Chronic lymphocytic leukemia is a malignant blood disorder characterized by the proliferation of abnormal B lymphocytes in the blood, lymph nodes, and bone marrow. It generally occurs after age 70 and is the fourth most common blood cancer in France, following multiple myeloma, diffuse large B-cell lymphoma, and myelodysplastic syndromes.
Treatments have advanced since 2015 with the introduction of immunotherapy and targeted therapies. The BCL2 inhibitor (venetoclax) is one of these innovative treatments. It is recommended as first-line therapy and for relapse in combination with anti-CD20 monoclonal antibodies and Bruton's tyrosine kinase inhibitors. Early studies showed that initial administration of venetoclax as monotherapy could lead to lysis syndrome as early as the first few days of treatment. This risk was correlated with the venetoclax dose and tumor burden. Prevention guidelines were subsequently proposed to guide management. This risk is therefore assessed before treatment begins (low, moderate, high), based on lymph node size and circulating lymphocyte count.
For patients at moderate and high risk, a treatment strategy is recommended that includes hyperhydration and uric acid-lowering agents, which may require hospitalization in some cases. The introduction of combination therapies has improved the depth and duration of response (obinutuzumab + venetoclax and ibrutinib + venetoclax). Venetoclax is added after the initiation of partner agents (22 days after obinutuzumab and 3 cycles after ibrutinib). This initial phase of treatment may reduce the risk of hemolytic syndrome. We propose here to reassess the risk of hemolytic syndrome before starting venetoclax in order to simplify management.
Patients with chronic lymphocytic leukemia/lymphocytic lymphoma
Meeting the treatment criteria according to iwCLL 2018
Eligible for treatment with venetoclax in combination with a Bruton's tyrosine kinase inhibitor (ibrutinib, other approved generations) or obinutuzumab
First-line treatment or relapse
Patients with meningeal and/or cerebral involvement
Patients with an active, uncontrolled infection
Patients scheduled to receive venetoclax monotherapy or rituximab-venetoclax according to the MURANO study regimen (Murano regimen: venetoclax is administered before rituximab)
Contraindications to contrast-enhanced CT scanning (severe renal insufficiency, documented allergy to contrast agents).
Single group
Cervical, Thoracic, Abdominal, and Pelvic CT Scan
Procedure/SurgeryCervical, Thoracic, Abdominal, and Pelvic CT Scan
risk level for tumor lysis syndrome
SLT is defined as any clinical and/or biological manifestation related to the destruction of tumor cells. It can be spontaneous (related to rapid disease progression, a rare occurrence in CLL) or treatment-induced. Clinical SLT may involve renal failure with decreased urine output and lower extremity edema, cardiac arrhythmias, fever, and seizures; its intensity may vary depending on severity. Biochemical SLT is defined by the presence of hyperkalemia, elevated serum creatinine levels, hyperuricemia, hyperphosphatemia, or hypocalcemia.
Event-free survival
Event free survival defined as the time from the date of enrollment to the date of the first event of interest. The events of interest in the study are: treatment reduction or discontinuation, relapse or disease progression, death, and any grade ≥ 3 event.
Change from baseline in EORTC QLQ-CLL17 total score
Health-related quality of life will be assessed using the European Organisation for Research and Treatment of Cancer Chronic Lymphocytic Leukemia questionnaire (EORTC QLQ-CLL17). Scores are linearly transformed to a 0-100 scale. Higher symptom scores indicate greater symptom burden and therefore a worse outcome, whereas higher functioning scores indicate better functioning and therefore a better outcome.
Progression-free survival
Progression-free survival is defined as the time from enrollment to the first documented disease progression according to iwCLL criteria or death from any cause, whichever occurs first. Patients without progression or death will be censored at the date of their last disease assessment.
Overall Survival
Overall survival is defined as the time from enrollment to death from any cause. Patients who are alive at the time of analysis will be censored at the date of last known contact.
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