222 The Lymphocyte and Lymphocytic Tissue 



that in Case 5 (Fig. 17-5) has had a benign course, the reverse was not neces- 

 sarily true. There was really very little difference between the marrows of 

 Cases 6 (Fig. 17-6) and 7 (Fig. 17-7), even though in the former the marrow 

 was able to produce a fairly normal number of peripheral blood cells. In 

 contrast, the marrow in Case 7 was severely deficient, at least in erythro- 

 poietic capacity. Since there was only a moderate decrease in red cell sur- 

 vival, excess hemolysis was not the major factor in the severe anemia in this 

 patient. Patients with apparently marked replacement of myeloid tissue may 

 still have functionally adequate marrows (Fig. 17-6). Further, an extreme 

 degree of replacement of myeloid by lymphatic tissue has been found at 

 autopsy in patients who have had chronic lymphatic leukemia and have 

 died of an unrelated cause at a time when their hemoglobin level was fairly 

 normal. 46 



An example of the pitfalls encountered when one attempts to predict the 

 ability of a patient to form red cells on the basis of histopathologic examina- 

 tion of the marrow was illustrated by the case of an elderly woman present- 

 ing with symptoms of severe plethora. She had a hemoglobin level of 28 

 gm. and a corresponding elevation of red cell volume. Biopsies of her mar- 

 row, liver, and spleen failed to demonstrate that these tissues differed from 

 those of any patient with moderately advanced chronic lymphatic leukemia, 

 such as Case 6, except for absence of tissue iron. The latter, of course, repre- 

 sented a diversion of iron from tissue stores into the expanded hemoglobin 

 mass incident to the polycythemia. 02 



Evaluation of Histopathology of Tissues Other Than Marrow 



Only sporadic attempts have been made to take biopsies of other 

 organs. 9, 10, 13 Lymph node tissue has not provided a useful index of prog- 

 nosis or therapeutic response. Liver biopsies have not been a reliable index 

 to therapeutic response either because of the limitations in size of the biopsy 

 or because the liver is an unsatisfactory area for study. Similarly, spleen 

 biopsies have not proved especially useful. If the spleen, liver, or nodes were 

 filled with small lymphocytes and were not too fibrous, any type of cytocidal 

 therapy would reduce their size and concomitantly lower the white blood 

 cell count without necessarily inducing a remission in the sense defined in 

 this chapter. 1 "' In general, but not universally, in the cases in which treat- 

 ment had been effective, there has been a lesser degree of lymphocytic 

 proliferation and of architectural distortion in the liver and spleen (Fig. 

 17-8D) than in those in which treatment had been ineffective. 



Effect of Treatment on the Natural History 



It is apparent from a review of the response to therapy of patients with 

 chronic lymphatic leukemia that patients who have experienced the most 



