A 67-Year-Old Man with Chronic Lymphocytic Leukemia - Episode 1

Case Presentation: A 67-Year-Old Man with Chronic Lymphocytic Leukemia

John Allan, MD, presents and reviews the case of a 67-year-old man with chronic lymphocytic leukemia.

John Allan, MD: Welcome, everyone. Thank you for joining, I’m John Allan. I'm an assistant professor of medicine here at Weill Cornell Medicine, in New York City.

I'm a lymphoma physician. I have a specialization in CLL [chronic lymphocytic leukemia], and treating patients with CLL, and we'll be going through a case and I’ll be giving you my insights on my thoughts about the case and how I might manage the patient potentially differently or the same. I would like to start out by presenting the case so everyone is on the same page here.

This is a 67-year-old male with a diagnosis of chronic lymphocytic leukemia. He's presenting to his primary care physician with complaints of fatigue and night sweats. In terms of past medical history, he's relatively healthy, except that he takes an over-the-counter antacid every few days, a couple times a week, for a sensitive stomach.

On a physical exam, he has a large mobile lymph node, these are bilaterally, in the cervical chain. No palpable spleen or liver, palpable liver is noted. Laboratory findings are consistent with a white blood cell count of a 102,000, lymphocytes are 79,000 of those 102. Hemoglobin is slightly low but relatively OK, and preserved at 11.4 grams per deciliter. His platelets are normal at 180,000. His neutrophil count is normal at 1.9. His LDH [lactate dehydrogenase] is actually very elevated, at 1470. And cytogenetics are showing a chromosome 11q deletion and IgHV [immunoglobulin heavy chain] unmutated status.

I presume this was sent off not by the primary care, but by his hematologist. And a beta-2 macroglobulin was also obtained and that's 3.0, right on the threshold of being abnormal. He's staged as a Rai Stage I, and the patient initiated treatment, and was started on ibrutinib once daily.

John Allan, MD: So, this case is a somewhat common presentation that we see, especially with a patient with these molecular abnormalities. Average age diagnosis of patients as a reminder is about 70 to 71 years of age, so the patient is well within that nice bell-shaped curve. He was relatively healthy, feeling well, up until very recently when these symptoms started.

The disease has been progressive relatively quickly, and associated with these B symptoms with a very elevated white blood cell count, along with the fevers and night sweats. Also note is that the LDH is rather elevated. The high end of normal, at least in my lab, is around 230 or 220. This patient is at 1470.

Additionally, the cytogenetics are identifying relatively high-risk features with the deletion 11q and IgHV unmutated status. This is somebody that I am concerned about. I do agree with the treatment decision to initiate therapy. A few things to note, deletion 11q, it's considered high risk feature, and patients do present a little bit differently with an 11q than some of the other patients with CLL.

Many times, the 11q patients have rather proliferative disease at diagnosis and they can present with a lot of bulky adenopathy. While this patient doesn't have technically bulky adenopathy, and really what's palpable is only about a centimeter and a half, it's very possible that with deep within the abdomen something that we're not palpating he can have a very large lymph node, 6 to 8 centimeters or larger.

Typically, that's associated with signs and symptoms, but given the fact that these fevers, night sweats and rather proliferative disease with an elevated LDH together with these high-risk features, this is someone I might be concerned about even with a transformation as an initial presentation of their CLL and would need to work up and rule that out appropriately.

With that said, the patient was started on ibrutinib, and overall is a good therapy. And so, those are the big, noteworthy aspects of this case, and can be a rather typical presentation for a patient with deletion 11q molecular features like this patient.

John Allan, MD: One other aspect of this case that's unique is that the patient is on over-the-counter antacids, and this is a relatively common thing. Many patients are takig either over-the-counter antacids like Pepcid [famotidine], Prilosec [omeprazole], etc.

I'm sorry, those are more PPIs [proton pump inhibitors] but acid suppressing medications either H2 [histamine2] blockers calcium absorbing, calcium carbonate like medications and or proton pump inhibitors.

And so, this is not just unique to CLL patients, this is just unique to older patients and patient population in general, where in the US specifically there is a lot of PPI use, whether it's over-the-counter or prescribed.

Ultimately, in clinical trials with BTK [Bruton’s tyrosine kinase] inhibitors and targeted agents we do see about 40% to 45% of patients on some type of acid suppressive medication. This is a very common scenario and it may have some relevance based on differentiating between BTKi's at this point in time.

Transcript Edited for Clarity

Initial Presentation

  • A 67-year-old man presented to PCP with complaints of fatigue and night sweats
  • PMH: patient takes OTC antiacid tablets a few times a week for a “sensitive” stomach
  • PE: Enlarged mobile lymph nodes bilaterally (~1.5 cm), no palpable spleen or liver
  • Laboratory findings:
  • WBC; 102 X 109/L
  • Lymphocytes; 79 X 109/L
  • Hb; 11.4 g/dL
  • Platelets; 180 X 109/L
  • ANC; 1,900/mm3
  • LDH 1470 U/L
  • Cytogenetics; del(11q), IgVH-unmutated
  • beta2M, 3.0 mg/L
  • Rai Stage I

Treatment Plan

  • Patient was started on ibrutinib