Javier Pinilla-Ibarz, MD, PhD: Treatment Options for Patients With Previously Treated CLL

What are the principle treatment options in this patient with previously treated CLL?

The 11q deletion typically may respond well to alkylating agents as front-line therapy, although other therapies can be newly indicated by the FDA, such as obinutuzumab plus chlorambucil. The fact that they respond well to alkylating agents doesn’t prevent them from relapsing, as do most patients with CLL. In this case, the time to relapse is shorter than in other chromosomal abnormalities, and they will represent another challenge for a practicing oncologist, regarding what kind of therapy will be the best for this patient.

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.