case_images: PMC6050796_01
case_images: Peripheral blood smear showing 3 medium to large prolymphocytes with moderate
  basophilic cytoplasm, indented nuclei, and prominent vesicular nucleoli.
  These prolymphocytes account for >55% of the circulating cells.
case_images: 10.1177_2324709618788674-fig1.jpg
case_images: PMC6050796_01_10.1177_2324709618788674-fig1.jpg
case_images: fig1-2324709618788674
case_images: The peripheral smear showed abundant prolymphocytes (Figure 1).
case_images: Bone marrow biopsy shows a marrow diffusely infiltrated by predominantly
  CD20-positive B-lymphocytes accounting for about 50% of marrow cellularity.
  B- and T-lymphocyte ratio is estimated to be 2:1. The infiltration is
  interstitial and with focal micronodularity.
case_images: 10.1177_2324709618788674-fig2.jpg
case_images: PMC6050796_01_10.1177_2324709618788674-fig2.jpg
case_images: fig2-2324709618788674
case_images: These lymphocytes accounted for about 50% of marrow cellularity, with B- and T-lymphocyte ratio estimated to be 2:1 (Figure 2).
case_images: Positron emission tomography/computed tomography at the time of diagnosis and
  prior to the initiation of treatment. The spleen is massively enlarged,
  measuring 29.2 x 11.4 x 11.7 cm. There is homogeneous density and
  homogeneous FDG activity similar to the liver with a maximum SUV of 2.6.
case_images: 10.1177_2324709618788674-fig3.jpg
case_images: PMC6050796_01_10.1177_2324709618788674-fig3.jpg
case_images: fig3-2324709618788674
case_images: A positron emission tomography (PET) scan revealed the spleen to be massively enlarged measuring 29 x 12 x 8 cm with significant mass effect on the intra-abdominal contents, with displacement of the left kidney to the midline and compression of the colonic splenic flexure (Figure 3).
case_images: PMC6050796_02
case_images: Positron emission tomography/computed tomography showing disease progression
  after treatment with rituximab and bendamustine. The study was done prior to
  her initial treatment with obinutuzumab and chlorambucil. There is interval
  development of bilateral cervical, mediastinal, and periportal adenopathy.
  The spleen is massively enlarged measuring 29 x 12 x 8 cm. There is diffuse
  increased uptake within the spleen with maximum SUV being 3.2.
case_images: 10.1177_2324709618788674-fig4.jpg
case_images: PMC6050796_02_10.1177_2324709618788674-fig4.jpg
case_images: fig4-2324709618788674
case_images: She also developed bilateral pleural effusions (Figure 4).
case_images: Positron emission tomography/computed tomography after 4 cycles of treatment
  with obinutuzumab and chlorambucil. The spleen is decreased in size compared
  with prior study, now measuring approximately 18.5 x 10.0 x 7.3 cm and
  decreased in uptake with maximum SUV now measuring 1.9, which is slightly
  above blood pool and less than liver uptake.
case_images: 10.1177_2324709618788674-fig5.jpg
case_images: PMC6050796_02_10.1177_2324709618788674-fig5.jpg
case_images: fig5-2324709618788674
case_images: A repeat posttreatment PET scan showed a decreased spleen size, which measured approximately 18.5 x 10.0 x 7.3 cm, and her lymphadenopathy and pleural effusions had resolved (Figure 5).