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Chronic lymphocytic leukemia

Chronic lymphocytic leukemia
Chronic lymphocytic leukemia is one of the types of blood cancer that develop when immature white blood cells known as lymphocytes change and start growing out of control. Chronic lymphocytic leukemia (CLL) is sometimes called chronic lymphatic leukemia. The term “Chronic’’ simply means leukemia progresses slowly over time and normally people with this type of leukemia don’t show any symptoms for at least a few years. By that time, cancer cells can spread to other parts of the body, including the liver, spleen and lymph nodes. To understand well about leukemia, it is important for one to have knowledge on blood first.

Chronic lymphocytic leukemia
Blood is a fluid flowing in our bodies and it is the one that usually conveys nutrients and oxygen. In the body blood is carried in specified tubes known as vessels (veins and arteries). Blood is pumped around the body by a muscular organ called heart. Blood is made up of cells carried in a clear fluid called plasma. Blood cells are mainly of three types, red blood cells, white blood cells and platelets.
• Red blood cells. These carry oxygen around the body
• White blood cells. These are responsible for fighting infections
• Platelets. These helps in blood clotting.
All these blood cell types have a limited life span, hence they are continuously replaced. Most are made in the bone marrow, which is the spongy part in the center of the bones such as the skull, ribs, hip bones, shoulder blades and backbones (vertebrae). Since leukemia is a blood cancer that mainly involves white blood cells, it is important to have a bit more knowledge on white blood cells.

Types of white blood cells
• Lymphocytes. These are the cells responsible for fighting infections and they develop from stem cells known as lymphoblast. Lymphocytes are the cells that mainly make up lymphoid tissues, which are the major part of the immune system. The two main types of lymphocytes are;
• B- Cell lymphocytes. These cells make antibodies that fight germs and other infections. These are also called B-Cells.
• T-Cell lymphocytes. These are responsible for destroying germs and they also trigger B-cell lymphocytes to produce antibodies
• Granulocytes. These are mature cells that are responsible for fighting infections. These cells develop from myeloblasts. They are known as granulocytes because they have granules that show up as spots under the microscope. Types of white blood cells known as granulocytes include; neutrophils, eosinophils and basophils. These three differ in color and size of granules.
• Monocytes. These develop from blood-forming monoblasts in the bone marrow. After sometime in the blood stream, monocytes will enter body tissues to become macrophages. Macrophages destroy germs but also they help lymphocytes recognize germs.

About leukemia
Leukemia is a term used to describe blood cancer. Leukemia originates from the term leucocytes meaning white blood cells. Leukemia begins in the bone marrow, the spongy part in the center of the bone where blood cells are produced.
Bone marrow contains stem cells. These are unspecialized blood cells that first develop into immature cells known as blast cells. Normally, the blast cells then become mature red or white blood cells or platelets and carry out their set functions but if the blasts fail to mature properly or if they are too many in the blood, it may result to leukemia. There are two types of stem cells;
• Myeloid stem cells. This develop into myeloblast cells that further develop to form red blood cells, platelets and most forms of white blood cells.
• Lymphoid stem cells. This develop into lymphoblast cells which then becomes lymphocytes which are type of white blood cells.
Following failure to mature properly into normal blood cells, myeloblast cells will result into development of type of leukemia known as myeloid leukemia while lymphoblast cells will result into lymphoblastic leukemia.
In leukemia, abnormal white blood cells grow out of control and multiply in such a way that they crowd the bone marrow. This affects bone marrow’s ability to produce normal levels of other blood cells, hence affecting the way the rest of the body work.
As leukemia progresses, more abnormal blood cells and fewer normal blood cells are produced in the marrow. Those abnormal cells in the marrow will spill out into the blood stream and build up in the blood, which may result into spread to other parts of the body such as lymph nodes, lungs, liver, spleen and kidneys
In this section the discussion will base on chronic lymphocytic leukemia (CLL), which is one of the main two type`s lymphocytic (lymphoblastic) leukemia. Lymphocytic leukemia is divided into acute and chronic lymphocytic leukemia. Acute means the disease progress quickly and can be fatal within few months if not treated while chronic is the vice versa. Both types develop from immature lymphocytes.
In addition to lymphocytic leukemia, another type of cancer that start in lymphocytes is known as lymphoma (Hodgkin or Non-Hodgkin lymphomas). The main difference between these types of cancer is that leukemia, mainly affects the bone marrow and the blood while Lymphomas mainly affect the lymph nodes although sometimes it may involve the bone marrow.
Sometimes during diagnosis cancer cells can be found in both bone marrow and lymph nodes. In cases like these it becomes a bit trick to tell if cancer is leukemia or lymphoma but to differentiate the two, doctors consider number of lymphocytes in the bone marrow and lymph nodes. If bone marrow and blood has large number of those cells (lymphocytosis), then it is leukemia but if nodes have more cells it is lymphoma (small lymphocytic lymphoma). Small lymphocytic lymphoma behaves very similarly to CLL and is treated in the same way as CLL.

Risk factors of chronic lymphocytic leukemia
When dealing with cancer, anything that increases your probability of developing cancer is called a risk factor. Risk factor only influence development of cancer but it does not directly cause cancer. Sometimes people with risk factors do not develop the disease while those with no risk factors do develop the disease. Knowing risk factors will help you live your life making some better healthy choices to reduce the risk. The risk factors for chronic lymphocytic leukemia (CLL) include the following;
• Age. Statistically, chronic lymphocytic leukemia is most common among older adults and less common among young adults and hardly ever develops in children.
• Gender. Statistics indicate that, number of men who develop this disease is slightly higher than women.
• Family history. Those in families with family history of this disease in one of their close relative such as father, siblings or children are said to be at slightly increased risk of developing this disease.
• Chemical exposure. Some studies suggest that, exposure to some chemicals like those in some pesticides can increase your chance of developing CLL. For example some studies have linked exposure to Agent Orange, an herbicide used during theVietnam War.

Prevention of chronic lymphocytic leukemia
To prevent something, you first need to know what causes it. But since the specific cause of chronic lymphocytic leukemia is still unknown, there is no way of completely preventing the development of this cancer.
In addition to that, the risk of developing many other cancers can be reduced with factors like lifestyle changes and others, but there are few known risk factors for this disease and most of them cannot be changed so preventing this disease becomes even more difficult.
Early detection and screening of chronic lymphocytic leukemia
When it comes to cancer, early detection normally provide better treatment outcome. When chronic lymphocytic leukemia (CLL) is found early, chances for better treatment outcome are very high. For most cancers, early detection has been greatly contributed by the presence of screening processes.
Screening is the process of running some tests to someone with no symptoms of the disease with the intention of determining presence or absence of the disease. Unfortunately, currently there are no widely recommended screening tests for chronic lymphocytic leukemia. The best way to detect this cancer while it is still at early stage is to see the doctor immediately upon experiencing any possible signs and symptoms of leukemia.

Signs and symptoms of chronic lymphocytic leukemia
Many people with chronic lymphocytic leukemia have no symptoms. Often the disease is discovered when a routine blood test shows a high white blood cell count. Even when they start experiencing symptoms, they are often mild but gets worse as time goes. Sometimes those symptoms may be caused by other medical conditions. Among the common signs and symptoms of CLL include the following;
• Fatigue
• Frequent and persistent infections
• Easily bruised and excessive bleeding
• Painless swelling of lymph nodes under armpits, neck and groin region.
• Enlarged spleen
• Feeling full even after a very small amount of meal
• Fever
• Unexplained weight loss
• Excessive night sweats

Diagnosis of chronic lymphocytic leukemia
Following suspicion of chronic lymphocytic leukemia, various tests are used to verify the suspicion, learn if the disease has spread to other organs of the body and some tests will help to determine prognosis of the disease. When running those diagnostic tests, the doctor will consider some of the factors including;
• Results of the previous tests
• General health condition
• Type of cancer suspected
The following are some of the diagnostic tests for chronic lymphocytic leukemia (CLL) although not everyone will need to go through all those tests during diagnosis.
• Medical history and physical examination. The doctor will review patient`s history for risk factors but also do some physical examinations to check if there is any enlarged lymph nodes (lymphadenopathy) and abdominal swelling which can be a result of enlarged liver (hepatomegaly) and spleen (spleenomegaly).
• Blood tests. Blood samples will be taken and checked in the laboratory for full blood count (FBC). The results will reveal whether the levels of blood cells are normal or not. Blood sample may also be used to find if the blood cells are normal or abnormal (leukemia cells).
• Bone marrow tests. If the blood test shows abnormalities in the number or appearance of the white blood cells, the doctor may take some bone marrow sample to check for signs of leukemia. There are two main procedures used in taking bone marrow samples for testing;
• Bone marrow aspiration. This involves the removal of a fluid sample by using a needle (fluid part of bone marrow).
• Bone marrow biopsy. This involves the removal of a small amount of solid tissue using a needle.
If the results from blood tests suggest presence of leukemia, bone marrow tests are advised to be done at the hospital where treatment will be given so as not to do these tests twice.
• Flow cytometry and cytochemistry. Flow cytometry is also known as immunophenotyping. It is one of the tests used in confirming CLL. By using blood sample, chemicals are applied to check for presence of specific surface proteins (markers) on cancer cells in the laboratory. This test also helps to distinguish CLL from other types of leukemia.
• Genetic tests. These include molecular tests and cytogenetics. Genetic makeup of cancer cells is different to that of normal cells as cancer cells have some faults to their genetic makeup. The study of those gene changes is called cytogenetics or molecular tests. Cytogenetic tests are usually done on cells from your blood or bone marrow, before treatment starts.
• Imaging tests.Imaging tests like CT scan, MRI scan, chest X-ray and PET scan are used to determine if the disease has spread to other structures of the body such as lymph nodes, liver and spleen.

Treatment of chronic lymphocytic leukemia
Following cancer diagnosis, the doctor will break the news and it is normally not very easy to accept that it is cancer. The doctor will be there to help the patient process the news and to help the patient in taking the next steps.
After the patient receives and processes the news that he/she has cancer, one of the most important steps that will follow is decision making. The doctor will present to the patient (relatives/parents/guardians) with all the possible treatment options and explain what they mean. Then with the help of the doctor, the patient (relatives/parents/guardian) will have to choose which treatment option is good depending on benefits of such option.
Despite all the information given by the doctor, sometimes the patient may still be unsatisfied with what he/she has been told. In such situation, the patient is free and advised to seek a second opinion. Second opinion is the opinion that the patient may seek from another specialist (doctor) regarding his/her health problem and in this case it is cancer. Second opinion may include confirmation of the diagnosis, more clarification on your primary doctor recommendations or even reassurances that all the options have been explored.
In addition to standard care treatment options, sometimes there are those new treatments or drugs or combination of treatments that have not been approved yet to be used as standard care treatments for a particular cancer (disease) but have shown some promising results that they may help. These type of treatments are called clinical trials.
If there are some clinical trials for your case, the doctor may present to the patient or the patient may ask if there are any clinical trials for the particular cancer case. Over the years, have improved treatments and led to better outcomes to people diagnosed with various diseases including cancer. If you have decided to take part in clinical trial, you can also withdraw at any time

Treatment options
Treatment of CLL requires a team of doctors and other health care professionals. This team work together and it is called multidisciplinary team. Team may vary depending on the treatment option for a particular case. But generally multidisciplinary team for treatment of CLL includes hematologist, medical oncologist, radiation oncologist, surgical oncologist and other health care professionals like oncology nurses and palliative care team. Treatment options include the following;

Watchful waiting
This is an option used for those early staged cases of CLL. In such cases,doctors normally recommend no treatment but close monitoring of your progress through regular check-ups and tests. If the CLL shows signs of worsening, active treatment would then begin immediately. Studies have shown that no harm comes from this approachcompared with immediate treatment for early-stage CLL. Because of lacking any symptoms of the disease for years,some patients will never need any treatment. However, because of lowered immunity as a result of CLL, your body could be prone to other health problems like flu and others hence, you need to talk to your doctor about any possible symptoms to watch out for, and get treatment as soon as possible if you experience them. Your doctor may also recommend an annual flu vaccination.

Chemotherapy is an option that involves the use of drugs to destroy cancer cells or slow its growth. It is given by a specialized doctor known as medical oncologist or hematologist. Chemotherapy is normally given through injection into veins (intravenously) and rarely swallowed as pill or capsule.
A chemotherapy schedule, usually consists of number of cycles given over a setperiod of time. Patients with CLL receive several different drugs throughout their treatment.

Side effects of chemotherapy
Side effects of chemotherapy depend on type of drug used, dose given and periodic time by which the drug has been used. Some of the possible side effects of chemotherapy include the following;
• Loss of hair
• Fatigue
• Mouth sores
• Nausea and/or vomiting
• Diarrhea
• Risk of infections
• Easily bruised and bleeding

Targeted therapy
Targeted therapy is an option that involve targeting specific molecules in the cancer cells using drugs. The drug will stop the growth and spread of cancer cells and at the same time limit harm to normal cells. Drugs for this kind of treatment work differently to that of normal chemotherapy drugs. Drugs for this treatment option can sometimes help even when chemo isn’t, but they can also be used along with normal chemotherapy to help it work better. Some of the targeted therapy drugs used in treatment of CLL include Rituximab and Obinutuzumab. These two drugs are taken as pill once a day.

Side effects of targeted therapy
Some of the possible side effects of targeted therapy include the following;
• Nausea and/or vomiting
• Mouth sores
• Muscle or bone pain
• Increased risk of infection
• Upper respiratory infection
• High blood sugar level
• Increased level of bilirubin
• Loss of appetite
• Diarrhea
• Bruising

Radiation therapy
Radiation therapy is an option that involves the use of high energy x-rays or other radiation particles to destroy cancer cells. It is a treatment given by a specialized doctor known as radiation oncologist. Between the two types of radiation therapy, external beam radiation therapy is the one that is used for management of CLL. It is used to shrink enlarged organs such as spleen and lymph nodes as a result of CLL.
The treatment is usually given as multiple small doses over several days or weeks to maximize the effect of the radiotherapy and reduce side effects. Radiation therapy is also sometimes given to the whole body (total body irradiation) before stem cell transplant. The aim of giving radiation therapy before transplantation is to kill remaining cancer cells in the bone marrow and also weakening body immunity to prevent rejection of transplanted cells

Side effects of radiation therapy
Side effects of radiation therapy will depend on the site of treatment and dose of radiations given. Some of the possible side effects of radiation therapy include the following;
• Mild skin reactions
• Loss of hair
• Feeling tired
• Upset stomach
• Loose bowel movement

Stem cell transplantation
Stem cell transplantation is a treatment option that involve replacing a patient`s bone marrow by highly specialized cells called hematopoietic stem cells. Bone marrow that contain cancer cells is destroyed first by using high dose of chemotherapy or radiation therapy, then replaced by healthy stem cells.
This treatment option is sometimes known as bone marrow transplantation. These cells will mature into heathy bone marrow. Hematopoietic stem cells are blood forming cells in the bone marrow.
A transplant is normally done in several stages and the entire procedure, including recovery, can take months. There are two types of stem cell transplantation;
• Autologous stem cell transplantation. This type uses stem cells that were previously removed from your blood stream and later are transplanted (reinfused) back into your body.
• Allogeneic transplantation. This involve the use of stem cells taken from another person (donor). The donor may be a family member or from a donor registry.
When dealing with CLL, allogenic stem cell transplantation is normally used. Stem cell transplantation is also sometimes used to younger patients when the standard treatment options have failed or when there is high possibility for CLL to return.

Side effects of stem cell transplantation
Most of the side effects of this treatment option resemble to those of chemotherapy but with this treatment options the side effects may be a little bit severe. Those possible side effects of stem cell transplantation include the following;
• Nausea and vomiting
• Hair loss
• Risk of infection
• Easily bruising and bleeding
• Fatigue.
Surgery is an option that involves removing the organ or part of the organ by operation. It is done by a specialized doctor known as surgical oncologist. When dealing with CLL, surgery is recommended occasionally to remove the spleen which has been affected due to CLL. This kind of surgery is called spleenectomy. Your doctor will give you more information about this option.

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