How I treat CLL up front.

Institute of Cancer, Queen Mary University of London, Barts and The London School of Medicine and Dentistry, London, United Kingdom.
Blood (Impact Factor: 9.78). 10/2009; 115(2):187-97. DOI: 10.1182/blood-2009-08-207126
Source: PubMed

ABSTRACT Although chronic lymphocytic leukemia (CLL) remains incurable, over the past decade there have been major advances in understanding the pathophysiology of CLL and in the treatment of this disease. This has led to greatly increased response rates and durations of response but not yet improved survival. Advances in the use of prognostic factors that identify patients at high risk for progression have led us to the question whether there is still a role for a "watch and wait" approach in asymptomatic high-risk patients or whether they should be treated earlier in their disease course. Questions remain, including, what is the optimal first-line treatment and its timing and is there any role of maintenance therapy or stem cell transplantation in this disease? CLL is a disease of the elderly and not all patients are eligible for aggressive up-front chemoimmunotherapy regimens, so what is the optimal treatment approach for more frail elderly patients? It is highly likely that our treatment approaches will continue to evolve as the results of ongoing clinical trials are released and that further improvements in the outcome of this disease will result from identification of therapies that target the underlying pathophysiology of CLL.

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    ABSTRACT: Chronic lymphocytic leukemia (CLL) is predominantly a disease of the elderly, with a median age of 70 years at diagnosis. Appropriate treatment approach requires physical examination, evaluation of performance status, co-morbidities and severity of comorbid conditions, biological age, peripheral, blood count with morphologic examination. In addition, in some patients bone marrow evaluation, serum biochemistry including serum lactate dehydrogenasis and β2-microglobulin, Coombs’ test, imaging of adenomegalies, assessed either by CT scan or by the combination of chest X-ray and abdomen ultrasound should be incorporated into decision-making process with regard to intensity of treatment. In patients requiring therapy, particularly a second-line treatment, del 17p and/or p53 mutations should be also checked. Elderly and/or comorbid patients with CLL may not tolerate more aggressive approach due to high risk of unacceptable toxicity of purine nucleoside analogs, especially in combination with cyclophosphamide and rituximab. Therefore in these patients population, chlorambucil +/- rituximab is still accepted as the first-line treatment and chlorambucil remains the backbone of treatment against which the new protocols should be tested. The results of ongoing trials investigating the role of new immunochemotherapies and the other novel agents will probably modify the treatment of CLL in the following years. In this article we present recommendations for diagnosis, prognosis and therapy of CLL elaborated by by PTH i T and PALG-CLL group.
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