A 67-year-old White man presents to his primary care physician with reports of fatigue, persistent fever, night sweats, and a 15-lb weight loss in the past 3 months. He also reports abdominal discomfort and bloating, especially when he eats (he reports feeling full very quickly during meals), as well as pain in the upper left abdomen that correlates to pain in his left shoulder. He also describes diminished function in his everyday life over the past several months, often needing help to complete daily tasks.

The patient has a history of poorly controlled hypertension, hyperlipidemia, and diabetes. After multiple switches of regimen to improve adherence, all of these are now controlled pharmacologically. He had a transient ischemic attack and carotid endarterectomy at age 58 years, with no additional incidences.

Physical exam reveals abdominal distention, lymphadenopathy in the cervical and inguinal nodes, with slight adenopathy in the axilla as well as slight hepatomegaly. The patient appears pale and tired. He has significant splenomegaly; the spleen is palpable deep into the abdomen and extends into the pelvis.

Initial laboratory testing reveals these values: complete blood count reveals lymphocytosis (4,500/µL), elevated lactate dehydrogenase (650 U/L), aspartate aminotransferase (40 U/L), alanine transaminase (60 U/L) and beta 2–microglobulin (3.0 mg/L). Gamma globulin levels are normal, and Coombs test is negative.

The patient's Performance Status score is 2.