What options might you consider to prolong survival in this patient?
Once a patient, such as the one in this case, has relapsed, the important goal of therapy is to keep him or her out of progression. Although there may be some transient response, the time to relapse is going to be even shorter. For this reason, therapy that can be maintained over a long period and produce good control of the disease will be the best choice for these patients. This includes the BCR inhibitors, such as ibrutinib or idelalisib.
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.