ONCAlert | 2018 ASCO Annual Meeting
Chronic Lymphocytic Leukemia Case Studies

Paul Barr, MD: Options to Prolong Survival

Paul Barr, MD
Published Online:Nov 02, 2015
James S is a 67-year old college professor from Ithaca, New York with a history of treatment for Agent Orange exposure

Relapsed and Refractory CLL with Javier Pinilla-lbarz, MD, PhD and Paul Barr, MD: Case 2

Relapsed and Refractory CLL with Javier Pinilla-lbarz, MD, PhD and Paul Barr, MD: Case 1
Relapsed and Refractory CLL with Javier Pinilla-lbarz, MD, PhD and Paul Barr, MD: Case 2
Relapsed and Refractory CLL with Javier Pinilla-lbarz, MD, PhD and Paul Barr, MD: Case 1
Relapsed and Refractory CLL with Javier Pinilla-lbarz, MD, PhD and Paul Barr, MD: Case 2
Relapsed and Refractory CLL with Javier Pinilla-lbarz, MD, PhD and Paul Barr, MD: Case 1
Relapsed and Refractory CLL with Javier Pinilla-lbarz, MD, PhD and Paul Barr, MD: Case 2

 

What options might you consider to prolong survival in this patient?

 

This patient is not that old but does have significant comorbidities and, as a result, has fewer treatment options available to him. We want to use our most effective agents, the ones that have provided an OS benefit.

 

One I mentioned previously, ibrutinib, in the Resonate trial did, where ibrutinib was compared to the anti-CD20 antibody ofatumumab. We did see an OS benefit for ibrutinib. Another option where we’ve seen an OS benefit is idelalisib plus rituximab. This was compared in a randomized trial to single-agent rituximab. In essence, patients with a short duration of remission and significant comorbidities having relapsed CLL were enrolled to either a, a course of idelalisib given twice a day plus rituximab, or placebo plus rituximab. Similar to the Resonate trial, we saw an improvement in PFS at a very early time point, but also an OS benefit for the doublet, the idelalisib-rituximab strategy.

Case 2: Relapsed and Refractory CLL

James S. is a 67-year-old college professor from Ithaca, New York; he is a Vietnam veteran with a history of treatment for Agent Orange exposure; his history is also notable for prior smoking (15-pack year) and mild COPD.

  • In November 2013, he presented to his PCP for a routine physical; his examination showed mild lymphadenopathy and his CBC showed evidence of lymphocytosis (lymphocytes 6 x 109/L); he was referred to an oncologist for further diagnostic evaluation.

  • Differential diagnosis showed B-cell CLL, with absolute lymphocytosis (19,000/mm3) and flow cytometry positive for CD5 and CD23.

  • Interphase cytogenetic analysis showed no deletion of 17p.

  • The oncologist initiates treatment with bendamustine/rituximab (BR) and James shows improvement in hematologic parameters after 6 cycles.

  • James was out of the country at a meeting, and he failed to return for a scheduled follow-up appointment in January 2015.

In March 2015, he presented to his oncologist with symptoms of unintentional weight loss over the past 2 months (>10%), severe fatigue (interfering with work), and dyspnea; his CBC is consistent with worsening anemia and thrombocytopenia.

  • CT scan shows evidence of extensive abdominal lymph node recurrence.

  • At the time of his recurrence, James’s ECOG performance status was 2, and liver and kidney functioning were within normal limits.

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