Sandbox:therapy

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Immunochemotherapy

  • The mainstay of therapy for symptomatic chronic lymphocytic leukemia patients is combination immunochemotherapy.[1]
  • Asymptomatic chronic lymphocytic leukemia patients are managed with observation, whereas symptomatic chronic lymphocytic leukemia patients are treated with immunochemotherapy.
  • Indications to initiate immunochemotherapy among patients with chronic lymphocytic leukemia include:[2]
  • Symptomatic chronic lymphocytic leukemia patients presenting with:
  • Fever of unknown origin (>38.1°C for a period greater than two weeks)
  • Night sweats for more than one month
  • Unintentional significant weight loss over a period of six months
  • An increase of greater than 50% over a 2-month period
  • A lymphocyte doubling period shorter than six months
  • Purine analogues used for the management of chronic lymphocytic leukemia patines may include:
  • Alkylating agents used for the management of chronic lymphocytic leukemia patients may include:
  • Monoclonal antibodies used for the management of chronic lymphocytic leukemia patients may include:
  • Immunomodulatory agents used for the management of chronic lymphocytic leukemia patients may include:
  • Corticosteroids used for the management of chronic lymphocytic leukemia patients may include:
  • Tyrosine kinase and B-Cell receptor pathway inhibitors used for the management of chronic lymphocytic leukemia patients may include:
  • Idelalisib (targets phosphoinositide 3-kinase delta)
  • Ibrutinib (targets bruton tyrosine kinase)
  • The optimal immunochemotherapeutic regimens used for the management of chronic lymphocytic leukemia depends on a number of factors which include:[2]
  • The algorithm below summarizes the management approach for chronic lymphocytic leukemia patients:[1][2][3]


 
 
 
 
 
Initial patients evaluation
 
 
 
 
 
 
 
 
 
 
History
Physical examination
Complete blood count
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Staging
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Rai Staging System
Binet Staging System
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Rai stage 3-4
Binet stage B-C
 
 
 
Rai stage 0-2
Binet stage A
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Evaluate patients by cumulative index illness rating scale
 
 
 
Patients managed by observation and close follow-up
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Frail patients (CIRS ≥6)
 
Fit patients (CIRS <6)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Retixumab/obinutuzumab AND chlorambucil
 
FISH chromosomal analysis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Immunochemotherapeutic regimens for management of patients without chromosome 17p deletion or chromosome 11q deletion can be found here
 
Immunochemotherapeutic regimens for management of patients with chromosome 17p deletion can be found here
 
Immunochemotherapeutic regimens for management of patients with chromosome 17p deletion can be found here
 
 
 
 
 
 
 
 
 
 
 
 


Immunochemotherapeutic regimens for the management of patients without chromosome 17p deletion or chromosome 11q deletion

First line therapy

  • Preferred immunochemotheraptic regimens for the treatment of such patients who are older than 70 years of age include (in order of preference):[3]
  • Preferred immunochemotheraptic regimens for the treatment of such patients who are younger than 70 years of age include (in order of preference):

Refractory/relapsed therapy

  • Preferred immunochemotheraptic regimens for the treatment of such patients who are older than 70 years of age include (in order of preference):[3]
  • Preferred immunochemotheraptic regimens for the treatment of such patients who are younger than 70 years of age include (in order of preference):

Immunochemotherapeutic regimens for the management of patients with chromosome 17p deletion

First line therapy

  • Preferred immunochemotheraptic regimens for the treatment of such patients regardless the age group include (in order of preference):[3]

Refractory/relapsed therapy

  • Preferred immunochemotheraptic regimens for the treatment of such patients regardless the age group include (in order of preference):

Immunochemotherapeutic regimens for management of patients with chromosome 11q deletion

First line therapy

  • Preferred immunochemotheraptic regimens for the treatment such patients who are older than 70 years of age include (in order of preference):[3]
  • Preferred immunochemotheraptic regimens for the treatment such patients who are younger than 70 years of age include (in order of preference):
  1. ↑ 1.0 1.1 1.2 Nabhan C, Rosen ST (2014). "Chronic lymphocytic leukemia: a clinical review". JAMA. 312 (21): 2265–76. doi:10.1001/jama.2014.14553. PMID 25461996.
  2. ↑ 2.0 2.1 2.2 Hallek M (2015). "Chronic lymphocytic leukemia: 2015 Update on diagnosis, risk stratification, and treatment". Am J Hematol. 90 (5): 446–60. doi:10.1002/ajh.23979. PMID 25908509.
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 NCCN Guidelines Version 2.2015 CLL/SLL. National Comprehensive Cancer Network. (2015) http://www.nccn.org/professionals/physician_gls/PDF/nhl.pdf Accessed on October, 15 2015
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