Case 1: Initiating Treatment for CLL

EXPERT PERSPECTIVE VIRTUAL TUMOR BOARD

Shuo Ma, MD, PhD:Coming back to our patient, it looks like she has at least 2 high risk prognostic markers — the 11q deletion and TheIGVHunmutated status. Because of her cytopenia she had a bone marrow biopsy done, and it did show diffuse infiltration by CLL confirming that her cytopenia is actually due to the end of production from the chronic lymphocytic leukemia [CLL] over infiltration. This is the case. In summary, the patient is a 66-year-old woman presenting with pancytopenia, adenopathy, splenomegaly; had some high-risk features, as I mentioned. What do you think?             

Anthony Mato, MD, MSCE:The first question that we should try to tackle as a group is whether or not this patient needs therapy in the first place. What do you think? What are your criteria that you would use to decide whether or not we should intervene?

Shuo Ma, MD, PhD:I think where the criteria for starting CLL treatment is well established for many years. The International Workshop on CLL [IwCLL] has established the indications for CLL treatment. Basically, this is indicated for patients with CLL who has progressive cytopenia that’s actually due to extensive development of CLL in the marrow, rather than due to autoimmune process.      

Anthony Mato, MD, MSCE:Do you think a Coombs test and a haptoglobin test is warranted here?

Shuo Ma, MD, PhD:Yes. Before I would do the bone marrow biopsy I would first do the basic immuno workup to rule out hemolytic anemia, rule out some other and more common causes of anemia. If that does not explain the patient’s anemia, then bone marrow biopsy will be the next step.

Bone marrow failure is 1 indication. The other indication is that if patient has progressive lymphadenopathy, or hepatosplenomegaly that’s bulky or progressive that’s causing symptoms.

Another indication would be if a patient is having actually autoimmune hemolytic anemia, or immune thrombocytopenia but is not responding to your typical immunosuppressive treatment. In that case by treating underline CLL, that will be an indication as well.

Anthony Mato, MD, MSCE:I have a question for you. I just came from clinic before our tumor board and one of the toughest things that I try to sort out are patients who have a constitutional symptom like fatigue in the absence of anemia, which actually is part of IwCLL criteria is a constitutional symptom that could warrant an intervention. Any thoughts as to how to evaluate that or determine whether that CLL is related?

Sameer A. Parikh, MBBS:I think that’s a very important question and it, it’s one of the challenges that as we all take care of our patients with CLL who may not meet some of the traditional criteria for treatment, the way I talk about it with my patients is that I think about many causes of fatigue, and I say that it’s a big pie and you have to figure out how much of a pie size is really, because of CLL, how much is CLL contributing to that, because you have to do a lot of the causes, and unfortunately those are never really addressed in the clinic in an outpatient. For example, hypothyroidism, depression, obstructive sleep apnea. These are all very underrecognized causes of fatigue. And what I tell my patients is that if you do not have a enough disease bulk, generally significant lymphadenopathy or bone marrow infiltration by CLL, then it is less likely that the fatigue you’re experiencing at the early stages of your CLL disease process is because of CLL.

Then if it is not truly CLL that’s causing the fatigue, by treating the CLL your fatigue is not going to get better, and so we would not have done you any favors by treating your disease. We would ideally like to investigate additional reasons of fatigue before proceeding with treatment for CLL.

Anthony Mato, MD, MSCE:I guess you’ve all encountered the same situation before.

Transcript edited for clarity.