron emission tomography/computed tomography

Protocol Users: therapists, doctors general practice, oncologists, hematologists.

Level of Evidence Scale

Classification

Clinical classification

Table 1. Classification of CLL stages according to K. Rai. [quoted from 2]

Table 2. Classification of stages of CLL according to J. Binet. [quoted from 2]

Clinical picture

Symptoms, course

Diagnostic criteria diagnosis :
Absolute monoclonal B-lymphocytosis (lymphocytes ≥5×109/l) in peripheral blood for at least 3 months;
· Cytological characteristics of peripheral blood lymphocytes: small narrow cytoplasmic lymphocytes with condensed chromatin nuclei without nucleoli.
· Confirmation of clonality of B-lymphocytes by light chains (λ or κ) and detection of aberrant immunophenotype (CD19+/CD5+/CD23+/CD20dim+/CD79βdim+) by flow cytometry.
· If the diagnosis of chronic lymphocytic leukemia is confirmed by flow cytometry of peripheral blood lymphocytes, cytological and histological/immunohistochemical studies of the bone marrow and lymph nodes are not necessary.

Complaints about:
· weakness;
· sweating;
· fatigue;
subfebrile condition;
· chilling;
pain in the bones or joints;
Decrease in body weight;
hemorrhagic rashes in the form of petechiae and ecchymosis on the skin;
epistaxis;
menorrhagia;
increased bleeding
swollen lymph nodes
pain and heaviness in the left upper abdomen (enlarged spleen);
heaviness in the right hypochondrium.

Anamnesis attention should be paid to:
Long-lasting weakness
fast fatigue;
frequent infectious diseases;
Increased bleeding
the appearance of hemorrhagic rashes on the skin and mucous membranes;
Enlargement of lymph nodes, liver, spleen.

Physical examination:
pallor skin;
hemorrhagic rashes - petechiae, ecchymosis;
shortness of breath
· tachycardia;
Enlargement of the liver
Enlargement of the spleen
enlargement of lymph nodes;
swelling of the neck, face, hands - appear with pressure from enlarged intrathoracic lymph nodes of the superior vena cava (a vessel that brings blood to the heart from the upper half of the body).

Diagnostics

The list of basic and additional diagnostic measures:

Basic (mandatory) diagnostic examinations carried out at the outpatient level:



Ultrasound of peripheral lymph nodes, organs abdominal cavity, incl. spleen.

Additional diagnostic examinations performed at the outpatient level:
myelogram;





ELISA for HIV markers;
ELISA for markers of herpes group viruses;
β2 microglobulin;
direct Coombs test, haptoglobin
Reberg-Tareev test;
· general urine analysis;
· coagulogram;

· HLA typing;
ECG;
Echocardiography;
Whole-body PET/CT for suspected Richter syndrome to determine preferred lymph node for biopsy;
CT scan of the thoracic and abdominal segments with contrast.

The minimum list of examinations that must be carried out when referring to planned hospitalization:
KLA (calculation of leukoformula, platelets in a smear);
blood type and Rh factor;
biochemical analysis of blood (total protein, albumin, globulins, IgA level, IgM, IgG, uric acid, creatinine, urea, LDH, ALT, AST, total and direct bilirubin);
Ultrasound of the abdominal organs and spleen, peripheral lymph nodes;
X-ray of organs chest.

The main (mandatory) diagnostic examinations carried out at the hospital level:
KLA (with counting platelets and reticulocytes);
· OAM;
Immunophenotyping of peripheral blood on a flow cytometer (CD3, CD5, CD10, CD20, CD23, cyclinD1, light chains, IgM);
biochemical blood test (total protein, albumin, globulins, IgA, IgM, IgG, uric acid, creatinine, urea, LDH, ALT, AST, total and direct bilirubin);
Ultrasound examination of peripheral lymph nodes, abdominal organs, incl. spleen;
x-ray of the chest;
myelogram;
Cytogenetic study of the bone marrow;
bone marrow examination by FISH (t(11;14), t(11q,v);+12; del(11q); del(13q); del(17p));
· molecular genetic study: mutational status of genes of variable regions of heavy chains of immunoglobulins (IGHV);
Immunochemical study of blood serum and urine (free light chains of blood serum, electrophoresis with immunofixation of blood serum and daily urine). In the absence of the possibility of an immunochemical study - electrophoresis of serum proteins;
ELISA and PCR for markers of viral hepatitis;
ELISA for HIV markers;
β2 microglobulin;
Direct Coombs test, haptoglobin;
ECG;
echocardiography;
Reberg-Tareev test;
· coagulogram;
blood type and Rh factor;
· HLA typing.

Additional diagnostic examinations carried out at the hospital level:
pro-BNP (atrial natriuretic peptide) in blood serum;
bacteriological examination of biological material;
· cytological examination biological material;
The immunogram
· histological examination biopsy (lymph node, iliac crest);
PCR for viral infections(viral hepatitis, cytomegalovirus, herpes simplex virus, Epstein-Barr virus, Varicella/Zoster virus);
radiography paranasal sinuses nose
radiography of bones and joints;
FGDS;
· Ultrasound of blood vessels;
bronchoscopy;
colonoscopy;
daily monitoring of blood pressure;
daily ECG monitoring;
spirography.

Diagnostic measures carried out at the ambulance stage medical care:
collection of complaints and anamnesis of the disease;
physical examination (determination of respiratory rate, heart rate, assessment of the skin, determination of the size of the liver, spleen, peripheral lymph nodes).

12.4 Instrumental Research:
· Ultrasound of the abdominal organs, lymph nodes: an increase in the size of the liver, spleen, peripheral lymphadenopathy.
· CT scan of the thoracic segment: to detect enlarged intrathoracic lymph nodes.
· ECG: violation of the conduction of impulses in the heart muscle.
· EchoCG: to exclude heart defects, arrhythmias and other diseases in patients, accompanied by damage to the heart.
· FGDS: leukemic mucosal infiltration gastrointestinal tract, which can cause ulcerative lesions of the stomach, 12 duodenal ulcer, gastrointestinal bleeding.
· Bronchoscopy: detection of the source of bleeding.

Indications for consultation of narrow specialists:
doctor for X-ray endovascular diagnostics and treatment - installation of a central venous catheter from peripheral access (PICC);
hepatologist - for the diagnosis and treatment of viral hepatitis;
· gynecologist - pregnancy, metrorrhagia, menorrhagia, consultation when prescribing combined oral contraceptives;
Dermatovenereologist - skin syndrome;
infectious disease specialist - suspicion of viral infections;
cardiologist - uncontrolled hypertension, chronic heart failure, cardiac arrhythmia and conduction disturbances;
· neuropathologist acute cerebrovascular accident, meningitis, encephalitis, neuroleukemia;
neurosurgeon - acute cerebrovascular accident, dislocation syndrome;
nephrologist (efferentologist) - kidney failure;
oncologist - suspicion of solid tumors;
otorhinolaryngologist - for the diagnosis and treatment of inflammatory diseases of the paranasal sinuses and middle ear;
ophthalmologist - visual impairment, inflammatory diseases eyes and appendages;
proctologist - anal fissure, paraproctitis;
psychiatrist - psychoses;
psychologist - depression, anorexia, etc.;
resuscitator - treatment of severe sepsis, septic shock, syndrome of acute pulmonary injury in differentiation syndrome and terminal states, installation of central venous catheters.
rheumatologist - Sweet's syndrome;
thoracic surgeon exudative pleurisy, pneumothorax, zygomycosis of the lungs;
· transfusiologist - for the selection of transfusion media in case of a positive indirect mantiglobulin test, transfusion failure, acute massive blood loss;
Urologist - infectious and inflammatory diseases of the urinary system;
phthisiatrician - suspicion of tuberculosis;
· surgeon - surgical complications(infectious, hemorrhagic);
· maxillofacial surgeon - infectious and inflammatory diseases of the dento-jaw system.

Laboratory diagnostics

Laboratory research:

• General blood analysis: leukocytes, erythrocytes and platelets are counted. This analysis is one of the first in patients with suspected blood disease. This analysis can reveal the presence in the peripheral blood of at least 5.0 x 10 / 9 l of small, morphologically mature lymphocytes, the presence of which during differential diagnosis cannot be caused by other diseases occurring with lymphocytosis. Upon initial contact with early stage diseases, the number of leukocytes can vary between 10-20x10 / l, the bulk (over 60%) of which are small lymphocytes with a small content of their transitional forms (lymphoblasts, prolymphocytes).
• Blood chemistry: there is an increase in LDH activity, hypogammaglobulinemia, signs of hemolysis.
• Morphological study: in a bone marrow aspirate, lymphocyte infiltration should be at least 30%.
• Immunophenotyping: lymphoid cells in CLL are mainly monoclonal and B-lymphocytes expressing both CD19, CD20, CD23 and CD5, while maintaining a low level of slg on the cell surface. T-cell antigen (eg, CD2, CD3) are absent.

Differential Diagnosis

differential diagnosis.
Using the phenotypic characteristics of cells in CLL, it is possible to make a differential diagnosis with other diseases that occur with an increased number of circulating atypical lymphocytes (plasma cell, prolymphocytic, hairy cell and variant hairy cell leukemia, as well as non-Hodgkin's lymphoma in the stage of leukemization).
· prolymphocytic leukemia. The morphological substrate is represented by cells with a large round nucleus and prominent nucleoli. In PPL, most peripheral blood mononuclear cells have the morphological characteristics of prolymphocytes; in PPL transformed from CLL, a polymorphic population of lymphocytes is present. The cells of PLL patients carry immunoglobulins that are different from the immunoglobulins of B-CLL. They may be CD5 and express the CD20 antigen. A high frequency of somatic mutation of the V(H) gene has been described in PLL.
· Hairy cell leukemia. Patients with HCL are characterized by the presence of cells with villous cytoplasm, thrombocytopenia (less than 100 x 109 /l), anemia, neutropenia (<0,5х 10/ 9). Ворсинчатые клетки имеют эксцентричное бобообразное ядро, характерные выросты цитоплазмы. Ворсинчатые клетки имеют В-клеточное происхождение, экспрессируют CD19, CD20 и моноцитарный антиген CD11с. Возможно, наиболее специфичным маркером для ворсинчатых клеток является антиген CD 103. Наличие мутации BRAFV600E при классической форме ВКЛ и ее отсутствие — при вариантной форме заболевания. В связи с этим в настоящее время выявление мутации BRAFV600E можно рассматривать как критерий диагностики типичной формы ВКЛ .
· Lymphoplasmacytic lymphoma. The tumor is represented by diffuse proliferation of small and plasmacytoid lymphocytes and plasma cells with a different number of immunoblasts. The volume of infiltration is usually less than in B-CLL and contains plasma and plasmacytoid cells in addition to small lymphocytes. Tumor cells have surface and cytoplasmic immunoglobulins, usually of the IgM class, less IgD, and necessarily express antigens that characterize B cells (CD 19, CB20, CD22, CD79a). CD5 cells are negative and do not contain CD10, CD23, CD43+ "~; CD25 or CDllc in some cases. The absence of CD5 and CD23, high levels of slg and CD20, the presence of cytoplasmic immunoglobulins are used for differential diagnosis with CLL. When combined with B-small cell infiltration of bone brain and IgM-monoclonal gammopathy with any concentration of monoclonal protein confirms the diagnosis of lymphoplasmacytic lymphoma.
· Lymphoma from marginal zone cells. Extranodal B-cell marginal zone lymphoma is defined as extranodal lymphoma of heterogeneous small B-lymphocytes containing cells (centrocyte-like) from the marginal zone, monocytoid cells, small lymphocytes in various ratios, scattered immunoblast-, centroblast-like and plasma cells (40%). Tumor cells express slg (IgM>IgG>IgA), to a lesser extent - IgD and from 40 to 60% cytoplasmic Ig, indicating plasmacytoid differentiation. The cells carry B cell antigens (CD19, CD20, CD22, CD79a) and are CD5 and CDlO negative. Immunophenotypic studies are usually performed to confirm the tumor and rule out B-CLL (CD5+), mantle zone lymphoma (CD5+), and follicle center lymphoma (CD1O, CD43, CD11c, and clg).
· Lymphoma from the cells of the mantle zone. Tumor-forming cells are composed of small to medium-sized lymphocytes, whose nuclei are irregularly shaped with a poorly visible nucleolus, and define a narrow rim of pale cytoplasm. Among the tumor cells, centroblasts or immunoblasts are detected. Tumor cells from the mantle zone are considered CD5, CD19, CD20, CD22, CD43 positive, carry surface immunoglobulins (slg+), but CD10 and CD23 are negative. In 50-82% of patients with lymphoma from the cells of the mantle zone, infiltration of the bone marrow by tumor cells is observed, which can be nodular, paratrabecular or interstitial in nature. Cytogenetic changes in tumor cells from the mantle zone are characterized by the presence of the t(ll;14)(ql3;q32) translocation.
· Follicular lymphoma. FL is composed of cells that are morphologically and immunophenotypically similar to normal germinal center cells and are one of the most common lymphoma variants. The histological picture of the lymph node is characterized by a nodular or follicular type of growth of tumor cells. The presence of diffuse infiltration of the lymph node worsens the prognosis of the disease.

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Treatment

Treatment goals:
Achieving and maintaining remission.

Treatment tactics:

Non-drug treatment:
Mode: general protection.
Diet: neutropenic patients are advised not to follow a specific diet ( level of evidence B).

Medical treatment

Indications for starting treatment:

The presence of B-symptoms that worsen the quality of life;
Anemia and/or thrombocytopenia due to infiltration of the bone marrow with leukemia cells (advanced stage of the disease: C according to Binet, III-IV according to Rai);
Massive lymphadenopathy or splenomegaly causing compression problems
Doubling the absolute number of lymphocytes in the blood in less than 6 months (only in patients with lymphocytosis more than 30 × 109 / l);
Autoimmune hemolytic anemia or thrombocytopenia refractory to standard therapy.
Indications for initiation of therapy should be critically assessed.
In case of autoimmune complications (hemolytic anemia, thrombocytopenia), if there are no additional indications for the start of CLL therapy, treatment is carried out according to the protocols for the treatment of autoimmune hemolytic anemia and autoimmune thrombocytopenia.

Treatment of early stages of CLL without signs of progression (Binet stages A and B, Rai stages 0-II with symptoms, Rai stages III-IV).

Treatment of early stages of CLL does not improve survival. The standard tactic in the early stages is the "watch and wait" strategy. A follow-up clinical and laboratory examination with a mandatory study of a deployed UAC should be carried out every 3-6-12 months.

Treatment of advanced stages of CLL stage A and B according to Binet with signs of activity, stage C according to Binet; Rai stages 0-II with symptoms, Rai stages III-IV (level of evidence B).

In this group, patients have indications for chemotherapy. The choice of treatment depends on the somatic status of the patient and the presence of concomitant diseases.
In patients younger than 70 years without comorbidities, FCR (Fludarabine + Cyclophosphamide + Rituximab), BR (Bendamustine + Rituximab) are the first-line therapy. Pentostatin and cladribine can be used as first-line therapy in CLL, but the FCR combination is preferred. The use of Bendamustine as a first-line therapy is a less toxic treatment option compared to FCR, more effective than Chlorambucil (median event-free survival 21.6 months vs 8.3 months; p<0,0001) и может быть рекомендовано при наличии противопоказаний к Флударабину.
In patients over 70 years of age and/or with severe comorbidities, Chlorambucil is the standard first-line therapy. Bendamustine, rituximab monotherapy, or reduced dose cycles of purine analogs may be the most common alternatives.

Drugs (active substances) used in the treatment

Groups of drugs according to ATC used in the treatment

Hospitalization

Indications for hospitalization:

Indications for emergency hospitalization:
infectious complications;
autoimmune hemolysis;
hemorrhagic syndrome.

Indications for planned hospitalization:
to verify the diagnosis

Prevention

Preventive actions: no.

Further management:
The effectiveness of consolidation or maintenance therapy in CLL has not been proven. Carrying out any maintenance therapy for CLL is possible only within the framework of clinical trials.

Information

Sources and literature

1. Minutes of the meetings of the Expert Council of the RCHD MHSD RK, 2015
   1. References: 1. Scottish Intercollegiate Guidelines Network (SIGN). SIGN 50: a guideline developer's handbook. Edinburgh: SIGN; 2014. (SIGN publication no. 50). . Available from URL: http://www.sign.ac.uk. 2. NCCN Clinical Practice Guidelines in Oncology: Non-Hodgkin's Lymphomas, 2014 (http://www.nccn.org). 3. Eichhorst B., HallekM., DreylingM. Chronic lymphocytic leukaemia: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up Ann Oncol (2010) 21 (suppl 5): v162-v164 4. Parker A., ​​Bain B., Devereux S. et al. Best Practice in Lymphoma Diagnosis and Reporting, 2012. 5. Cheng MM , Goulart B, Veenstra DL, Blough DK, Devine EB A network meta-analysis of therapies for previously untreated chronic lymphocytic leukemia Cancer Treat Rev. 2012 Dec;38(8):1004-11. 7. Moody K, Finlay J, Mancuso C, Charlson M. Feasibility and safety of a pilot randomized trial of infection rate: neutropenic diet versus standard food safety guidelines J Pediatr Hematol Oncol 2006 Mar;28(3):126-33 8 Gardner A, Mattiuzzi G, Faderl S, Borthakur G, Garcia-Manero G, Pierce S, Brandt M, Estey E. Randomized comparison of cooked and noncooked diets in patients undergoing remission induction therapy for acute myeloid leukemia. J Clin Oncol. 2008 Dec 10;26(35):5684-8. 9. Carr SE, Halliday V. Investigating the use of the neutropenic diet: a survey of UK dietitians. J Hum Nutr Diet. 2014 Aug 28. 10. Boeckh M. Neutropenic diet--good practice or myth? Biol Blood Marrow Transplant. 2012 Sep;18(9):1318-9. 11. Trifilio, S., Helenowski, I., Giel, M. et al. Questioning the role of a neutropenic diet following hematopoetic stem cell transplantation. Biol Blood Marrow Transplant. 2012; 18:1387–1392. 12. DeMille, D., Deming, P., Lupinacci, P., and Jacobs, L.A. The effect of the neutropenic diet in the outpatient setting: a pilot study. Oncol Nurs Forum. 2006; 33:337–343. 13. Raul C. Ribeiro and Eduardo Rego Management of APL in Developing Countries: Epidemiology, Challenges and Opportunitiesfor International Collaboration Hematology 2006: 162-168. 14. Shanshal M, Haddad RY. Chronic lymphocytic leukemia Dis Mon. 2012 Apr;58(4):153-67. 15. NCCN Clinical Practice Guidelines in Oncology: Non-Hodgkin's Lymphomas, 2014 16. http://www.nccn.org/about/nhl.pdf 17. Bruton's tyrosine kinase inhibitors and their clinical potential in the treatment of B-cell malignancies: focus on ibrutinib. 18. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4212313/ 19. A Phase 3 Study of Ibrutinib (PCI-32765) Versus Ofatumumab in Patients With Relapsed or Refractory Chronic Lymphocytic Leukemia (RESONATE™) https://clinicaltrials.gov/ct2/show/NCT01578707.

Information

List of protocol developers with qualification data:
1) Kemaikin Vadim Matveyevich - Candidate of Medical Sciences, JSC "National Scientific Center of Oncology and Transplantation", Head of the Department of Oncohematology and Bone Marrow Transplantation.
2) Klodzinsky Anton Anatolyevich - Candidate of Medical Sciences, JSC "National Scientific Center of Oncology and Transplantation", Hematologist, Department of Oncohematology and Bone Marrow Transplantation.
3) Ramazanova Raigul Mukhambetovna - doctor of medical sciences, professor of JSC "Kazakh Medical University of Continuing Education", head of the course of hematology.
4) Gabbasova Saule Telembaevna - RSE on REM "Kazakh Research Institute of Oncology and Radiology", head of the department of hemoblastoses.
5) Karakulov Roman Karakulovich - Doctor of Medical Sciences, Professor, Academician of the MAI RSE on REM "Kazakh Research Institute of Oncology and Radiology", Chief Researcher of the Department of Hemoblastoses.
6) Tabarov Adlet Berikbolovich - Head of the Innovation Management Department of the RSE on the REM "Hospital of the Medical Center Administration of the President of the Republic of Kazakhstan", clinical pharmacologist, pediatrician.

Indication of no conflict of interest: missing.

Reviewers:
1) Afanasiev Boris Vladimirovich - Doctor of Medical Sciences, Director of the Research Institute of Children's Oncology, Hematology and Transplantation named after R.M. Gorbacheva, Head of the Department of Hematology, Transfusiology and Transplantology of the State Budgetary General Educational Institution of Higher Professional Education of the First St. Petersburg State Medical University. I.P. Pavlova.
2) Rakhimbekova Gulnara Aibekovna - Doctor of Medical Sciences, Professor, JSC "National Scientific Medical Center", Head of Department.
3) Pivovarova Irina Alekseevna - Medicinae Doctor, Master of Business Administration, Chief Freelance Hematologist of the Ministry of Health and Social Development of the Republic of Kazakhstan.

Indication of the conditions for revising the protocol: revision of the protocol after 3 years and / or when new methods of diagnosis and / or treatment with a higher level of evidence appear.

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Oncological diseases are usually very difficult. Any manifestations of cancer have a complex negative impact on the body and human well-being. Tumor diseases of the blood can affect any organ of the human body. Chronic lymphocytic leukemia (CLL) occurs in the blood cells of lymphocytes and causes malignant lesions of the lymphatic tissue. Today there is no treatment that would guarantee the patient a complete recovery, but modern medicine has all available means to slow down the course of the disease and prolong life.

Causes

The specificity of blood diseases indicates a certain pathological process that leads to a change and degeneration of cells. Chronic lymphocytic leukemia is caused by changes in white blood cells, lymphocytes. This disease in its acute form affects immature leukocyte cells, chronic forms destroy mature lymphocytes. Until now, medicine does not know the exact causes of this disease. Knowledge about the order of development and spread of the disease is based on medical observations and statistical studies.

Among the reasons that provoke the development of chronic lymphocytic leukemia, physicians call the following.

• hereditary factor. This is one of the main reasons that can be traced by examining the medical history of a particular family. If there have been cases of blood tumors in the past, this increases the likelihood of developing lymphocytic leukemia in future generations.
• Congenital diseases and pathologies. A number of medical studies have found that certain types of pathological conditions significantly increase the risk of developing cancer. Chronic lymphocytic leukemia is more likely to appear in a person suffering from Down syndrome, Wiskott-Aldrich, etc.
• The effect of viruses on the body. In the course of medical studies on animals, the negative effect of viruses on DNA and RNA was confirmed. Thus, this gives the right to assume that some severe viral diseases can provoke chronic lymphocytic leukemia. For example, the Epstein-Barr virus, which is also known as the herpes virus type 4.
• consequences of irradiation. At low doses of radiation, as a rule, the body does not receive significant damage. At the same time, with a serious influence of radiation, radiation therapy, there is a risk of blood diseases. About 10% of patients undergoing radiation therapy subsequently develop lymphocytic leukemia.

To date, scientists have not come to a consensus about the factors provoking the development of chronic lymphocytic leukemia. One of the main theories is the hereditary factor. However, studies have been conducted in which a clear relationship has not been established between genetic material and the likelihood of a blood tumor. Other researchers refute the influence of carcinogens and toxic substances. The causes of the development of the disease are visible in statistical observations, but require confirmation.

Symptoms of the disease

Before the start of diagnosis, any disease manifests itself with specific signs that worsen the state of human health. Chronic lymphocytic leukemia develops gradually. The symptoms of this type of cancer also develop slowly. The following signs of the disease are distinguished.

• General weakness and a feeling of fatigue that accompany a person throughout the day. This symptom is often confused with normal fatigue. Most often, a person really gets tired due to physical or nervous tension, but if the ailment lasts longer than a week, you should consult a doctor.
• Enlarged lymph nodes.
• Chronic lymphocytic leukemia causes severe sweating in a person, especially during a night's sleep.
• With the development of a blood tumor, an increase in the liver and spleen is observed. As a result, a person may feel soreness and a feeling of heaviness in the abdomen, more often on the left side.
• During physical exertion, even minor, shortness of breath is observed.
• In chronic lymphocytic leukemia, the symptoms are supplemented by loss of appetite.
• A blood test usually detects a decrease in the concentration of platelets in the patient's blood.
• Chronic lymphocytic leukemia leads to a decrease in neutrophils. This is due to changes in granulocyte cells in the blood, in particular those cells that mature in the bone marrow.
• Patients are often exposed to the manifestation of allergies.
• Chronic lymphocytic leukemia reduces the overall immune system of the body. A person begins to get sick more often, especially infectious and viral diseases (ARVI, influenza, etc.).

One or two of these symptoms are unlikely to indicate that the patient is developing leukemia or leukemia, but if a person has several forms of malaise, you should immediately consult a doctor. Only an examination by a qualified specialist and the subsequent delivery of the necessary tests can confirm or refute the development of the disease.

Diagnostics

Most tests and studies in the diagnosis of any disease begin with a general or clinical blood test. Chronic lymphocytic leukemia is no exception. The diagnostic process is not difficult for a qualified doctor. The main tests that the doctor can prescribe are the following.

• General blood analysis. This type of study of the autoimmune form of the disease is aimed at identifying the number of leukocytes and lymphocytes in the patient's blood. With an increase in the concentration of lymphocytic cells by more than 5×10 9 g/l, lymphoblastic leukemia is diagnosed.
• Biochemistry of blood. Biochemical research allows you to determine the deviations in the work of the body caused by a weakened immune system. According to the general indicators, the doctor can judge which organs were affected. At the initial stage of development of lymphocytic leukemia, biochemistry does not reveal any violations.
• Myelogram. This is a special type of study for lymphocytic leukemia, which allows you to determine the replacement of red bone marrow cells with lymph tissue. In the initial stages of the disease, the concentration of lymphatic cells does not exceed 50%. With the development of cancer, the number of lymphocytes reaches 98%.
• Immunophenotyping. A specific study aimed at searching for oncological markers of lymphocytic leukemia.
• Biopsy of lymphatic tissue. This type of diagnosis is usually accompanied by a cytological examination, ultrasound, computed tomography and a number of other procedures. It is carried out to confirm the diagnosis, as well as to determine the stage of the disease and the degree of damage to the body.

Disease classification and prognosis

Today, in world medicine, two forms are used to reflect the severity of chronic lymphocytic leukemia. The first was developed by the American scientist Rai in 1975. Later, this methodology was supplemented and revised. The development of the disease according to Rai has 5 stages from 0 to IV. The initial form of lymphocytic leukemia is considered to be a zero mark, in which there are no symptoms, and the life of the patient belonging to the treatment exceeds a decade.

In Europe, as well as in domestic medicine, the division into stages developed by French scientists in 1981 is used. The scale is known as the Binet stages. For staging, a blood test is used that determines the patient's hemoglobin and platelet levels. Damage to the lymph nodes of the main zones is also taken into account: axillary and inguinal regions, neck, spleen, liver and head. Depending on the data obtained, lymphocytic leukemia is divided into 3 stages.

1. Stage A. In the human body, the disease affects less than 3 main zones. At the same time, the hemoglobin level is not lower than 100 g/l, and the platelet concentration exceeds 100×10 9 g/l. At this stage, doctors make the most optimistic prognosis for the patient, the life expectancy exceeds 10 years.
2. Stage B. The second stage of severity of lymphocytic leukemia is diagnosed when 3 or more major areas of the lymph nodes are affected. This state corresponds to blood parameters: hemoglobin more than 100 g/l, platelets more than 100×10 9 g/l. The prognosis for such a lesion of the body is on average about 6-7 years of life.
3. Stage C. The third most severe stage of the disease is characterized by blood tests with a hemoglobin content of less than 100 g/l, and platelets less than 100×10 9 g/l. This means that such damage to the body is almost irreversible. Any number of affected areas of the lymph nodes can be observed. On average, survival at this stage of the disease is about one and a half years.

Treatment

The development of modern medicine and science, supported by the technological equipment of medical institutions, gives doctors the opportunity to treat many diseases. However, treatment for chronic lymphocytic leukemia is supportive. This disease cannot be completely cured.

Every year, new means and methods of influencing the disease are developed.

At the initial stages of special exposure to medications is not required. Medicine knows many cases when the course of chronic lymphocytic leukemia is so slow that it does not cause inconvenience to a person. Therapy is prescribed for the progressive development of cancer. A significant increase in the concentration of lymphocytes in the blood, as well as a deterioration in the functioning of the spleen and liver, are an indication for the appointment of special drugs.

• For chronic lymphocytic leukemia, treatment is always complex. The most effective and common form of drug exposure includes intravenous fludarabine, intravenous cyclophosphamide, and ruthiximab. Depending on the individual characteristics of the patient, other drugs or combinations of drugs may be prescribed.
• In the absence of the effectiveness of drug treatment, as well as in the later stages of the disease, radiation therapy can be used. As a rule, at this stage, there is a significant increase in the lymph nodes and the penetration of lymphatic tissue into the nerve trunks, internal organs and human systems.
• If the spleen is severely enlarged, surgery may be performed to remove it. This method is considered insufficiently effective for combating chronic lymphocytic leukemia and increasing the number of lymphocytes. However, it is still used in medicine.

No matter how terrible the disease may seem, you should definitely resort to professional medical help. The active course of the disease without treatment of lymphocytic leukemia leads to damage to the body and death of the patient. At the same time, exposure to medication in 70% of cases leads to remission and prolongs life.

In contact with

- an oncological disease accompanied by the accumulation of atypical mature B-lymphocytes in the peripheral blood, liver, spleen, lymph nodes and bone marrow. In the initial stages, it is manifested by lymphocytosis and generalized lymphadenopathy. With the progression of chronic lymphocytic leukemia, hepatomegaly and splenomegaly are observed, as well as anemia and thrombocytopenia, manifested by weakness, fatigue, petechial hemorrhages and increased bleeding. There are frequent infections due to a decrease in immunity. The diagnosis is established on the basis of laboratory tests. Treatment - chemotherapy, bone marrow transplantation.

General information

Chronic lymphocytic leukemia is a disease from the group of non-Hodgkin's lymphomas. Accompanied by an increase in the number of morphologically mature, but defective B-lymphocytes. Chronic lymphocytic leukemia is the most common form of hemoblastoses, accounting for one third of all leukemias diagnosed in the US and Europe. Men are affected more often than women. The peak incidence occurs at the age of 50-70 years, in this period about 70% of the total number of chronic lymphocytic leukemias are detected.

Young patients rarely suffer, up to 40 years the first symptom of the disease occurs in only 10% of patients. In recent years, experts have noted some "rejuvenation" of the pathology. The clinical course of chronic lymphocytic leukemia is very variable, ranging from a prolonged absence of progression to an extremely aggressive variant with a fatal outcome within 2-3 years after diagnosis. There are a number of factors that can predict the course of the disease. Treatment is carried out by specialists in the field of oncology and hematology.

Etiology and pathogenesis of chronic lymphocytic leukemia

The causes of occurrence have not been fully elucidated. Chronic lymphocytic leukemia is considered the only leukemia with an unconfirmed relationship between the development of the disease and adverse environmental factors (ionizing radiation, contact with carcinogens). Experts believe that the main factor contributing to the development of chronic lymphocytic leukemia is hereditary predisposition. Typical chromosomal mutations that cause damage to oncogenes at the initial stage of the disease have not yet been identified, but studies confirm the mutagenic nature of the disease.

The clinical picture of chronic lymphocytic leukemia is due to lymphocytosis. The cause of lymphocytosis is the appearance of a large number of morphologically mature, but immunologically defective B-lymphocytes, incapable of providing humoral immunity. It was previously believed that abnormal B-lymphocytes in chronic lymphocytic leukemia are long-lived cells and rarely undergo division. Subsequently, this theory was refuted. Studies have shown that B-lymphocytes multiply rapidly. Every day, 0.1-1% of the total number of atypical cells is formed in the patient's body. In different patients, different clones of cells are affected, so chronic lymphocytic leukemia can be considered as a group of closely related diseases with a common etiopathogenesis and similar clinical symptoms.

When studying cells, a great variety is revealed. The material may be dominated by wide-plasma or narrow-plasma cells with young or wrinkled nuclei, almost colorless or brightly colored granular cytoplasm. Proliferation of abnormal cells occurs in pseudofollicles - clusters of leukemic cells located in the lymph nodes and bone marrow. The causes of cytopenia in chronic lymphocytic leukemia are autoimmune destruction of blood cells and suppression of stem cell proliferation due to an increase in the level of T-lymphocytes in the spleen and peripheral blood. In addition, in the presence of killer properties, atypical B-lymphocytes can cause destruction of blood cells.

Classification of chronic lymphocytic leukemia

Taking into account the symptoms, morphological features, rate of progression and response to therapy, the following forms of the disease are distinguished:

• Chronic lymphocytic leukemia with a benign course. The patient's condition remains satisfactory for a long time. There is a slow increase in the number of leukocytes in the blood. From the moment of diagnosis to a stable increase in lymph nodes, it can take several years or even decades. Patients retain their ability to work and their usual way of life.
• Classical (progressive) form of chronic lymphocytic leukemia. Leukocytosis builds up over months, not years. There is a parallel increase in lymph nodes.
• Tumor form of chronic lymphocytic leukemia. A distinctive feature of this form is a mildly pronounced leukocytosis with a pronounced increase in lymph nodes.
• Bone marrow form of chronic lymphocytic leukemia. Progressive cytopenia is detected in the absence of enlargement of the lymph nodes, liver and spleen.
• Chronic lymphocytic leukemia with enlarged spleen.
• Chronic lymphocytic leukemia with paraproteinemia. Symptoms of one of the above forms of the disease are noted in combination with monoclonal G- or M-gammapathy.
• Prelymphocytic form X chronic lymphocytic leukemia. A distinctive feature of this form is the presence of lymphocytes containing nucleoli in blood and bone marrow smears, tissue samples of the spleen and lymph nodes.
• Hairy cell leukemia. Cytopenia and splenomegaly are detected in the absence of enlarged lymph nodes. Microscopic examination reveals lymphocytes with a characteristic "youthful" nucleus and "uneven" cytoplasm with breaks, scalloped edges and sprouts in the form of hairs or villi.
• T-cell form of chronic lymphocytic leukemia. It is observed in 5% of cases. Accompanied by leukemic infiltration of the dermis. Usually progresses quickly.

There are three stages of the clinical stage of chronic lymphocytic leukemia: initial, advanced clinical manifestations and terminal.

Symptoms of chronic lymphocytic leukemia

At the initial stage, the pathology is asymptomatic and can only be detected by blood tests. Within a few months or years, a patient with chronic lymphocytic leukemia has 40-50% lymphocytosis. The number of leukocytes is close to the upper limit of the norm. In the normal state, peripheral and visceral lymph nodes are not enlarged. During the period of infectious diseases, the lymph nodes can temporarily increase, and after recovery they decrease again. The first sign of the progression of chronic lymphocytic leukemia is a stable increase in lymph nodes, often in combination with hepatomegaly and splenomegaly.

First, the cervical and axillary lymph nodes are affected, then the nodes in the mediastinum and abdominal cavity, then in the inguinal region. Palpation reveals mobile, painless, densely elastic formations that are not soldered to the skin and nearby tissues. The diameter of the nodes in chronic lymphocytic leukemia can range from 0.5 to 5 or more centimeters. Large peripheral lymph nodes may swell with a visible cosmetic defect. With a significant increase in the liver, spleen and visceral lymph nodes, compression of the internal organs can be observed, accompanied by various functional disorders.

Patients with chronic lymphocytic leukemia complain of weakness, unreasonable fatigue and decreased ability to work. According to blood tests, there is an increase in lymphocytosis up to 80-90%. The number of erythrocytes and platelets usually remains within the normal range, in some patients minor thrombocytopenia is detected. In the later stages of chronic lymphocytic leukemia, weight loss, night sweats and fever to subfebrile figures are noted. Immune disorders are characteristic. Patients often suffer from colds, cystitis and urethritis. There is a tendency to suppuration of wounds and the frequent formation of abscesses in the subcutaneous fatty tissue.

The cause of death in chronic lymphocytic leukemia is often severe infectious diseases. Possible inflammation of the lungs, accompanied by a collapse of the lung tissue and gross violations of ventilation. Some patients develop exudative pleurisy, which may be complicated by rupture or compression of the thoracic lymphatic duct. Another common manifestation of advanced chronic lymphocytic leukemia is herpes zoster, which in severe cases becomes generalized, capturing the entire surface of the skin, and sometimes the mucous membranes. Similar lesions can be seen in herpes and chickenpox.

Among other possible complications of chronic lymphocytic leukemia is infiltration of the vestibulocochlear nerve, accompanied by hearing disorders and tinnitus. In the terminal stage of chronic lymphocytic leukemia, infiltration of the meninges, medulla and nerve roots can be observed. Blood tests reveal thrombocytopenia, hemolytic anemia, and granulocytopenia. It is possible to transform chronic lymphocytic leukemia into Richter's syndrome - diffuse lymphoma, manifested by the rapid growth of lymph nodes and the formation of foci outside the lymphatic system. About 5% of patients survive to develop lymphoma. In other cases, death occurs from infectious complications, bleeding, anemia and cachexia. Some patients with chronic lymphocytic leukemia develop severe renal failure due to infiltration of the renal parenchyma.

Diagnosis of chronic lymphocytic leukemia

In half of the cases, the pathology is discovered by chance, during examination for other diseases or during a routine examination. When making a diagnosis, complaints, anamnesis, objective examination data, results of blood tests and immunophenotyping are taken into account. The diagnostic criterion for chronic lymphocytic leukemia is an increase in the number of leukocytes in the blood test up to 5×109/l in combination with characteristic changes in the immunophenotype of lymphocytes. Microscopic examination of a blood smear reveals small B-lymphocytes and Gumprecht shadows, possibly in combination with atypical or large lymphocytes. Immunophenotyping confirms the presence of cells with an aberrant immunophenotype and clonality.

The determination of the stage of chronic lymphocytic leukemia is carried out on the basis of the clinical manifestations of the disease and the results of an objective examination of the peripheral lymph nodes. To draw up a treatment plan and assess the prognosis for chronic lymphocytic leukemia, cytogenetic studies are carried out. If Richter's syndrome is suspected, a biopsy is prescribed. To determine the causes of cytopenia, a sternal puncture of the bone marrow is performed, followed by a microscopic examination of the punctate.

Treatment and prognosis for chronic lymphocytic leukemia

At the initial stages of chronic lymphocytic leukemia, expectant management is used. Patients are scheduled for examination every 3-6 months. In the absence of signs of progression, they are limited to observation. An indication for active treatment is an increase in the number of leukocytes by a factor of two or more within six months. The main treatment for chronic lymphocytic leukemia is chemotherapy. The combination of rituximab, cyclophosphamide, and fludarabine is usually the most effective drug combination.

In the persistent course of chronic lymphocytic leukemia, large doses of corticosteroids are prescribed, bone marrow transplantation is performed. In elderly patients with severe somatic pathology, the use of intensive chemotherapy and bone marrow transplantation may be difficult. In such cases, monochemotherapy with chlorambucil is performed or this drug is used in combination with rituximab. In chronic lymphocytic leukemia with autoimmune cytopenia, prednisolone is prescribed. Treatment is carried out until the patient's condition improves, while the duration of the course of therapy is at least 8-12 months. After a stable improvement in the patient's condition, treatment is stopped. The indication for resuming therapy is clinical and laboratory symptoms, indicating the progression of the disease.

Chronic lymphocytic leukemia is considered as a practically incurable long-term disease with a relatively satisfactory prognosis. In 15% of cases, an aggressive course is observed with a rapid increase in leukocytosis and progression of clinical symptoms. Lethal outcome in this form of chronic lymphocytic leukemia occurs within 2-3 years. In other cases, slow progression is noted, the average life expectancy from the moment of diagnosis ranges from 5 to 10 years. With a benign course, the life span can be several decades. After the course of treatment, improvement is observed in 40-70% of patients with chronic lymphocytic leukemia, but complete remissions are rarely detected.

Acute lymphocytic leukemia(other name - acute lymphoblastic leukemia) is a malignant disease that most often manifests itself in children whose age is from 2 to 4 years.

Symptoms of acute lymphocytic leukemia

With the manifestation of lymphocytic leukemia, patients first of all complain of feelings of weakness, malaise. Their body temperature is greatly reduced, the body temperature rises unmotivated, the skin turns pale due to anemia and general condition intoxication . Pain is most often manifested in the spine and limbs. As the disease progresses, an increase peripheral , and in some cases mediastinal lymph nodes . Approximately half of the cases are characterized by the development hemorrhagic syndrome , which is characterized petechiae And hemorrhages .

Due to the occurrence of extramedullary lesions of the central nervous system, neuroleukemia . In order to correctly establish the diagnosis in this case, computed tomography of the brain, EEG, MRI, as well as a study of cerebrospinal fluid are performed. More rarely seen leukemic infiltration of the testicles . In this case, the diagnosis is based on the study of biopsy specimens obtained as a result.

Diagnosis of acute lymphocytic leukemia

As a rule, the examination of patients begins with a peripheral analysis. Its results in almost every case (98%) will be the presence of exclusively blasts and mature cells without intermediate stages. In the case of acute lymphocytic leukemia, normochromic anemia And thrombocytopenia . A number of other signs are already characteristic of a smaller number of cases: in about 20% of cases, leukopenia develops, in half of the cases - leukocytosis . A specialist can suspect this disease already on the basis of the patient's complaints, as well as the general picture of the blood. However, it is impossible to establish an accurate diagnosis without a detailed study of the red bone marrow. The first focus of this study is on histological , cytochemical And cytogenetic characteristic bone marrow blasts . Quite informative identification Philadelphia chromosome (Ph chromosomes). In order to make the most accurate diagnosis and plan the correct course of treatment, a number of additional examinations should be carried out to determine whether there are lesions in other organs. For this patient, additionally examines otolaryngologist , urologist , neuropathologist , studies of the abdominal cavity are carried out.

When making a diagnosis, the patient's age over 10 years, the presence of high leukocytosis, the morphology of B-ALL, male sex, and leukemic lesions of the central nervous system are considered as factors of poor prognosis.

The doctors

Treatment of acute lymphocytic leukemia

Basically, with proper treatment, the disease is cured completely.

In most cases, a complete cure can be achieved. The treatment of acute lymphocytic leukemia applies certain principles that are important for successful treatment.

The principle of a wide range of effects is important, the essence of which is the use of chemotherapy drugs with different mechanisms of action. Using the principle of adequate dosages is no less important, because with a sharp decrease in doses of the drug, a relapse of the disease is possible, and at too high doses, the risk of complications of lymphocytic leukemia increases. When prescribing chemotherapy drugs to a patient, the doctor adheres to the principle of stages, as well as continuity.

However, the defining principle in the process of therapy is the continuity of treatment from the very beginning to the end. The occurrence of relapses of the disease greatly reduces the chance for the final recovery of the patient. When relapses occur, several short blocks in high doses are used for treatment.

Symptoms of chronic lymphocytic leukemia

This is an oncological disease of the lymphatic tissue, which is characterized by the accumulation of tumor cells in peripheral blood , lymph nodes And bone marrow . If we compare this form of lymphocytic leukemia with an acute condition, then in this case the growth of the tumor occurs more slowly, and hematopoietic disorders occur only at a late stage of the disease.

Symptoms chronic lymphocytic leukemia is a general weakness, a feeling of heaviness in the abdomen, especially in the left hypochondrium, excessive sweating. The patient has a sharp decrease in body weight, greatly increased lymph nodes. It is the enlargement of the lymph nodes, as a rule, that is observed as the first symptom of the chronic form of lymphocytic leukemia. Due to the fact that during the development of the disease the spleen enlarges, there is a feeling of severe heaviness in the abdomen. Often patients become more susceptible to various kinds of infections. However, the development of symptoms occurs rather slowly and gradually.

Diagnosis of chronic lymphocytic leukemia

According to available data, about a quarter of cases, the disease is discovered by chance during a blood test that is prescribed to a person for another reason. To make a diagnosis of chronic lymphocytic leukemia, a patient is prescribed a series of studies. However, first of all, the doctor examines the patient. A clinical blood test is mandatory, during which the leukocyte formula is calculated. The picture of the lesion, which is characteristic of this particular disease, is revealed during the study of the bone marrow. Also, during a complete examination of a patient with suspected chronic lymphocytic leukemia, immunophenotyping of bone marrow and peripheral blood cells is performed, enlarged lymph node.

Study of tumor cells cytogenetic analysis . And it is possible to predict the level of risk of developing infectious complications of the disease by determining the level .

In the process of diagnosis, the stage of chronic lymphocytic leukemia is also determined. Guided by this information, the doctor decides on the tactics and features of his treatment.

Stages of chronic lymphocytic leukemia

Today there is a specially developed staging system for chronic lymphocytic leukemia, according to which it is customary to determine the three stages of the disease.

Stage A is characterized by damage to no more than two groups of lymph nodes, or there is no damage to the lymph nodes at all. Also at this stage, the patient does not have anemia And thrombocytopenia .

At stage B of chronic lymphocytic leukemia, three or more groups of lymph nodes are affected. The patient has no anemia and thrombocytopenia.

Stage C is characterized by the presence of thrombocytopenia or anemia. Moreover, these manifestations do not depend on the number of affected groups of lymph nodes.

Also, when making a diagnosis, Roman numerals are added to the designation of the stage of lymphocytic leukemia in letters, denoting a specific symptom:

I - presence lymphadenopathy

II - enlarged spleen (splenomegaly)

III - the presence of anemia

IV - the presence of thrombocytopenia

Treatment of chronic lymphocytic leukemia

A feature of the treatment of this disease is that experts determine inappropriate therapy in the early stages of the disease. Treatment is not carried out due to the fact that most patients in the initial stages of the chronic form of this disease have a so-called "smoldering" course of the disease. Accordingly, for a sufficiently long period, people can do without drugs, lead a normal life and feel relatively well. Therapy for chronic lymphocytic leukemia is started only if a number of symptoms appear.

So, treatment is advisable if the number of lymphocytes in the patient's blood increases very quickly, the lymph nodes enlargement progresses, the spleen increases very much, anemia and thrombocytopenia increase. Also, treatment is required if the patient has signs of tumor intoxication: increased sweating at night, rapid weight loss, constant severe weakness.

To date, there are a number of approaches to the treatment of the disease.

Actively used for treatment chemotherapy . However, if, until relatively recently, the drug was used for this procedure chlorbutin , then at the moment a group of drugs - purine analogues is considered to be a more effective remedy. The method is also used to treat chronic lymphocytic leukemia. bioimmunotherapy using monoclonal antibodies. After the introduction of such drugs, tumor cells are selectively destroyed, and healthy tissues in the patient's body are not damaged.

If the applied methods of treatment do not produce the desired effect, then, as prescribed by the attending physician, the method of high-dose chemotherapy is used, followed by transplantation of hematopoietic stem cells. If the patient has a large tumor mass, then the method is used as an adjunct to treatment.

With a strong increase in the spleen, the patient may be shown the complete removal of this organ.

When choosing the tactics of treating a patient with chronic lymphocytic leukemia, the doctor must be guided by the extensive data of all studies and take into account the individual characteristics of a particular patient and the course of the disease.

Prevention of lymphocytic leukemia

As the reasons that can provoke the manifestation of lymphocytic leukemia, the influence of a number of chemicals is determined. Therefore, you should be very careful about contact with such substances.

Patients who have a history immunodeficiency , hereditary chromosomal defects, people whose relatives have been diagnosed with chronic lymphocytic leukemia should regularly undergo preventive examinations and visit specialists. Patients who have undergone chemotherapy should take infection prevention very seriously. In view of this, patients after chemotherapy need to stay in isolation for a certain period, observe a sanitary and hygienic regimen, and avoid contact with people with infectious diseases. Also, for the purpose of prevention, in some cases, patients are prescribed a reception antiviral funds, .

Persons diagnosed with chronic lymphocytic leukemia should eat protein-rich meals, constantly donate blood for analysis, and be sure to use all the drugs prescribed by the doctor on time. Cannot be consumed , as well as aspirin-containing drugs that can provoke.

With the manifestation of tumors of the lymph nodes, discomfort in the abdomen, the patient should immediately contact the attending physician.

Diet, nutrition for lymphocytic leukemia

List of sources

• Clinical oncohematology: a guide for doctors / ed. M.A. Volkova. M. : Medicine, 2001;
• Aliev M.D., Polyakov V.G., Mentkevich G.L., Mayakova S.A. Pediatric oncology. National leadership. - M.: Publishing group RONTS, Practical medicine, 2012;
• Guide to hematology: in 3 volumes / ed. A.I. Vorobyov. - 3rd ed., revised. and additional - M. : Newdiamed, 2002-2005;
• Pediatric oncology: a guide for doctors / ed. M.B. Belogurova. -SPb. : SpecLit, 2002;
• Volkova MA. Chronic lymphocytic leukemia and its treatment. Lech. doctor. 2007.

3.2 Choice of treatment tactics in CLL.

3,2,1 First-line treatment of CLL in young patients with good physical status.

3.3 Maintenance therapy for CLL.

3,4 Choice of second and subsequent line therapy in CLL.

3.5 Indications for radiotherapy in CLL.