Updates in CLL: Optimizing Testing Rates - Episode 3
Recommendations for conducting imaging scans and biopsies to help guide the treatment of newly diagnosed chronic lymphocytic leukemia.
Alexey Danilov, MD, PhD: When my patients have newly diagnosed CLL [chronic lymphocytic leukemia], when we talk about all the prognostic tests that we do, we also talk about some diagnostic tests. We talk about immunophenotyping, flow cytometry, and I typically do that on peripheral blood. They sometimes ask me, “Do I need to get a bone marrow biopsy? Do I need to get a CT scan?” What do you tell them, Anthony?
Anthony Mato, MD, MSCE: I generally tell them no, particularly if there’s no cytopenia that’s hard to explain. There’s no rationale for CT imaging, particularly if I’m not thinking about treating them. The risks of the radiation, contrast dye, and morbidity associated with the bone marrow biopsy aren’t worth it. There’s almost nothing you can learn from a bone marrow that you couldn’t learn from peripheral blood study, except for maybe getting a better karyotype. For iwCLL [International Workshop on Chronic Lymphocytic Leukemia], it’s not required at diagnosis. It’s not even required in clinical care unless there’s a cytopenia that needs to be explained. I don’t do them, although I’m very surprised by the number of patients I see in consultation who come in with a bone marrow biopsy, lymph node biopsy, and peripheral blood studies. I often think it’s overkill. What do you think?
Alexey Danilov, MD, PhD: I completely agree. In this particular situation, less is more. With CLL, unless I’m suspicious of some other process going on, I try to be minimalistic. For me, when a patient is referred with lymphocytosis and I suspect CLL, peripheral blood flow cytometry is typically sufficient, combined with clinical exam. It’s fairly easy to detect splenomegaly or superficial lymph nodes, so I don’t do CT scans. I don’t perform a bone marrow biopsy. If I suspect disease transformation, Richter syndrome, I might consider CT scans or a PET [positron emission tomography]-CT to look for SUV [standardized uptake value] activity. That’s another test that I don’t do for CLL outside of that setting. PET-CT isn’t recommended or particularly informative unless you’re looking for transformation. But I do see that some patients are referred and get PET-CTs. I also think it’s overkill in terms of testing.
Anthony Mato, MD, MSCE: I completely agree.
Transcript edited for clarity.