Sandbox:therapy
- 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
- Preferred immunochemotheraptic regimens for the treatment of such patients who are older than 70 years of age include (in order of preference):
- Obinutuzumab AND chlorambucil
- Ofatumumab AND chlorambucil
- Rituximab AND chlorambucil
- Bendamustine ± rituximab
- Obinutuzumab alone
- Fludarabine ± rituximab
- Chlorambucil
- Rituximab alone
- Cladribine alone
- Preferred immunochemotheraptic regimens for the treatment of such patients who are younger than 70 years of age include (in order of preference):
- Fludarabine AND cyclophosphamide AND rituximab
- Fludarabine AND rituximab
- Pentostatin AND cyclophosphamide AND rituximab
- Bendamustine AND rituximab
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):
- Ibrutinib
- High-dose methylprednisolone AND rituximab
- Fludarabine AND rituximab
- Fludarabine AND cyclophosphamide AND rituximab
- Obinutuzumab AND chlorambucil
- Alemtuzumab ± rituximab
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):
- Obinutuzumab AND chlorambucil
- Ofatumumab AND chlorambucil
- Rituximab AND chlorambucil
- Bendamustine ± rituximab
- Cyclophosphamide AND prednisone ± rituximab
- Fludarabine AND cyclophosphamide AND rituximab (reduced dose)
- Rituximab alone
- Preferred immunochemotheraptic regimens for the treatment such patients who are younger than 70 years of age include (in order of preference):
- Fludarabine AND cyclophosphamide AND rituximab
- Bendamustine ± rituximab
- Pentostatin AND cyclophosphamide AND rituximab
- Pentostatin AND cyclophosphamide AND rituximab