July 20, 2020

Jeff Sharman, MD, reviews a case of a 79-year-old man with relapsed chronic lymphocytic leukemia.

Case: A 79-Year-Old Man With Relapsed Chronic Lymphocytic Leukemia

Initial presentation

  • A 79-year-old man presented to a new medical oncologist for the first time complaining of vague intermitted abdominal pain, and progressive fatigue
  • PMH:
    • Hypertension, medically controlled
    • MI, 8 years ago, on 81 mg aspirin
    • CLL, diagnosed 7 years ago
    • After a period of watchful waiting he began treatment with ibrutinib 420 mg PO qDay; symptoms improved and achieved stable disease, resolution of lymphadenopathy
    • After 5 years of disease control on ibrutinib he complained of increasing fatigue and decreased appetite, on physical exam there was return of palpable lymphadenopathy; spleen was palpable ~4 cm below costal margin
    • He was started on rituximab
    • Currently after 6 months on rituximab monotherapy he presents to the clinic
  • PE: palpable bilateral cervical and right-sided inguinal lymphadenopathy

Clinical workup

  • Labs: WBC 55,000, lymphocyte 82%, ANC 3100/mm3, Hb 9.4 g/dL, plt 90 x 109/L, LDH 220 U/L, Beta-2-microglobulin 3.9 mg/L; creatinine clearance 31 mL/min
  • FC CD 5+, CD19+, CD20+ monoclonal B-cell population
  • FISH: CLL probe set tested, deletion 17p
  • IgHV mutational status: unmutated
  • Rai stage IV; ECOG PS 1
  • Treatment of idelalisib 150 mg PO BID was added to rituximab