Coutre Evaluates Treatment Options in Relapsed/Refractory CLL

This article was originally published by Targeted Oncology

During a virtual Case Based Peer Perspectives event, Steven Coutre, MD, professor of Medicine (Hematology), Standford University Medical Center, reviewed a case of a 53-year-old woman who first presented with elevated white blood cell count. The patient was later diagnosed with chronic lymphocytic leukemia (CLL).

Targeted Oncology™What are your initial impressions of this case?

COUTRE: I think we’d all agree that this is a patient who requires observation at this point. Clinically, this patient is at Rai stage 0. That 1 × 1 cm [lymph node] doesn’t qualify as lymphadenopathy. It certainly doesn’t need a CT scan or a bone marrow, and we can choose whether to do mutation analysis or FISH, but those results are not going to change the management approach.

To establish a diagnosis, flow cytometry was carried out showing the typical immunophenotype. Additional testing was conducted, showing the patient has no cytogenetic abnormality by FISH. Unfortunately, the patient had a bone marrow done, and it showed evidence of CLL. She was observed and did fine for 5 years, and she’s still quite young. Her WBC count has more than doubled, she’s significantly anemic, her platelet count has gone down, and the lymphadenopathy is 4 cm × 3

What are the treatment options for this patient?

The RESONATE trial [NCT01578707] evaluated patients who were previously treated for CLL and SLL [small lymphocytic leukemia] and who were randomized to receive ibrutinib [Imbruvica] at 420 mg once daily versus IV ofatumumab [Arzerra] at an initial dose of 300 mg, followed by 2000 mg for 11 doses over 24 weeks.¹

It’s no big surprise how well ibrutinib did compared with ofatumumab. The differences were highly significant. The most recent data involving 6-year follow-up published last year in Blood show that the median PFS [progression-free survival] is still not reached. These patients who entered this trial were not your average patients. The patient in our case would not have been eligible for the trial. Having a 4-year response to FCR would not [have met eligibility] for this trial. These were much worse relapsed patients, and yet here we are in 2020, and the median PFS has still not been reached with ibrutinib in this trial versus 8.11 months for the ofatumumab arm [HR, 0.133; 95% CI, 0.099-0.178].

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