Case Review: 62-Year-Old Man Diagnosed with CLL

Ian W. Flinn, MD, PhD:The case is one of a 62-year-old man who had been feeling well until several months before he presented to his primary care physician with complaints of significant fatigue and night sweats. When he was seen by his primary care physician, he was noted to have an elevated white blood cell count of approximately 100,000/mcL with an absolute lymphocyte count of around 82,000/mcL. He was also found to be slightly anemic, with a hemoglobin level of 11.2 g/dL. His platelet count was normal, at 190,000/mcL. On physical exam, he had multiple lymph nodes that were enlarged. This prompted the primary care physician to refer him to his community oncologist, where he underwent an evaluation for chronic lymphocytic leukemia [CLL].

The oncologist sent his peripheral blood for flow cytometry, which revealed a classic immunophenotype for CLL. FISH [fluorescence in situ hybridization] testing revealed an 11q deletion. He also sent the mutational status of his immunoglobulin heavy chain, which revealed that it was unmutated. The patient had a normal LDH [lactate dehydrogenase].

Because this patient was symptomatic, he was started on therapy. The therapy consisted of ibrutinib and rituximab. I think this was warranted because this patient has symptoms. He was anemic and had night sweats and significant fatigue that prevented him from doing many of his normal activities.

The normal triggers for initiating therapy include anemia, thrombocytopenia, rapid doubling of white [blood cell] counts to the point that within 6 months, the absolute lymphocyte count is doubling in a very short fashion, and huge lymph nodes. By this, I mean not just a 1.5-cm lymph node but massive lymph nodes—5 to 10 cm—and a large spleen that’s palpable and progressive in nature. In addition, anemia is another reason to treat patients. The reasons that we treat patients today are the same as the reasons we treated patients 10 years ago. Those indications really haven’t changed.

Transcript edited for clarity.

Case:A 62-Year—Old Male WithIgVH-Unmutated CLL

• A 62-year-old male presented to PCP with complaints of extreme fatigue and night sweats
• PE: Enlarged mobile lymph nodes bilaterally (~1.5 cm), no palpable spleen or liver
• Laboratory findings:
  • WBC; 100 X 10⁹/L
  • Lymphocytes; 82 X 10⁹/L
  • Hb; 11.2 g/dL
  • Platelets; 190 X 10⁹/L
  • ANC; 1,950/mm³
  • LDH 150 U/L
• Cytogenetic; del(11q),IgVH-unmutated
• β2M, 2.9 mg/L
• Referred to community oncology who diagnosed patient with chronic lymphocytic leukemia
• Patient was started on ibrutinib + rituximab (IR)
• Rai Stage I