A 71-year-old woman with no significant past medical history is investigated for lymphocytosis. She has recently lost 7kg in weight and complains of lethargy. The following blood results are obtained:
| Hb | 9.8 g/dl |
|---|---|
| Plt | 104 * 109/l |
| WBC | 70.3 * 109/l |
| Blood film: | Lymphocytosis. Smudge cells seen |
Four months previously her white cell count was 30.5 * 109/l. What is the most appropriate management?
Imatinib
Chlorambucil
No treatment, monitor full blood count
Fludarabine, cyclophosphamide and rituximab
Allogeneic stem cell transplantation
This patient has chronic lymphocytic leukaemia. The lymphocyte doubling time is less than 6 months, the patient has some evidence of marrow failure and also has systemic symptoms. She should therefore be treated and of the options given a combination of fludarabine, cyclophosphamide and rituximab (FCR) is the most appropriate treatment. Chlorambucil used to be the first-line treatment of choice but studies have shown it not to be as effective as FCR.
As with many haematological cancers such patients are often entered into randomised trials
Chronic lymphocytic leukaemia: management
Indications for treatment
- progressive marrow failure: the development or worsening of anaemia and/or thrombocytopenia
- massive (>10 cm) or progressive lymphadenopathy
- massive (>6 cm) or progressive splenomegaly
- progressive lymphocytosis: > 50% increase over 2 months or lymphocyte doubling time < 6 months
- systemic symptoms: weight loss > 10% in previous 6 months, fever >38ºC for > 2 weeks, extreme fatigue, night sweats
- autoimmune cytopaenias e.g. ITP
Management
- patients who have no indications for treatment are monitored with regular blood counts
- fludarabine, cyclophosphamide and rituximab (FCR) has now emerged as the initial treatment of choice for the majority of patients
- ibrutinib may be used in patients who have failed a previous therapy