Clinician-to-Clinician Update Clinician-to-Clinician Update

Patient with Refractory CLL Achieves Durable Response in Immunotoxin Trial

October 2015

Contributed by Veronika Bachanova, MD

Quality of life is a key consideration in elderly patients with relapsed/ refractory hematologic malignancies. Here we describe an 80-year-old woman with refractory chronic lymphocytic leukemia (CLL) who requested that her next therapeutic plan minimize side effects. She was effectively treated in a phase 1 trial of the DT2219 immunotoxin, resulting in a partial response that has been durable for the past 15 months.

Fig-1-case-study Hem-Cancers-Consult-10-7-v.2
— Figure 1. CT scan of the patient’s abdomen showing a large tumor mass before treatment with DT2219.

Patient

An 80-year-old woman presented at the Masonic Cancer Clinic with a long-standing history of CLL refractory to chemotherapy, which included treatments with chlorambucil, bendamustine, lenalidomide, and rituximab. She had progressive CLL and presented with a slowly growing large abdominal mass over 20cm in size (Figure 1), progressive fatigue, weight loss, and widespread adenopathy. The patient had a good performance status, and she strongly desired a new treatment with a tolerable safety profile that would not make her feel more ill.

Management

The team recommended that the patient enroll in the ongoing phase I study of the DT2219 immunotoxin, and she agreed. She received 1 cycle of DT2219 (a total of 4 doses spaced 48 hours apart), which she tolerated well. Following only one cycle of treatment, a follow-up CT scan showed that the abdominal mass had been reduced approximately 40% in size, indicating a partial response (Figure 2). The patient reported significant improvements in her appetite and energy and was pleased with the treatment. After 4 months, the patient began maintenance therapy with ibrutinib. She continues to feel better and is still in partial remission at 15-months follow-up.

Fig-2-case-study Hem-Cancers-Consult-10-7-v.3
— Figure 2. Repeat scan of the same patient after 1 cycle of therapy with DT2219. The abdominal mass has reduced by 40%.

Discussion

Although the introduction of immunochemotherapy has improved overall survival rates over the past 5 years, CLL remains an incurable disease except in a percentage of patients who undergo allogeneic donor transplantation.1 Unfortunately, with allogeneic transplantation, there is a risk of treatment-related mortality, and at least 25% of survivors will experience chronic graft-versus-host disease during the first few post-transplant years and some require ongoing treatment. For these reasons, allogeneic transplantation is not generally undertaken in elderly patients with poor-risk CLL. Because the patient in this case study specifically requested a therapy that would maintain her quality of life, the team determined that enrollment in the phase I clinical trial of DT2219 was her best option, and the patient concurred. With this therapy, she experienced a positive outcome at 15-months post-DT2219 treatment.

References

  1. Dreger P, Schetelig J, Andersen N, et al. Managing high-risk CLL during transition to a new treatment era: stem cell transplantation or novel agents? Blood. 2014;124:3841-3849.
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