August 2019

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MONTHLY QUIZ: CT scans should be used in CLL:

1. At time of diagnosis to establish a baseline.
2. Before treatment to assess staging.
3. After treatment to assess response.
4. Only in combination with a PET scan to assess both anatomy and the metabolic activity of any nodes or masses.
5. While they may be needed in some circumstances, outside of a clinical trial there is no mandatory role for CT imaging.

ANSWER: The correct answer is # 5. While there are many circumstances where a CT may be helpful, their routine use with diagnosis or treatment is not generally indicated. PET scans measure metabolic activity and are used to look for a second cancer such as Richter’s Transformation (RT). RT is more metabolic active than CLL and therefore and will “light up” on a PET scan. Outside of clinical trials, CT and PET scans are not helpful in the routine management our CLL. For more details, see: https://cllsociety.org/beyond-the-basics/what-about-ct-scans/

NEWS:

On July 23, 2019 the U.S. Food and Drug Administration (FDA) approved rituximab-pvvr a biosimilar to rituximab for treatment of CD20-positive non-Hodgkin B-cell Lymphoma and CLL. Others have been approved too, but it doesn’t mean that we can start saving money because none are available due to patent litigation. More info see: https://cllsociety.org/2019/07/approval-of-a-biosimilar-for-rituximab/

The Lymphoma & Myeloma Congress, an annual conference for advances, innovation and research on hematologic malignancies, is taking place October 23-26 in New York City. More info is available on https://cllsociety.org/upcoming- cll-patient-education-programs/

BASICS: Response to Therapy

In order to be consistent, doctors and researchers have agreed on standard ways to describe response to therapy. The definitions are actually quite technical and are changing. This is a simplified version. We start with the worst and work towards the best.

Progressive disease (PD): As the name suggests, the cancer continues to grow despite the treatment. This is not good news.

Stable disease (SD): The cancer neither progresses nor recedes. This can be a durable and quite an OK circumstance, especially if the CLL is not causing problems.

Partial Remission (PR): The cancer has been knocked back, but there are still cancer cells to be found in the blood or marrow or nodes. PR requires at least a 50% reduction in the size of lymph nodes and in the number of lymphocytes in the peripheral blood stream.

Complete Remission (CR): The absence of clonal lymphocytes in the blood is one of the major criteria. All lymph nodes need to be normal size (<1.5 cm). In a clinical trial, the confirmation of a CR usually requires a bone marrow biopsy that shows no CLL.

Undetectable Minimal Residual Disease (U-MRD): This is the best news with the longest durations of response. Special tests can be used to find a single CLL cell hiding among 10.000 or more cells in the blood or bone marrow. If no cells are found, you are U-MRD, a very good thing. Just to confuse things, it is possible to be U-MRD and be in a PR if your nodes are still enlarged. This happens when enlarged nodes don’t shrink back to normal size but are cancer free.

WORD OF THE MONTH: FLOW CYTOMETRY

Flow Cytometry is a powerful blood test that looks at markers on the cell surface. It is the test to confirm the diagnosis of CLL by identifying the typical clonal population of cells (CD19, CD20(dim), CD23 and CD5). It can also find CLL when there is only one cancer cell in 10,000 lymphocytes.

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