Highlighter is on. Drag to highlight text. Click a highlight to remove it.
ALL / Haematology
Chronic lymphocytic leukaemia: management
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 cytopenias (e.g. ITP, AIHA) refractory to steroids
Management
- patients without indications → active monitoring ('watch and wait')
- the mainstay of treatment for CLL for many years was chemoimmunotherapy using fludarabine, cyclophosphamide and rituximab (FCR)
- now, first-line treatment for the majority of patients is targeted therapy with BTK inhibitors
- blocks B-cell receptor signalling
- particularly favoured if del(17p) or TP53 mutation
- examples: ibrutinib or acalabrutinib
- treatment is continuous (indefinite); disease typically relapses if stopped
- other targeted agents used include venetoclax
- inhibits BCL-2 (anti-apoptotic protein)
- directly triggers apoptosis
- given as fixed-duration therapy (usually with an anti-CD20 antibody) and can achieve deep remission (MRD-negative)
- requires careful dose ramp-up due to risk of tumour lysis syndrome
- FCR is now only used first-line in:
- selected younger, fit patients with favourable genetics (e.g. IGHV-mutated CLL)
- may be considered in resource-limited settings
+PassMedicine Notes
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 cytopenias (e.g. ITP, AIHA) refractory to steroids
- patients without indications → active monitoring ('watch and wait')
- the mainstay of treatment for CLL for many years was chemoimmunotherapy using fludarabine, cyclophosphamide and rituximab (FCR)
- now, first-line treatment for the majority of patients is targeted therapy with BTK inhibitors
- blocks B-cell receptor signalling
- particularly favoured if del(17p) or TP53 mutation
- examples: ibrutinib or acalabrutinib
- treatment is continuous (indefinite); disease typically relapses if stopped
- other targeted agents used include venetoclax
- inhibits BCL-2 (anti-apoptotic protein)
- directly triggers apoptosis
- given as fixed-duration therapy (usually with an anti-CD20 antibody) and can achieve deep remission (MRD-negative)
- requires careful dose ramp-up due to risk of tumour lysis syndrome
- FCR is now only used first-line in:
- selected younger, fit patients with favourable genetics (e.g. IGHV-mutated CLL)
- may be considered in resource-limited settings
