Relapsed and Refractory CLL with Javier Pinilla-lbarz, MD, PhD and Paul Barr, MD: Case 2 - Episode 7

Paul Barr, MD: Bendamustine/Rituximab Therapy

Would you consider retreatment with bendamustine/rituximab (BR) therapy in this patient?

I would not consider another course of bendamustine/rituximab for such a patient. That strategy of repeating the same therapy that someone received before came from a time when we had fewer treatment options and was useful in patients who had a very long duration of remission. So, say someone received bendamustine/rituximab and was in remission for 10 years or so. It’s not a bad idea to think about retreatment in a case like that. But for such a patient we are interpreting his duration of remission as being very short, being only a year. We would expect a second course to result in a duration of remission only measured in a few months. So to endure the toxicities of another course of chemoimmunotherapy for very little benefit just doesn’t seem like a good option 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.