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Oncology


Answer 1
  1. No treatment is indicated at this time. This patient has stage 0 CLL, and no therapy is warranted. Early treatment of CLL has not been demonstrated to prolong survival compared with observation and delayed initiation of therapy.1 Reasons to consider treatment include increasing symptoms (fatigue, night sweats, weight loss), a lymphocyte count that doubles in less than 6 months, significant anemia or thrombocytopenia, or symptomatic lymphadenopathy. When patients do need treatment, single-agent chlorambucil (an alkylating agent) or fludarabine (a nucleoside analog) both are appropriate, but there is a higher response rate with fludarabine. The combination of chlorambucil and fludarabine is relatively toxic, and the treatment arm of a trial that included this combination was closed early.2 Patients with CLL rarely get symptomatic leukostasis, so hydroxyurea is almost never indicated. Bone marrow transplantation may cure a small percentage of patients with CLL, but this treatment is quite toxic and not appropriate as an initial therapy.

    REFERENCES
    1. Natural history of stage A chronic lymphocytic leukaemia untreated patients. French Cooperative Group on Chronic Lymphocytic Leukaemia. Br J Haematol 1990;76:45–57.

    2. Rai KR, Peterson BL, Appelbaum FR, et al. Fludarabine compared with chlorambucil as primary therapy for chronic lymphocytic leukemia. N Engl J Med 2000;343:1750–7.

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