A 61-year-old man with small lymphocytic lymphoma–chronic lymphocytic leukemia presented with neck stiffness and bilateral axillary discomfort associated with increasing, diffuse lymphadenopathy. He had received the diagnosis of small lymphocytic lymphoma–chronic lymphocytic leukemia in 1999 and over subsequent years underwent multiple chemotherapy regimens, with partial disease control. At the time of presentation, physical examination revealed massive adenopathy involving the neck, from the level of the mastoid to the supraclavicular fossa (Panel A, arrow), and large nodal masses (9 cm in diameter) in both axillae (Panel B, arrow). A computed tomographic scan of the chest, abdomen, and pelvis confirmed the findings on examination and revealed progressive supraclavicular, axillary, mediastinal, abdominal, retroperitoneal, and pelvic lymphadenopathy. Over the course of five treatments, the patient received a total of 10 Gy of external-beam radiotherapy to the mediastinum, neck, and axillae with a mantle field. He had a good partial response and resolution of axillary discomfort.
Catherine S. Kim, M.D., and Maria Werner-Wasik, M.D.
N Engl J Med 2008; 359:1602October 9, 2008DOI: 10.1056/NEJMicm071065

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