Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma (CLL/SLL) Management

Introduction to CLL/SLL

• CLL/SLL typically presents in the sixth or seventh decade of life, with a median age of 72, according to the National Comprehensive Cancer Network 1
• The National Comprehensive Cancer Network recommends considering a CT scan of chest, abdomen, and pelvis if lymphadenopathy or other concerning features for lymphoma are present, and PET-CT for patients with high suspicion of malignancy 2, 3, 4
• Age >40 years with risk factors for malignancy is a concern for malignancy, as suggested by the American College of Radiology 4

Clinical Presentation and Differential Diagnosis

• Night sweats can be caused by a wide range of conditions, including tuberculosis, lymphoma, and other malignancies, Q fever, fungal infections, neuroendocrine tumors, hypoglycemia, inflammatory bowel disease, and gastroesophageal reflux disease (GERD), as reported by the Centers for Disease Control and Prevention, the American Thoracic Society, and the Infectious Diseases Society of America 5, 6, 7, 8, 9, 10, 11, 12
• Tuberculosis and lymphoma, particularly Hodgkin lymphoma, are characterized by night sweats as part of their clinical presentation, according to the National Comprehensive Cancer Network, the American College of Radiology, and the European Society for Medical Oncology 2, 3, 13, 14

Initial Evaluation and Laboratory Testing

• Initial laboratory testing should include complete blood count (CBC), thyroid-stimulating hormone (TSH), comprehensive metabolic panel, and ferritin levels, as recommended by the American Geriatrics Society 15
• A comprehensive metabolic panel should include electrolytes, liver function tests, renal function tests, and glucose levels, and initial laboratory testing should also include erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP), HIV testing, tuberculosis testing (PPD or interferon-gamma release assay), and chest radiography, as recommended by the European Urology guidelines and the American Thoracic Society 5, 15, 16, 7
• Electrolytes/renal function tests and urine albumin:creatinine ratio can help identify renal or endocrine disease and potential indicator of chronic kidney disease, respectively 16

Sleep Evaluation and Diagnosis

• Polysomnography (PSG) is an overnight sleep study used to evaluate sleep architecture and identify sleep disorders, and Multiple Sleep Latency Test (MSLT) is a daytime test following PSG to measure sleep latency and identify narcolepsy, as recommended by the American Geriatrics Society 15, 17
• The Epworth Sleepiness Scale (ESS) score can be used to assess the risk of sleep disorders, with a score of 11 or greater indicating high risk and warranting referral for further sleep evaluation, and the following codes can be used to classify insomnia:

18, 19

• Sleep apnea and restless legs syndrome are sleep disorders that can be diagnosed through sleep study and laboratory testing, as recommended by the National Comprehensive Cancer Network 17

Comorbid Conditions and Sleep

• Congestive heart failure, hypertension, and coronary artery disease can disrupt sleep, with symptoms such as nocturnal dyspnea, orthopnea, and nocturnal angina, according to the American Academy of Sleep Medicine 18
• Asthma and COPD can disrupt sleep quality, with symptoms such as nocturnal coughing, wheezing, and dyspnea, and oxygen desaturations, as reported by the American Academy of Sleep Medicine 18
• Gastroesophageal reflux disease (GERD) and peptic ulcer disease can awaken patients with heartburn, coughing, and nocturnal pain, while inflammatory bowel disease can cause pain during flares, according to the American Academy of Sleep Medicine 18
• Depression, anxiety disorders, and post-traumatic stress disorder can cause sleep disturbances, as reported by the American Academy of Sleep Medicine 18

Medications and Sleep

• Antidepressants, stimulants, decongestants, pain medications, cardiovascular drugs, and respiratory medications can affect sleep, according to the American Academy of Sleep Medicine 18
• Alcohol, caffeine, and nicotine can disrupt sleep, as reported by the American Academy of Sleep Medicine 18

Treatment and Referral

• Treatment should be directed at the underlying cause, including appropriate anti-tuberculosis therapy for TB, referral to oncology for malignancies, and acid suppression for GERD, as recommended by the American Academy of Sleep Medicine and the European Urology guidelines 18, 12
• Referral to a sleep specialist should be considered if initial workup is negative and symptoms persist, especially if the ESS score indicates high risk for sleep disorders, as recommended by the American Academy of Sleep Medicine 18