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 presentation follow.
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(Drug information on prednisone), although cyclosporine and azathioprine(Drug information on 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(Drug information on 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(Drug information on 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 disorders.