Medical Challenge Question 11 Cancer

A 48 year-old man comes to the clinic for follow-up complaining of fatigue. He describes decreased ability to perform routine task at home. He reports no abnormal bleeding, fever, chills, or other complaints. Currently he is taking no medication. His family history is significant for a mother with transfusion-dependent myelodysplastic syndrome and siblings who are well.

On exam, his vital signs are normal. Enlarged cervical, axillary, and inguinal lymph nodes are palpated. Splenomegaly extends 15 cm below the costal margin at the anterior axillary line. The remainder of the examination is unremarkable.

Laboratory studies show a hemoglobin level of 9.1 g/dL, a leukocyte count of 40,000/μL with 70% small mature lymphocytes, and a platelet count of 50,000/μL.

A biopsy of a lymph node is positive for chronic lymphocytic leukemia. Flow cytometry show small mature B cells co-expressing CD5 and CD23. Fluorescence in situ hybridization indicates a chromosome 17p deletion.

His chest radiograph is normal. CT scans of the chest, abdomen, and pelvis show extensive cervical, axillary, abdominal, and pelvic lymphadenopathy and splenomegaly.

Which of the following is the most appropriate next step in treatment?

A. Hematopoietic stem cell transplantation

B. Leukapheresis

C. Lymph node radiation

D. Splenectomy

E. Start ibrutinib

References:

Burger JA, Tedeschi A, Barr PM, et al. Ibrutinib as Initial Therapy for Patients with Chronic Lymphocytic Leukemia. The New England journal of medicine. 2015;373(25):2425-2437. doi:10.1056/NEJMoa1509388.
van Besien K, Keralavarma B, Devine S, Stock W. Allogeneic and autologous transplantation for chronic lymphocytic leukemia. Leukemia. 2001 Sep;15(9):1317-25.