Treatment Sequencing in a Chronic Lymphocytic Leukemia Patient with Central Nervous System Involvement

Figure 2

Evaluation of the CNS response and the clinical outcomes over time. (a) Flow cytometry analysis of the CSF over time, illustrating the % of CLL cells detected. The absolute number of counted CLL cells present in the diluted sample is shown underneath the percentage of cells detected, in dark grey. (b) Treatment course followed, illustrating therapy combinations and ibrutinib interruptions as well as the patient’s clinical outcomes. Triple IC with methotrexate, cytarabine, and prednisone was administered 15 times, biweekly, but did not result in a positive response. Liposomal cytarabine was given 2 times (on the 10th and on the 24th of November 2015) but led to no response and might have led to the worsening of the neurologic symptoms due to a toxic myelitis. After resolution of the first toxicity (grade-2 hematuria), systemic high-dose methotrexate was administered together with ibrutinib. Whole-brain radiotherapy was administered (30 Gy/10 fr, in a regimen of 3 Gy/cycle/day, from the 24th of November until the 9th of December 2016) to decrease the CSF infiltration. After the first interruption, ibrutinib was restarted at 140 mg/day and then weekly increased to 280 mg/day and to 420 mg/day. After the second interruption, it was restarted at full dose (420 mg/day).