Javier Pinilla-Ibarz, MD, PhD: Relapse Following Purine Analog Therapy

Is the fact that the patient relapsed after purine analog therapy important to consider?

Patients with 17p are intrinsically resistant to the purine analogs. However, there are also instances where patients don’t present 17p deletion in the chromosomes from the leukemic cells. They have a short time to relapse after this regimen containing fludarabine. Those patient outcomes are as poor as 17p, and, they should be treated with alternative therapies, such as a BCR inhibitor, ibrutinib, or idelalisib with rituximab.

Case 2: Relapsed and Refractory CLL

James S. is a 67-year-old college professor from Ithaca, New York; he is a Vietnam veteran with a history of treatment for Agent Orange exposure; his history is also notable for prior smoking (15-pack year) and mild COPD.

In November 2013, he presented to his PCP for a routine physical; his examination showed mild lymphadenopathy and his CBC showed evidence of lymphocytosis (lymphocytes 6 x 109/L); he was referred to an oncologist for further diagnostic evaluation.

Differential diagnosis showed B-cell CLL, with absolute lymphocytosis (19,000/mm3) and flow cytometry positive for CD5 and CD23.

Interphase cytogenetic analysis showed no deletion of 17p.

The oncologist initiates treatment with bendamustine/rituximab (BR) and James shows improvement in hematologic parameters after 6 cycles.

James was out of the country at a meeting, and he failed to return for a scheduled follow-up appointment in January 2015.

In March 2015, he presented to his oncologist with symptoms of unintentional weight loss over the past 2 months (>10%), severe fatigue (interfering with work), and dyspnea; his CBC is consistent with worsening anemia and thrombocytopenia.

CT scan shows evidence of extensive abdominal lymph node recurrence.

At the time of his recurrence, James’s ECOG performance status was 2, and liver and kidney functioning were within normal limits.