Guidelines for the Management of Haematological Malignancies

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Lymph node biopsy is indicated if: The diagnosis is uncertain from the peripheral blood and bone marrow examinations. To assess localized bulky lymphadenopathy to exclude transformation CT-scans/US If the presence of splenomegaly is uncertain on physical examination To assess lymphadenopathy prior to therapy Management of CLL All newly diagnosed patients with CLL should have their management defined by a formal Multi- Disciplinary Team Meeting. Monoclonal B-lymphocytosis (CLL phenotype) – MBL-CLL MBL-CLL is defined as the presence of a B-cell clone that has a CLL immunophenotype but at a level too low to meet the current criteria for the diagnosis of CLL (50% increase over 2 months lymphocyte doubling time 10% in previous 6 months Fever >38 o C for >2 weeks Extreme fatigue Severe night sweats Autoimmune cytopenias which are poorly controlled by corticosteroids. Guidelines for the Management of Haematological Malignancies 8. CHRONIC LYMPHOCYTIC LEUKAEMIA 18
Initial therapy for advanced CLL There are several trials to be opened in the near future for untreated advanced CLL: CLL 6: For patients without comorbidities to address the role of rituximab and mitoxantrone, to be started by the end of 2007. (Level 1) CLL208/CLL7: For patients with co-morbidity to address role of rituximab added to chlorambucil. (CLL208-Single arm Phase II trial of chlorambucil+rituximab by summer 2007 and CLL7-Randomised Phase III trial comparing chlorambucil +/- rituximab by 2008) (Level 1) CLL205 (CamPred) study- Trial open for patients with 17p deletion. Chlorambucil and fludarabine are both licensed for the front-line therapy of CLL. Fludarabine monotherapy as front-line therapy results in higher response rates and prolonged progression-free survival compared to chlorambucil but does not result in an improved overall survival. The combination of fludarabine with cyclophosphamide results in higher response rates and prolonged progression-free survival compared to fludarabine monotherapy. (Eichhorst, Busch et al. 2003; Flinn, Kumm et al. 2004; Catovsky, Richards et al. 2005)The follow-up of the key trials comparing fludarabine to FC is not mature enough to address the question of overall survival. FC has several advantages over fludarabine alone which include: lower incidence of autoimmune haemolytic anaemia lower cost (due to lower dose of fludarabine used in FC) higher response rates and prolonged progression-free survival Recommendations for initial therapy in CLL: In patients without significant co-morbid conditions (regardless of age) the combination of fludarabine plus cyclophosphamide (FC) should be considered standard first line therapy for the above reasons. NICE has not reported on the FC combination but has recommended against single agent Fludarabine. (more cytopenias were observed with FC in patients over 70 years of age in the LRF CLL4 trial but FC therapy was still significantly superior in terms of response rate and progression-free survival). (Level 1) Patients considered fit enough for more intensive therapy and achieving a very good partial response or a complete remission should be considered for entry into MRD eradication trial CLL207 (Single arm Phase II trial of alemtuzumab consolidation) or its successor CLL8 (Randomised Phase III trial comparing alemtuzumab consolidation versus watch and wait.) when they are open. (Level 1 or 2 decided by MDT) Chlorambucil is indicated for elderly patients and those with significant co-morbid conditions. (Level 1) Relapsed but not refractory CLL (fludarabine-sensitive relapse) Patients who have no significant co-morbid conditions should be considered for entry into the NCRI FCM/FCM-R trial (a randomised Phase II trial of FCM [fludarabine + cyclophosphamide + mitoxantrone] versus FCM-rituximab). (Level 1) Patients with relapsed but not refractory CLL who are not eligible or decline entry into the NCRI FCM/FCM-R trial should be considered for re-treatment with the same therapy as long as their initial remission was at least a year from the end of therapy. If the initial therapy was fludarabine alone then it is reasonable to re-treat with FC (see above). Patients relapsing between 6 and 12 months after completing initial therapy should be considered for alternative therapies such as FC or FCM. (Level 1) Patients who are considered eligible for either conventional myeloablative or reduced intensity conditioning allogeneic stem cell transplantation should be referred for an opinion to the CLL MDT in Leeds either after initial therapy (if they have adverse prognostic features) or following second-line therapy. (Level 4) Fludarabine-refractory CLL The prognosis for patients with fludarabine-refractory CLL treated with conventional therapy is very poor with a median survival of less than 12 months and a 5-year survival of approximately 10%. The incidence of p53 pathway abnormalities in these patients is extremely high and probably largely Guidelines for the Management of Haematological Malignancies 8. CHRONIC LYMPHOCYTIC LEUKAEMIA 19
Page 1 and 2: Yorkshire Cancer Network and Humber
Page 3 and 4: 18 MYELODYSPLASTIC SYNDROMES ......
Page 5 and 6: 2 IMAGING FOR HAEMATOLOGICAL MALIGN
Page 7 and 8: 3 CLASSICAL HODGKIN LYMPHOMA Key Is
Page 9 and 10: Assessments • Assessments should
Page 11 and 12: 5 DIFFUSE LARGE B-CELL LYMPHOMA (DL
Page 13 and 14: • Patients not considered candida
Page 15 and 16: 7 FOLLICULAR LYMPHOMA Key Issues
Page 17: 8 CHRONIC LYMPHOCYTIC LEUKAEMIA The
Page 21 and 22: 9 MANTLE CELL LYMPHOMA Key Issues U
Page 23 and 24: • Splenectomy should only be cons
Page 25 and 26: • Surgery is generally to be avoi
Page 27 and 28: 13 PERIPHERAL T-CELL LYMPHOMA Key I
Page 29 and 30: Relapse Treatment • Patients with
Page 31 and 32: Essential Investigations • CT sca
Page 33 and 34: • Peripheral blood for flow cytom
Page 35 and 36: Guide to treatment options by stage
Page 37 and 38: 15.3 Plasmacytoma of Bone Diagnosti
Page 39 and 40: 15.6 Amyloidosis Primary and Relaps
Page 41 and 42: Primary Treatment BCSH guidelines s
Page 43 and 44: Patients aged 15-24 (up to 25th bir
Page 45 and 46: 18 MYELODYSPLASTIC SYNDROMES Diagno
Page 47 and 48: • Both the degree of thrombocytop
Page 49 and 50: • Patients presenting in blast cr
Page 51 and 52: A more difficult decision concerns
Page 53 and 54: Diagnostic Criteria With the except
Page 55 and 56: 21.4 Reporting Standards All specim
Page 57 and 58: All members of Haemato-oncology MDT
Page 59 and 60: 22.3 Clinical Support • On-site a
Page 61 and 62: • Principle treatment centres mus
Page 63 and 64: • It is envisaged that relevant s
Page 65 and 66: 24.4 Acute Myeloid leukaemia There
Page 67 and 68: Data Collection The network is obli
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27 FLIP Index for Follicular Lympho
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29 BINET DISEASE STAGE FOR CLL STAG
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31 ECOG PERFORMANCE STATUS Grade EC
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33 WEBSITES UK Websites HMDS www.hm
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Dearden, C. E., E. Matutes, et al.
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Mead, G. M., M. R. Sydes, et al. (2
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35 Appendices DRAFT Haematological
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CT: Routine staging should include
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Multiple Myeloma and Related Disord
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Host factor, Microbiological and cl
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Guidelines for the Management of Haematological Malignancies

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