67-year-old woman with recently diagnosed aggressive SLL (borderline IGHV mutated 3%; trisomy 12, 18 and 19; FBXW7 mutation at 1.1% VAF). She presented with lymphadenopathy and biopsy of neck lymph node revealed "accelerated" SLL with Ki-67 30%. PET revealed bulky lymphadenopathy in the axilla (5 cm range) but SUV max was only in the 3-4 range. Her lymphadenopathy appears to have developed quickly since a CT chest for lung cancer screening about a year ago revealed no lymphadenopathy. Labs at initial visit showed WBC of 3.23, hemoglobin 10.7, platelets 141. With prior labs showing iron saturation of 11% and known history of GERD/esophagitis, started her on iron supplementation to see if this would improve her anemia. Hemolysis labs were negative. At her return visit a few days ago, she is more symptomatic from her lymphadenopathy and labs revealed progression of pancytopenia with a WBC of 1.06 (ANC 340), hemoglobin 10, and platelets of 103. Results from bone marrow biopsy done a few days ago to confirm suspicion that the cytopenias are due to her SLL infiltration are pending. Gave her Neulasta to try and improve her neutrophil count, but suspect it may have limited benefit since the likely etiology is marrow infiltration. She consented to start treatment with acalabrutinib. Would you start treatment ASAP regardless of her ANC (and if so would you dose reduce the acala) or are there any strategies to improve her hematologic reserve before starting treatment?
I agree, it sound like SLL is causing her cytopenia. Bmbx is important to rule out comcomittent MDS picture. I generally feel comfortable proceeding with Acala full dose as it seems the main issue is CLL. However, since cytopenia is significant and BTKi tend to have less efficacy in bm disease. I would consider giving obinu with the Acala to clear the bone simultaneously while acala shrinks the LNs. For the neutropenia I would give ppx abx for now. One caveat to giving GCSF just hopefully you gave it after the bmbx as giving it before the bmbx could lead to falsely showing MDS changes
Oncologist Response:
Thank so much for the quick response. I am indeed keeping obin in mind, to start a few weeks after the acala per ELEVATE-TN (and had chosen acala over zanu given the possibility to add obin) though it looks like she will have a large co-pay with acala and I might need to go with zanu if that is more affordable. Did give her the G-CSF after the marrow (though I'm not expecting a significant response of her neutrophil count to it and will thus plan on proceeding with treating her SLL ASAP regardless of her ANC)
CLL Specialist:
You can still do obinu with zanu.
