Burger Reviews BTK Inhibitors and Beyond in Frontline CLL

This article was originally published by Targeted Oncology

During a virtual Case Based Peer Perspectives event, Jan A. Burger, MD, PhD, professor, Department of Leukemia, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center in Houston, TX, discussed testing and the treatment options for chronic lymphocytic leukemia (CLL), based on the a case of 71-year-old female patient.

Targeted OncologyTM: What testing would you order to confirm diagnosis if you saw this patient in the clinic?

BURGER: We need to establish the diagnosis by flow cytometry and then we would do, at a minimum, FISH cytogenetics and, ideally, the mutational status. Cytogenetics can change, but
mutational status usually doesn’t change. If that’s been established somewhere outside [of your clinic], then you don’t have to repeat that test.

It’s important to repeat cytogenetics if you talk about the relapse setting. But here, we’re treating in the frontline setting, and she was tested. She was found to be IGHV unmutated and [positive
for] del(11q). That, traditionally, has been regarded as a higher-risk disease status because these patients respond OK to standard chemotherapy, but they have short remissions and survival times with FCR [fludarabine, cyclophosphamide, and rituximab (Rituxan)], BR [bendamustine plus rituximab], and those kinds of regimens compared with low-risk patients, such as those [who are positive for] deletion 13q and have IGHV mutated disease.

In terms of these sequences, when you see a patient with lymphocytosis, you send for flow cytometry, and part of the flow cytometry panel can test for additional markers, CD38 and ZAP-70. We have it [at MD Anderson], but I’m not sure if there are any outside routine flow cytometry labs reporting CD38 positivity or negativity or ZAP-70. These markers used to be very popular 10
years or so ago when IGHV-mutation status was not so commonly done and was more complicated to get. Nowadays, there’s a shift with sending a sample directly for IGHV-mutation testing.

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