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A 62-year-old man presents with fatigue, drenching night sweats for 6 weeks, and 8 kg weight loss over 3 months. Examination reveals rubbery cervical, axillary and inguinal lymphadenopathy (each nodal area under 2 cm) and spleen palpable 4 cm below the costal margin. Full blood count: Hb 95 g/L, WBC 78×10⁹/L (85 percent lymphocytes), platelets 95×10⁹/L. Blood film shows numerous smudge cells. LDH is mildly raised; direct Coombs test is negative.
Questions
a) Diagnosis and rationale? (2 marks) State the most likely diagnosis and the two film/immunophenotype findings that confirm it (lymphocytosis over 5×10⁹/L with smudge cells; CD5+ CD19+ CD23+ B-cell with dim CD20 on flow cytometry).
b) Stage this patient (3 marks) Stage using BOTH the modified Rai system (High — stage IV: lymphocytosis plus thrombocytopenia platelets under 100) AND the Binet system (Binet C: 3+ lymphoid areas plus Hb below 10 g/dL or platelets under 100). State which findings count and which do NOT (autoimmune cytopenia does not count toward Binet C).
c) List the iwCLL 2018 indications for treatment (3 marks) Progressive marrow failure (Hb under 10 or Plt under 100); massive/progressive/symptomatic splenomegaly or lymphadenopathy; lymphocyte doubling time under 6 months; refractory autoimmune cytopenia; B-symptoms (weight loss at least 10 percent in 6 months, fever at least 38°C for at least 2 weeks, night sweats for at least 1 month).
d) First-line management and complications (2 marks) State a first-line regimen and the key complication to exclude at treatment initiation (tumour lysis syndrome prophylaxis with rasburicase/hydration). Identify two high-yield late complications (Richter transformation to DLBCL; recurrent infection from hypogammaglobulinaemia).