Case Overview: A 72-Year-Old Woman with Newly Diagnosed Chronic Lymphocytic Leukemia
John Allan, MD, presents the case of a 72-year-old woman with newly diagnosed chronic lymphocytic leukemia and shares his initial impressions.
Case: A 72-Year-Old Woman with Newly Diagnosed Chronic Lymphocytic Leukemia (CLL)
- Patient KM is a 72 y/o woman.
- PMH: Hypertension (well controlled on medication)
- SMH: Does not smoke; drinks occasional glass of wine in social setting; Walks with friends 2-3 times weekly.
Clinical Presentation:
- In October 2022, KM visited her PCP for her annual checkup. She reported having persistent fatigue and recent occurrences of night sweats.
Clinical Workup and Diagnosis:
- WBC: 186,000; 80% lymphocytes
- Hgb, 9.4 g/dL
- Platelets, 85 x 109/L
- ECOG PS 0
- Elevated serum beta-2-microglobulin
- Flow cytometry, CD5+, CD20+, CD23+
- TP53 mutation status – unmutated; IGHV mutation status – unmutated
- Bone marrow biopsy confirms diagnosis of chronic lymphocytic leukemia (CLL)
Current Treatment:
- After discussions with her family and clinical team, KM was initiated on fixed duration of venetoclax + obinutuzumab.
- KM was started on obinutuzumab at 100 mg IV Day 1, followed by 900 mg IV on Day 2, then 1000 mg IV on Days 8 and 15 of Cycle 1; Currently infused with 1000 mg IV on Day 1 of remaining cycles.
- She was initiated on a ramp-up dosing schedule of venetoclax starting on C1D22 and currently taking the recommended dose of 400 mg PO daily.
Transcript:
John Allan, MD: Hi everyone. Thank you for joining us this afternoon. I’m John Allan, I’m coming to you from New York City at Weill Cornell [Medicine]. This is a Targeted Oncology™ program, Case-Based Peer Perspectives. We’ll be taking you through a case today of a 72-year-old patient with newly diagnosed CLL [chronic lymphocytic leukemia] and going through issues that arise as we’re thinking about specific treatment choices. What do we need to be thinking about as we come up with the best choice for that patient? How do we assess risk, how do we manage toxicity, and so on and so forth? And we’ll be going through certain issues that arise in a case-based format. So without further ado, I’ll jump into our case.
This is a 72-year-old female with newly diagnosed CLL. Her past medical history is significant for hypertension, which is well controlled; she is on medication for it. Her social history shows that she does not smoke. She has an occasional glass of wine in a social setting once or twice a week. She is walking with friends and remains rather active, out and about 2 to 3 times a week. In October 2022, the patient visited her primary care physician for an annual checkup. She reported having persistent fatigue and recent occurrences of night sweats that seemed to be persistent and continued to escalate.
At that time when she was evaluated last year, her white blood cell count was markedly elevated at 186,000 per microliter, with 80% of that being lymphocytes. Her hemoglobin was 9.4 g/dL. Her platelets were 85,000, or 85 x 109/L. ECOG performance status was 0, so she’s very fit and active. She did have an elevated serum beta-2 microglobulin. Flow cytometry was sent at that visit, confirming classic CLL immunophenotype: CD5 positive, CD20 dim, CD23 positive, CD200 bright. TP53 mutational status was assessed, and she was found to be unmutated, so wild-type TP53. Her IGHV mutational status was also assessed, and she was found to have an unmutated IGHV. FISH [fluorescence in situ hybridization] was still pending at this time.
A bone marrow biopsy was done to assess the cytopenias, despite the fact that there was probably good evidence this was going to be CLL, given such an elevated white blood cell count. And it confirmed extensive involvement by CLL. She was recommended for treatment and provided some options. She went home and talked with her family and thought about it for a week or so. Given her active lifestyle, she wished for a fixed duration of venetoclax and obinutuzumab. She came back about a couple of weeks later and got that all set up after approval. She started on her induction with obinutuzumab, 100 mg of IV [intravenous] obinutuzumab on day 1, followed by the standard day 2 dosing of 900 mg, and then 1000 mg on day 8 and 15 of cycle 1. She was then infused with 1000 mg on day 1 of the remaining cycles up to cycle 6. She started on venetoclax on cycle 1 day 22 per the CLL14 [trial] protocol, during her week off from obinutuzumab in that first cycle. She was escalated without issue and is on the recommended 400 mg once daily orally.
Now we’ll go through some case questions and try to understand how we assess risk and how to best care for this patient going forward, and any issues that may arise as the case goes on.
This case represents a classic presentation for many of our patients with CLL, an older patient in their 70s. As you may know, the median age of diagnosis is about 70. Frequently patients are requiring therapy in this range. Not so commonly are they diagnosed and instantly needing treatment. But sometimes that can happen where we see patients having symptoms for quite some time and maybe not having the best follow-up. All of a sudden they’re coming in with advanced disease and needing treatment relatively soon.
Transcript edited for clarity.
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