‘Prolymphocytoid’ Cells in Chronic Lymphocytic Leukaemia and their Prognostic Significance

The morphology of lymphocytes in blood and bone marrow smears from 103 patients with chronic lymphocytic leukaemia (CLL) was studied. Special attention was paid to the finding of immature cells with the morphological features of prolymphocytes (prolymphocytoid cells - PLC). Subsequently the prognostic significance of these cells was examined. It was found that in 85 cases no PLC were found (Group I); in 8 cases the percentage was ≤ 10% (Group II) and in 10 cases the PLC were > 10% (Group III). The cases with PLC, especially in group III, fell in advanced stages of the disease (III-IV) and presented with increased lymphocytosis. In 8 patients of group III, who were followed till death, the disease became refractory to any treatment and the survival was short. We suggest that ‘prolymphocytoid’ transformation is a bad prognostic sign in CLL.     

Studies in Chronic Lymphocytic Leukaemia

1. 9 Studies of lymphocyte transport are reported in which the ⁵¹Cr labelling technique of Hersey (1971) was employed on 8 patients with chronic lymphocytic leukaemia (CLL) and 1 with lymphosarcoma. 2. A new approach to the analysis of the data was formulated employing the principles of impulse analysis. This allowed the quantitation of cell transport between various locations making the minimum number of assumptions. It was also possible to take account of the principal defect of this label, its tendency to elute from live cells. 3. In spite of marked lymphocytosis, numbers of cells moving between those tissues whose lymphocytes exchange relatively slowly and the bloodstream was found to be normal. The blood and lymph nodes may therefore accumulate lymphocytes in response to a transport defect which hinders the progress of these cells from one pool to another. 4. The finding that CLL lymphocytes fluxes are normal in certain locations casts doubt on the hypothesis that lymphocyte proliferation is uncontrolled in this disease. An alternative possibility is that cell proliferation is regulated so as to maintain these fluxes within the normal range.     

Splenectomy in Chronic Lymphocytic Leukaemia

In a retrospective study it was endeavoured to evaluate the effects of splenectomy in chronic lymphocytic leukaemia (CLL) characterised by splenomegaly. The material comprises 42 patients subjected to the operation in the course of the past 20 years. In the majority the spleen weighed more than 1000 g. The main indication for splenectomy was anaemia, while in 9 cases it was thrombocytopenia and in 14 cases hypercatabolism. Splenectomy is followed by a pronounced increase in the venous haemoglobin level and platelet count to higher values which have been recorded for up to 3 years after the procedure. In cases where data were available, there has been weight gain and a falling basal metabolic rate. Splenectomy is effective especially in cases predominated exclusively by splenomegaly, but even in cases with marked extrasplenic manifestations, splenectomy often greatly reduces the need for prednisone and cytostatics. Increasing hepatomegaly and lymphomas were not more common after splenectomy than in a control series, and the incidence of infections was not increased after the operation. For comparison, 37 non-splenectomised patients with splenomegaly were assessed. X-radiation of the spleen seems to be insufficient, since usually it has to be repeated. Splenomegaly does not decrease spontaneously and rarely after treatment with prednisone/cytostatics. The findings indicate that splenectomy of patients with CLL and increasing splenomegaly should be performed more often and presumably also earlier than recommended in the literature.     

Prognostic Significance of Cytogenetical Studies in Chronic Granulocytic Leukaemia

In a series of 121 patients with chronic granulocytic leukaemia (CGL) the frequence and prognostic significance of two cytogenetical features (absence of ph¹-chromosome and presence of ph¹-mosaicism) were studied. 13% of the patients were ph¹-negative, these patients showing a shorter survival than the ph¹-positive ones (P < 0.005). 23 instances of ph¹-mosaicism were found (22.5%). This feature was observed either at diagnosis or after treatment, and irrespective of the patient's being in chronic or blastic phase of CGL, but in no case later than 2 years from diagnosis of the disease. ph¹-mosaicism patients vs the remainder of the ph¹-positive group were compared for survival, and no difference was found. The lack of prognostic significance of ph¹-mosaicism was evident regardless of the latter feature being detected at diagnosis or after treatment.     

Lymphocyte Kinetics in Chronic Lymphocytic Leukaemia

51-Chromium was used to study lymphocyte kinetics in patients with chronic lymphocytic leukaemia. Lymphocytes were found to equilibrate with a pool larger than that accounted for by blood volume and the blood lymphocyte count. Lymphocyte disappearance from the blood stream was exponential and complex, with an initial large rapid component and a smaller slower second component. The shape of the lymphocyte disappearance curve was not influenced by the size of the spleen, the white blood cell count or the duration of the disease. Body surface scanning revealed that infused lymphocytes were not sequestered in the lungs and circulated in and out of the spleen. Little radioactivity was noted over the liver or the iliac crest.     

Chronic Lymphocytic Leukaemia Associated with Acute Myelomonocytic Leukaemia

S ummary . An elderly male, with no previous medical history of note, presented with haematological changes of chronic lymphocytic leukaemia combined with acute myelomonocytic leukaemia. This patient had never received cytotoxic drugs or radiotherapy.     

Biochemical Characteristics of Chronic Lymphocytic Leukaemia

Chronic lymphocytic leukaemia (CLL) has a variable clinical course and there is a great need of new prognostic laboratory parameters in this disease. 24 CLL patients were subjected to routine haematological and clinical investigation. The leukaemic cells were analyzed for surface immunoglobulins, complement and sheep red blood cell receptors, Concanavalin A-induced agglutination, cytoplasmic glucocorticoid receptor and for proliferative activity by measurement of tritiated thymidine incorporation. The surface markers studied indicated that all cases were of B-cell origin. Only 5 of 23 patients studied had normal serum immunoglobulin levels. These cases showed a nonprogressive disease. 8 patients had increased infection tendency, all of whom had subnormal IgG levels; 4 of them also had subnormal IgA and IgM and 2 had subnormal IgA levels. 5 out of 6 patients with progressive disease and 3 of 11 with nonprogressive disease had an increased proliferative index, indicating a correlation between this parameter and disease progression. ConA agglutinability was not correlated to disease activity. Cells from 17 of 22 patients showed measurable amounts of glucocorticoid receptor. The 5 patients lacking this receptor had inactive disease.     

'Prolymphocytoid' Transformation of Chronic Lymphocytic Leukaemia

S ummary . We report clinical, morphological and surface marker studies on seven patients with the common type of chronic lymphocytic leukaemia (CLL) whose disease underwent an insidious though progressive change in character with increasing refractoriness to treatment. This transformation was accompanied by the appearance of a population of immature-appearing cells in the peripheral blood which resembled prolymphocytes, both at light and electron microscopy. The characteristic morphological feature was the presence of two distinct populations of cells, the typical CLL lymphocytes and the 'prolymphocytoid' cells. These cells retained the surface marker characteristics of CLL, i.e. the formation of mouse RBC rosettes and sparse surface-bound immunoglobulin. This transformation can be distinguished by morphological and surface marker criteria from acute leukaemia occurring in CLL, Richter's syndrome and prolymphocytic leukaemia. The recognition of this group of CLL patients may add a new prognostic index to CLL and may help plan subsequent trials for the treatment of the disease.     

β2-Microglobulin in Chronic Lymphocytic Leukaemia

The serum level of β₂-microglobulin (S-β₂m), a cell membrane protein associated with HLA-antigens, was quantitated in a series of 23 consecutive patients with chronic lymphocytic leukaemia (CLL). Markedly elevated values of S-β₂m (> 4.5 mg/l) were found in 10 patients, while only 3 patients had normal values (< 3.0 mg/l). High serum values correlated with a large tumour mass, as estimated by Rai's clinical staging and by the total peripheral lymphocyte count. Blood lymphocyte proliferative activity, which has been suggested as reflecting disease activity in CLL, was measured by ³H-thymidine uptake in cells in vitro. The ³H-thymidine uptake was high in 3 patients all of whom were among the 5 patients with the highest S-β₂m-values. S-β₂m-determinations seem to be of definite interest in the study of patients with CLL although long term studies will be necessary for evaluation of the practical clinical value.     

Chronic Lymphocytic Leukaemia of T Cell Origin

Based on the literature and 2 patients studied, we suggest that at least 2 different clinical entities are included in the concept of T CLL: (i) a clinical variant characterized by a relatively benign course, splenomegaly without lymphadenopathy, low lymphocyte count and granulocytopenia; the proliferating lymphocyte is morphologically mature, of medium size and a cytoplasm with azurophilic granules staining positively for acid phosphatase and corresponding to parallel tubular arrays as demonstrated by electron microscopy. The cells form E-rosettes, have no surface-membrane-bound Ig, but Fc-receptors for IgG. With monoclonal antibodies, the phenotype is OKT₃+, OKT₄^- and OKT₈+, theoretically corresponding to the suppressor/cytotoxic T lymphocyte subset, but functionally the cells demonstrate killer cell (responsible for ADCC), but not natural or suppressor cell activity. (ii) another clinical variant with an aggressive course, massive hepato-splenomegaly, lymph node enlargement and very high lymphocyte counts; the lymphocytes are small without cytoplasmic granules; their immunological and functional characteristics have not been determined, but morphologically the cells correspond to the T helper/inducer lymphocyte subset. Thus, involvement of different T lymphocyte subsets may be the reason for the clinical variation in T CLL.     

Stereological Studies on Chronic Lymphocytic Leukaemia and Hairy Cell Leukaemia

Using stereological techniques at the ultrastructural level, 7 quantitative parameters for 7 patients with hairy cell leukaemia, 27 patients with chronic lymphocytic leukaemia, and 8 normal individuals. These quantitative data show clear differences between normal lymphocytes, CLL cells and the abnormal cells of HCL. They also show that it may be possible to subdivide CLL into distinct groups on quantitative criteria.     

Heat Production by Lymphocytes in Chronic Lymphocytic Leukaemia

Using microcalorimeters of the thermopile conduction type heat production was measured in lymphocytes from peripheral blood in 8 normals and 10 patients with chronic lymphocytic leukaemia (CLL). The heat production per CLL lymphocyte was lower (1. 8 pW/cell) than that found in normal lymphocytes (2. 6 pW/cell). Due to the high numbers of lymphocytes in the peripheral blood the estimated heat production of the intravascular lymphocyte pool in CLL was considerably higher than in normals. Since the circulating lymphocytes constitute a minute fraction of the total lymphoid mass in CLL it is suggested that the accumulation of metabolically active lymphocytes in blood and tissues may explain the common clinical signs of hypermetabolism in this disease. The results also indicate that calorimetry may be a useful technique for metabolic studies in suspensions of malignant cells.     

Nephrotic Syndrome Associated with Chronic Lymphocytic Leukaemia

The simultaneous presentation of B-cell chronic lymphocytic leukaemia and nephrotic syndrome is described. The leukaemia responded to cytotoxic therapy but prednisolone was required to achieve remission of the nephrotic syndrome. The nephrotic syndrome relapsed when the leukaemia again became active and the white cell count rose above 20 × 10 9 /l, and it remitted again with treatment. The relationship between the two diseases is discussed.     

3H-Thymidine Uptake in Chronic Lymphocytic Leukaemia Cells

The clinical variability of chronic lymphocytic leukaemia (CLL) is well known. The short and long term prognosis is usually difficult to predict in the individual case. In the present work the proliferative activity in peripheral CLL cells of 38 patients was analysed by ³H-thymidine uptake and a proliferative index (PI = labelling index × white blood cell count/l × 10⁻⁹) was calculated. A strong correlation between PI and clinical disease activity was found. Thus 22 out of 23 patients with non-progressive disease had normal values (PI < 10). 8 out of 8 cases with PI > 20 had a clear disease progression in all blood variables. The PI interval 10–20 comprised both patients with progressive and patients with non-progressive disease. Variations in PI correlated well to variations in clinical disease activity in 8 patients examined at intervals during long term treatment. The results indicate that determination of PI might be used as therapy guide since it was normalized during successful treatment.     

Thymus with B Lymphocytes in Chronic Lymphocytic Leukaemia

Summary: Thymus with B lymphocytes in chronic lymphocytic leukaemia.
A 67-year-old man with a diagnosis of chronic lymphocytic leukaemia died suddenly following a coronary occlusion. Peripheral blood lymphocytes labelled with fluorescein conjugated polyvalent antisera to immunoglobulin and immunoglobulin G, and failed to label with absorbed anti-thymocyte serum. At necropsy, a large thymic tumour, and enlarged mediastinal lymph nodes also contained immunoglobulin G bearing B lymphocytes. The paradoxical finding of B lymphocytes with monoclonal surface immunoglobulin in a thymic mass is most unusual in chronic lymphocytic leukaemia.     

B Cell Leukaemia Distinguished from Chronic Lymphocytic Leukaemia by Surface Markers

Summary: Four cases of lymphocytic leukaemia were distinguished from CLL by surface marker analysis. CLL cells have relatively little Slg and have the mouse erythrocyte receptor. Cells in these cases had denser Slg and lacked the mouse erythrocyte receptor.
The group presented a fairly uniform picture with onset in sixth or seventh decade, very high lymphocyte counts, splenomegaly (gross in three), heavy infiltration of marrow, relative resistance to chemotherapy and response to splenectomy. The lymphocytes were somewhat larger than those usually found in CLL and histological examination showed a quasi-nodular pattern in lymph nodes with diffuse infiltration of the spleen. Difficulties of classification are discussed.
The addition of surface marker analysis to clinical and morphological parameters allows these cases of B-lymphocytic leukaemia (mouse erythrocyte-negative B leukaemia) to be distinguished clearly from chronic lymphocytic leukaemia. The mouse erythrocyte receptor is particularly useful in making this distinction.     

B Cell Leukaemia Distinguished from Chronic Lymphocytic Leukaemia by Surface Markers

Summary: B cell leukaemia distinguished from chronic lymphocytic leukaemia by surface markers. I. J. Forbes, P. D. Zalewski, A. S. Y. Leong, R. E. Sage, B. Dale and P. A. Cowled, Aust. N.Z. J. Med. , 1978, 8, pp. 532–538.
Four cases of lymphocytic leukaemia were distinguished from CLL by surface marker analysis. CLL cells have relatively little Slg and have the mouse erythrocyte receptor. Cells in these cases had denser Slg and lacked the mouse erythrocyte receptor.
The group presented a fairly uniform picture with onset in sixth or seventh decade, very high lymphocyte counts, splenomegaly (gross in three), heavy infiltration of marrow, relative resistance to chemotherapy and response to splenectomy. The lymphocytes were somewhat larger than those usually found in CLL and histological examination showed a quasi-nodular pattern in lymph nodes with diffuse infiltration of the spleen. Difficulties of classification are discussed.
The addition of surface marker analysis to clinical and morphological parameters allows these cases of B-lymphocytic leukaemia (mouse erythrocyte-negative B leukaemia) to be distinguished clearly from chronic lymphocytic leukaemia. The mouse erythrocyte receptor is particularly useful in making this distinction.     

Increase in Ty Lymphocytes in B-Cell Chronic Lymphocytic Leukaemia

S ummary . The proportion of Tγ and Tμ lymphocytes was studied in 40 cases of B-chronic lymphocytic leukaemia (B-CLL) and six of B-prolymphocytic leukaemia (B-PLL). The significant increase in Ty cells, previously reported in two small B-CLL series, was confirmed and shown to be directly correlated with the clinical stages of the disease (P < 0.01 to < 0.001). The normal Tμ: Tγ ratio (2.3:1) was reversed in B-CLL (1:1.4) and B-PLL (1:1.9). The proportion of Tμ cells was decreased but was not related to stage.
Our findings suggest that the increase in Ty cells may be responsible for the hypogammaglobulinaemia of B-CLL. This is supported by two sets of observations. First, serum Ig levels were more often normal in cases in Stages 0 and 1 than in Stages II-IV (P < 0.05), while the levels of two or three Ig classes were below normal in Stages II-IV twice as frequently. Secondly, splenic irradiation in one case was followed by a fall in the absolute number of Ty lymphocytes, a reversion to normal of the TμW: Tγ ratio and an improvement in serum Ig levels. Thus, the imbalance in the regulatory T-cell subsets may provide an important clue to understand the pathogenic mechanism of the immunodeficiency in the chronic B-cell leukaemias.     

Extra Chromosome 12 and Prognosis in Chronic Lymphocytic Leukaemia

Peripheral blood lymphocytes from 22 consecutive patients with chronic lymphocytic leukaemia were stimulated with the polyclonal B-cell mitogens lipopolysaccharide from E. coli (LPS) and Epstein-Barr virus (EBV). Stimulation was successful for chromosome analysis in 14 patients. Eleven patients had chromosomal aberrations and 7 of these had an extra chromosome 12. In 2 patients an extra chromosome 12 was the only abnormality, while additional aberrations were found in 5 patients. 3 patients had complex aberrations involving deletion of chromosome 6. 1 of these patients also had a translocation between chromosomes 12 and 14. 1 patient had a translocation between chromosomes 11 and 14. In 3 patients no aberrations were detected. The time elapsing between diagnosis and appearance of clinical symptoms which were indications for treatment was significantly shorter in patients with an extra chromosome 12 than in those without this abnormality. Thus, it appears that an extra chromosome 12 is associated with a more rapid course of the disease, and may therefore be of importance for the prediction of prognosis.