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===Immunochemotherapeutic regimens for the management of patients with chromosome 17p deletion===
===Immunochemotherapeutic regimens for the management of patients with chromosome 17p deletion===
*Preferred immunochemotheraptic regimens for the treatment of such patients include (in order of preference):
====First line therapy====
:*[[Ibrutinib]]
* Preferred immunochemotheraptic regimens for the treatment of such patients include ('''in order of preference'''):
:*High-dose [[methylprednisolone]] {{and}} [[rituximab]]
:* [[Ibrutinib]]
:*[[Fludarabine]] {{and}} [[rituximab]]
:* High-dose [[methylprednisolone]] {{and}} [[rituximab]]
:*[[Fludarabine]] {{and}} [[cyclophosphamide]] {{and}} [[rituximab]]
:* [[Fludarabine]] {{and}} [[rituximab]]
:*[[Obinutuzumab]] {{and}} [[chlorambucil]]
:* [[Fludarabine]] {{and}} [[cyclophosphamide]] {{and}} [[rituximab]]
:*[[Alemtuzumab]] {{withorwithout}} [[rituximab]]
:* [[Obinutuzumab]] {{and}} [[chlorambucil]]
:* [[Alemtuzumab]] {{withorwithout}} [[rituximab]]
:* [[Rituximab]] {{and}} [[chlorambucil]]
:* [[Rituximab]] {{and}} [[chlorambucil]]


Revision as of 20:55, 16 October 2015

  • Asymptomatic chronic lymphocytic leukemia patients are managed with observation, whereas symptomatic chronic lymphocytic leukemia patients are treated with immunochemotherapy.
  • Indications to initiate immunochemotherapy among patients with chronic lymphocytic leukemia include:
  • Symptomatic chronic lymphocytic leukemia patients presenting with:
  • Fever of unknown origin (>38.1°C for a period greater than two weeks)
  • Night sweats for more than one month
  • Unintentional significant weight loss over a period of six months
  • Patients presenting with thrombocytopenia or anemia due to bone marrow failure
  • Patients presenting with refractory autoimmune anemia or refractory autoimmune thrombocytopenia
  • Evidence of symptomatic splenomegaly, with the spleen being palpated more than 6cm below the costal margin
  • Evidence of symptomatic progressive lymph nodes swelling, with a size greater than 10 cm in diameter
  • Evidence of a rapidly progressive lymphocytosis, which may be indicated by:
  • An increase of greater than 50% over a 2-month period
  • A lymphocyte doubling period shorter than six months
  • The mainstay of therapy for symptomatic chronic lymphocytic leukemia patients is combination immunochemotherapy.
  • Immunochemotherapies for chronic lymphocytic leukemia include purine analogues, alkylating agents, monoclonal antibodies, Tyrosine kinase and B-Cell receptor pathway inhibitors.
  • Purine analogues used for the management of chronic lymphocytic leukemia patines may include:
  • Cladribine
  • Fludarabine
  • Pentostatin
  • Alkylating agents used for the management of chronic lymphocytic leukemia patients may include:
  • Bendamustine
  • Chlorambucil
  • Cyclophosphamide
  • Monoclonal antibodies used for the management of chronic lymphocytic leukemia patients may include:
  • Rituximab
  • Ofatumumab
  • Obinutuzumab
  • Alemtuzumab
  • Immunomodulatory agents used for the management of chronic lymphocytic leukemia patients may include:
  • Lenalidomide
  • Tyrosine kinase and B-Cell receptor pathway inhibitors used for the management of chronic lymphocytic leukemia patients may include:
  • Idelalisib (targets phosphoinositide 3-kinase delta)
  • Ibrutinib (targets bruton tyrosine kinase)
  • The optimal immunochemotherapeutic regimens used for the management of chronic lymphocytic leukemia depends on a number of factors which include:
  • The clinical presentation of the patients
  • The performance status of the patients
  • The stage of the tumor
  • The presence of specific genetic mutations
  • First line therapy vs. recurrent/refractory therapy
  • The algorithm below summarizes the management approach for chronic lymphocytic leukemia patients:


 
 
 
 
 
Initial patients evaluation
 
 
 
 
 
 
 
 
 
 
History
Physical examination
Complete blood count
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Staging
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Rai Staging System
Binet Staging System
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Rai stage 3-4
Binet stage B-C
 
 
 
Rai stage 0-2
Binet stage A
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Evaluate patients by cumulative index illness rating scale
 
 
 
Patients managed by observation and close follow-up
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Frail patients (CIRS ≥6)
 
Fit patients (CIRS <6)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Retixumab/obinutuzumab AND chlorambucil
 
FISH chromosomal analysis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Immunochemotherapeutic regimens for management of patients without chromosome 17p deletion or chromosome 11q deletion can be found here
 
Immunochemotherapeutic regimens for management of patients with chromosome 17p deletion can be found here
 
Immunochemotherapeutic regimens for management of patients with chromosome 17p deletion can be found here
 
 
 
 
 
 
 
 
 
 
 
 


Immunochemotherapeutic regimens for the management of patients without chromosome 17p deletion or chromosome 11q deletion

First line therapy

  • Preferred immunochemotheraptic regimens for the treatment of such patients who are older than 70 years of age include (in order of preference):
  • Preferred immunochemotheraptic regimens for the treatment of such patients who are younger than 70 years of age include (in order of preference):

Refractory/relapsed therapy

  • Preferred immunochemotheraptic regimens for the treatment of such patients who are older than 70 years of age include (in order of preference):
  • Preferred immunochemotheraptic regimens for the treatment of such patients who are younger than 70 years of age include (in order of preference):

Immunochemotherapeutic regimens for the management of patients with chromosome 17p deletion

First line therapy

  • Preferred immunochemotheraptic regimens for the treatment of such patients include (in order of preference):

Immunochemotherapeutic regimens for management of patients with chromosome 11q deletion

  • Preferred immunochemotheraptic regimens for the treatment such patients who are older than 70 years of age include (in order of preference):
  • Preferred immunochemotheraptic regimens for the treatment such patients who are younger than 70 years of age include (in order of preference):
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