The Therapeutic Approach for High-Risk CLL

Case: A Young Male Patient with High-Risk CLL and Nodal Involvement

January 2017

• A 53-year-old male presents with fatigue, night sweats, and swollen glands
• PMH: hypertension managed with losartan
• PE: left axillary and bilateral cervical adenopathy, 4 cm X 3 cm
• Laboratory findings:
  • WBC; 117.3 X 10⁹/L
  • Lymphocytes; 109.2 X 10⁹/L
  • Hb; 9.6 g/dL
  • Platelets; 174 X 10⁹/L
  • ANC; 1,950/mm³
  • LDH 160 U/L
• Flow cytometry; CD19++, CD5+, CD20+, CD23++, CD38+
• BM; CLL in 86% of cells
• IgVH mutated
• Cytogenetics by FISH; del17p
• Diagnosis; chronic lymphocytic leukemia
• The patient was treated with FCR and achieved a partial response to therapy after 6 cycles
  • Left axillary lymph node, 2 cm X 2 cm
  • Lymphocytes; 10 X 10⁹/L
  • Symptoms resolved
• The patient was started on maintenance therapy with lenalidomide

December 2017

• The patient complained of increasing bouts of extreme fatigue, abdominal bloating and intermittent moderate to severe abdominal pain
• PE:
  • Bulky adenopathy in the cervical and axillary lymph nodes, inguinal lymphadenopathy
  • Fluid wave test positive for ascites
• Abdominal CT showed multi-station bulky lymphadenopathy, hepatomegaly, and splenomegaly
• Patient underwent large-volume paracenteses, ascites sampling positive for CLL involvement
• Laboratory findings:
  • WBC; 84,000, 97% lymphocytes
  • Hb; 9.4 g/dL
  • Platelets; 110,000/mm³
  • ANC; 1,600/mm³(WNL)
  • LDH; 262 U/L
  • Beta-2-microglobulin; 8.9 µg/L
• The patient was started on venetoclax
• The patient developed grade 3 neutropenia after 4 weeks on therapy which was managed and later resolved