216 The Lymphocyte and Lymphocytic Tissue 



revealed mild (1 cm.) generalized lymphadenopathy but no splenomegaly. 

 The red blood cell count was 4.3 million, reticulocytes were 2 per cent, and 

 at least 90 per cent of the 104,000 white cells were small lymphocytes. In 

 June, 1953, she inadvertently received one dose of 3 inc. of radiophosphorus, 

 lowering her white blood cell count from 112,000 to 60,000 without any 

 other change in her clinical status. She continued asymptomatic until June, 

 1956, when she had an episode of cellulitis involving her left foot. Her 

 hemoglobin was 13.7 and the white blood cell count 214,000. From August, 

 1956, to date, she has received Gantrisin for chronic cystitis. In May, 1958, 

 she had carious teeth removed without incident. She developed an asympto- 

 matic anemia with a hematocrit of 34 per cent for the first time in October, 

 1958, when she was admitted with phlebitis. Her white blood cell count was 

 237.000, and there was a slight thrombopenia. The spleen was enlarged 4 

 cm. below the costal margin and the liver 2 cm. below the costal margin. 



Figure 17-6 is from a marrow biopsy obtained in October, 1958, showing 

 the dense, diffuse, small lymphocytic metaplasia characteristic of most of 

 the tissue in the biopsy. There were isolated myeloid cells (Fig. 17-6C), 

 obviously enough to produce almost a normal number of red cells, granulo- 

 cytes, and platelets. 



Case 7 is an example of a more fulminating course. The patient was 58 

 years of age in January, 1957, when he noted weight loss and generalized 

 lymphadenopathy. From February, 1957, to August, 1958, he was treated 

 intermittently with local x-ray therapy, transfusions, and chlorambucil, but 

 at no time did he ever improve enough to resume a gainful occupation, even 

 though his total white blood cell count was kept near normal. 



When first seen in August, 1958, the patient was pale, emaciated, febrile, 

 and dyspneic. He had generalized lymphadenopathy, slight hepatospleno- 

 megaly, a hemoglobin of 6.2 gm., and a white blood cell count of 6,600 with 

 100 per cent small lymphocytes. He was treated only by transfusions until 

 December, 1958, when his white blood cell count rose to 115,000. His con- 

 dition was unaltered in other respects. 



Figure 17-7 is from a surgical biopsy of the sternum resorted to after an 

 adequate specimen was not obtained by three needle biopsies. As in Case 

 6, (Fig. 17-6/4), there was an apparent replacement of the myeloid marrow by 

 dense sheets of small lymphocytes. However, unlike Case 6, higher power 

 magnification (Figs. 17-65 and C vs. 17-7 B) failed to reveal any myeloid 

 cells, suggesting a much poorer prognosis. Severe hemosiderosis, in part due 

 to prior transfusions, was noted. The patient failed to respond to prednisone, 

 nitrogen mustard, and final x-ray therapy and died in April, 1959. During 

 tlie last few months of his life, he had a positive direct Coombs test and 



