MONTHLY QUIZ: The cancerous B lymphocytes that cause our CLL can proliferate in all the following areas of the body except:
- The lymph nodes
- The bloodstream
- The bone marrow
- The spleen
ANSWER: The correct answer is # 2. CLL is a cancer of the B cells. It is both a leukemia and lymphoma. The cancer clonal cells accumulate in the blood hence the high lymphocyte count. However, they only proliferate or reproduce in the nodes, bone marrow, and the spleen. They cannot reproduce in the bloodstream.
NEWS: Since we last met, there has been much regulatory news, all of it good:
- A 3rd dose of the Pfizer and Moderna had been authorized for the immunocompromised including those with CLL.
- The Pfizer vaccine was fully approved, no longer just available through emergency use authorization (EUA).
- Regen-Cov was authorized for post exposure prophylaxis meaning that you no long must wait to test positive to receive the anti-COVID-19 mix of antibodies if you had a high-risk exposure.
Several trials have now shown while some of us will respond to the vaccines, and some won’t. A greater percentage of immunocompromised patients are having “breakthrough” infections and are being hospitalized.
The AZD7442 PROVENT trial showed that an injection of antibodies pre- exposure reduced the risk of symptomatic COVID-19 by 77%. The injection should provide 6-12 months of protection.
Save the date: Join us on September 24th for COVID-19 Virtual Community Meeting: The Delta Variant and Staying Protected, register here. Faculty: 2 top CLL doctors, a virologist, and an infectious disease doctor.
Everyone should complete their own COVID-19 checklists on the website. They can really help in a crisis.
BASICS: Types of CLL Treatment – This month we start describing broad categories of therapy.
Chemo-immunotherapy (CIT) used to be the main treatment for CLL. Today, depending on which CLL expert you consult, there would be no role or a very limited role for only a few frontline patients with the best predictive markers. Sadly, it is being used often in the community. It consists of chemo drugs that damage the cell’s DNA and so non-specifically kill anything that grows quickly such as cancer cells, but also skin, hair, gut, and normal blood cells. In CLL, common drugs are fludarabine (F), cyclophosphamide (C), bendamustine (B), and chlorambucil. Chemo is more effective when combined with immunotherapy (IT), usually a monoclonal antibody (mAb): rituximab (R) and obinutuzumab (Gazyva) that target a specific marker (CD20) found only on CLL and normal B cells. Common CIT are FCR, BR and chlorambucil and obinutuzumab. There is NO role for chemotherapy alone to treat CLL, though that too is still used by many community hematologists. Studies have shown that ibrutinib in almost all situations is superior to both FCR and BR, making the role of CIT even more limited.
WORD/ACRONYM OF THE MONTH: CD
CD or Clusters of Differentiation are proteins on the cell surface used by flow cytometry (cellular fingerprinting) for diagnosis of CLL, or to look for measurable (minimal) residual disease. They are also a target for monoclonal antibodies and CAR-T to attack, such as how rituximab seeks CD20 or CAR-Ts seek CD19.
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