Notes on CLL
At the Meet the Professor Session, Dr. George Canellos of the Dana-Farber
Cancer Institute, Harvard Medical School, discussed his view about current
issues relating to the diagnosis and management of chronic lymphocytic leukemia
(CLL) and its different stages. Dr. Canellos is an experienced clinician who
manages many patients with CLL, and some pearls that we could gather during his
1. Autoimmune phenomena, particularly when they are severe, including
hemolytic anemia, thrombocytopenia, and at times even pulmonary involvement
with bronchiolitis obliterans, require immune suppression primarily with
prednisone, although cyclosporine and azathioprine (Imuran) can also be
necessary, depending on the severity of the problem.
2. Prolymphocytic transformation is fairly common and is managed generally
with a lymphoma (CHOP) type of chemotherapy regimen. In addition to known
prognostic factors that indicate a more serious course, such as short doubling
time of lymphocyte proliferation, advanced age, and prolymphocytic histology,
the role of certain new prognostic factors was mentioned such as the presence
of CD38. The latter is associated with a poorer prognosis.
3. Cytogenetic abnormalities can also be associated with a more serious
course, but testing is generally not indicated in the initial management. Bone
marrow examination is also optional at the outset, and most studies can now be
done in the peripheral blood.
4. Chemotherapy options: Dr. Canellos uses low-dose weekly doxorubicin in
patients with advanced disease who would not otherwise tolerate other more
myelosuppressive or aggressive regimens. Similarly, in frail patients who need
therapy, he has utilized fludarabine (Fludara) on a relatively low-dose weekly
regimen. Rituximab (Rituxan) can be helpful in autoimmune anemia, including
conditions such as cold agglutinin disease. He does not think that the
management of T-CLL, a rare condition, differs much from the treatment of B-CLL.
In patients who have had previous immune thrombocytopenia or immune
hemolytic anemia, which is now not active, he indicated that fludarabine is not
necessarily contraindicated. He said that there are no data to indicate that
fludarabine would be unsafe in patients with CLL who have had prior autoimmune