Diagnosis
Suspicion of chronic lymphocytic leukemia (CLL) or mantle cell lymphoma (MCL). The exact diagnosis has not been established. The patient doubts the appropriateness of the prescribed treatment.
Patient:
Male, 63 years old, Kazakhstan
Physician:
Director of Department of Oncology, Hematology, and Stem Cell Transplantation, University Hospital Essen, Professor Peter Reimer
Patient Questions
- Was the diagnosis made correctly?
- Is R-BAC therapy appropriate considering the diagnosis and the patient’s cardiac status?
- Can chemotherapy cause pain in the right upper abdomen even if liver tests are normal?
- Can metastases cause facial distortion?
Professor Reimer’s Answers
- Based on the reports provided, it is difficult to clearly distinguish chronic lymphocytic leukemia from mantle cell lymphoma. However, this is the decisive point. I recommend a repeat review of the biopsy material by an experienced pathologist specializing in lymph nodes and bone marrow.
- In Germany, the use of the R-BAC protocol is very uncommon. Given the patient’s cardiac status, anthracyclines should be avoided. However, in my view, the therapeutic strategy here is not entirely clear. For purely palliative treatment, I would recommend R-Bendamustine; if intensive, high-dose therapy is feasible, then R-DHAP. For chronic lymphocytic leukemia, a completely different strategy is used depending on treatment intensity — for example, R-FC; Obinutuzumab–Chlorambucil; Ibrutinib.
- Chemotherapy very rarely causes localized pain in the right upper abdomen. In this case, an abdominal ultrasound — or if necessary, a CT scan — should be performed.
Following Prof. Reimer’s recommendation, an additional bone marrow FISH analysis was performed; it did not show IHG/CCND1 rearrangement. CSF analysis was also within normal limits.
Additional Patient Questions
- Considering the FISH result, which diagnosis do you consider more likely?
- What treatment plan do you recommend?
- What could be the cause of facial asymmetry?
Physician’s Answers
- The absence of an IHG/CCND1 gene rearrangement — which can be interpreted as the absence of a cyclin D translocation — speaks against the diagnosis of mantle cell lymphoma.
- Since we assume the diagnosis is chronic lymphocytic leukemia (CLL) and the patient is in good general condition, treatment with Rituximab/Fludarabine/Cyclophosphamide is reasonable. If the patient’s current condition is not satisfactory, then Rituximab/Bendamustine or Obinutuzumab/Chlorambucil. If a 17p deletion is detected, therapy with Ibrutinib may also be indicated.
- The fact that CSF analysis was normal, combined with an MRI that also showed no abnormalities, indicates that facial asymmetry is not directly related to lymphoma. I can assume that this may be associated with previous medical treatment or lymphotherapy. Sometimes the cause cannot be determined, and inflammatory nerve changes often improve over time.
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