Case Presentation: Elderly Patient With CLL With High-Risk Features and Chronic Medical Issues

John Allan, MD, Weill Cornell Medicine, New York, New York, provides background on an elderly patient with high-risk, deletion 17p chronic lymphocytic leukemia (CLL) who also has chronic medical problems such as atrial fibrillation.

In this case, the patient is a 75-year-old man who was referred to a previous hematologist by his primary care physician when he was found to have an asymptomatic lymphocytosis. This patient is otherwise generally fit for his age but has some chronic medical problems, including atrial fibrillation, which is well-controlled on beta blockers. He is currently taking [apixaban] (Eliquis). The patient also has diabetes, which is well-controlled on a diabetic regimen, and is working closely with an endocrinologist.

The patient was initially diagnosed in December of 2021. At that time, the patient had a measured absolute lymphocyte count of 18,000, and he was diagnosed with chronic lymphocytic leukemia (CLL). Following the workup by the previous hematologist, the patient was found to have relatively high-risk disease with an unmutated immunoglobulin heavy chain variable region (IGHV), a deletion 17p, and a trisomy 12 (+12) coexisting together, and on sequencing, a P53 mutation.

The patient was recommended for observation, and he started to progress late in 2023. During this time, the patient’s medical team changed. The current treating hematologist repeated the diagnostic workup and again identified these high-risk features with deletion 17p present, as well as the trisomy 12. The P53 mutation was also identified and in this 3-year period, there [were] no new mutations or additional clonal evolution notice.

The unmutated IGHV was also identified, and an extra step was completed that isn't commonly done in community settings, where the CLL cells were karyotyped. Results did not identify a high complex karyotype. The patient’s white blood count began pushing up to about 60,000, and while there wasn't a lot of lymphadenopathy palpable, there was a clear trend in the hemoglobin dropping, with the hemoglobin approaching 11 and platelets around 110, 115 from normal the few years earlier.

This patient case is of interest due to his age, chronic medical problems such as atrial fibrillation and diabetes, and the high-risk molecular features getting close to, or meeting, indications for therapy.