COVID-19 in patients with chronic lymphocytic leukemia: a multicenter analysis by the Czech CLL study group

Patients with chronic lymphocytic leukemia (CLL) have a high risk of poor outcomes related to coronavirus disease 2019 (COVID-19). This multicenter cohort study evaluated the impact of COVID-19 infection on the population of CLL patients in the Czech Republic. Between March 2020 and May 2021, 341 patients (237 males) with CLL and COVID-19 disease were identified. The median age was 69 years (range 38-91). Out of the 214 (63%) patients with the history of therapy for CLL, 97 (45%) were receiving CLL-directed treatment at diagnosis of COVID-19: 29% Bruton tyrosine kinase inhibitor (BTKi), 16% chemoimmunotherapy (CIT), 11% Bcl-2 inhibitor, and 4% phosphoinositide 3-kinase inhibitor. Regarding the severity of COVID-19, 60% pts required admission to the hospital, 21% pts were admitted to the intensive care unit (ICU), and 12% received invasive mechanical ventilation. The overall case fatality rate was 28%. Major comorbidities, age over 72, male gender, CLL treatment in history, CLL-directed treatment at COVID-19 diagnosis were associated with increased risk of death. Of note, concurrent therapy with BTKi compared to CIT was not associated with better outcome of COVID-19.

Real-world data on efficacy and safety of obinutuzumab plus chlorambucil, rituximab plus chlorambucil, and rituximab plus bendamustine in the frontline treatment of chronic lymphocytic leukemia: The GO-CLLEAR Study by the Czech CLL Study Group

Until recently, a combination of anti-CD20 antibody plus less intensive chemotherapy was a standard of care in elderly population with previously untreated chronic lymphocytic leukemia (CLL). The aim of this observational study was to retrospectively assess efficacy and safety of obinutuzumab + chlorambucil (G-Clb), rituximab + chlorambucil (R-Clb), and bendamustine + rituximab (BR) given as the frontline therapy within routine practice. The final analyzed dataset included 398 consecutive CLL patients from 10 hematology centers cooperating within the Czech CLL Study Group: 63 treated with G-Clb, 78 with R-Clb, and 257 with BR. There were no significant differences in prognostic and predictive markers among the groups. On the contrary, median age at the start of therapy and cumulative illness rating scale (CIRS) score was significantly higher in R-Clb group. Obinutuzumab plus chlorambucil regimen was preferably offered to elderly patients (compared to BR) with less severe comorbidities and lower CIRS score (compared to R-Clb). A time period when a treatment was indicated had also a strong impact on the choice of the regimen. The overall response rate reached 76% (30% complete remissions, CRs) in G-Clb, 75% (22% CRs) in R-Clb, and 85% (47% CRs) in BR group. Median event-free survival was 49.0 months for G-Clb, 20.3 months for R-Clb, and 37.0 months for BR group. Neutropenia grade ≥ 3 developed in 43% of G-Clb, 31% of R-Clb and in 49% of BR patients, grade ≥ 3 infections were recorded in 17% of G-Clb, 6.4% of R-Clb, and 17% of BR patients. In conclusion, real-world therapeutic activity of G-Clb appears to be at least comparable to prospective clinical trial data. R-Clb yields relatively good results in very old and severely comorbid patients.

[Long-term treatment of venous thromboembolism in patients with cancer]

BACKGROUND

The treatment with low-molecular-weight heparin (LMWH) is recommended for patients with cancer associated thrombosis (CAT) during the first 6 months; the initial therapeutic dose can be reduced to 60-75 % after one month. The therapy should be reevaluated after 6 month and subsequent therapy using LMWH or warfarin is recommended indefinitely, unless the cancer is resolved or any major contraindications arise.

AIMS

To analyze the usage of various treatment modalities in CAT patients after the initial 6 month period according to the course of cancer.

PATIENTS AND METHODS

87 patients with CAT were followed prospectively during the treatment period. The proportion of patients, in whom LMWH was replaced by warfarin during the first 6 months and during the entire follow up, was analyzed in relation to the course of the cancer. The χ2 test and χ2 test with Yates correction were used for the statistical evaluation.

RESULTS

The median follow-up was 445 days, mean duration of follow up was 743 days. 6 months after the diagnosis of thrombosis 9/30 (31.0 %) patients with complete remission (CR) of the cancer were treated with warfarin, while only 3/12 (25 %), 0/9 (0 %) and 1/13 (7.7 %) of the patients with partial remission (PR), stable disease (SD) and progression, respectively, were treated with warfarin. Patients with CR and PR were more frequently treated with warfarin than patients with SD or progression (P = 0.02). 13 patients died during the first 6 months, and 8 patients were followed less than 6 months. During the entire follow up, 25/30 (83.3 %) patients with CR switched to warfarin, while only 5/12 (41.7 %), 1/9 (11.1 %) and 1/13 (7.7 %) patients with PR, SD, and progression, respectively, were treated with warfarin. The proportion of patients with CR which switched to warfarin was higher, than the proportion of patients with PR (P = 0.007), with SD (P = 0.0003), and with progression (P < 0.0001). Median time from thrombosis onset to the switch from LMWH to warfarin was 219 days in patients in complete remission after 6 months and was not reached in patients in PR,SD, and progression.

CONCLUSIONS

The course of malignant disease is important for the choice of appropriate therapy of CAT after the initial period of LMWH therapy. The patients achieving complete remission are more prone to switch from LMWH to warfarin.

KEY WORDS

cancer - low-molecular-weight-heparin - venous thromboembolism - warfarin.

[Thrombophilic states: their relevance in prevention and treatment of venous thromboembolism]

Thrombophilic states are congenital or acquired haemostasis disorders with pathophysiological and statistical association to increased risk of thrombosis. Venous thromboembolism is their most important clinical manifestation. More than 50% of patients with unprovoked thrombosis have one of the known thrombophilias. Patients with congenital thrombophilias have, in comparison to those without thrombophilia, increased risk of the first thromboembolic event, while the impact of genetically defined thrombophilic states on recurrence is less evident. The risk of recurrence in patients with idiopathic thrombosis is 7-10% per year even in the absence of a known thrombophilia. The risk of recurrent event is affected by a range of other factors (persisting or undiagnosed precipitating factor, proximal thrombosis and pulmonary embolism, incomplete recanalization, vessel thrombosis, presence of some thrombophilias, high D-dimmer levels after anticoagulant therapy discontinuation). Identification and subsequent monitoring of these factors is crucial for optimal selection of the treatment to be used as a secondary prevention of venous thromboembolism and its duration. Primary prevention of venous thromboembolism requires good knowledge of general precipitating factors as well as the specific risks in each patient and thus also means an early investigation of thrombophilic states in patients who will benefit from their identification and in whom there is at least medium probability of their identification. Universal long-term prevention in so far asymptomatic carriers of congenital thrombophilias is not indicated considering the potential complications of anticoagulant treatment. Women with thrombophilic disorders have an increased risk of thromboembolic event if using hormonal contraception and during pregnancy. They also have an increased risk of pregnancy complications related to placental circulation blood flow disorders.

[Thrombophilic conditions in the pathogenesis of venous thromboembolism]

Thrombophilic conditions are congenital or acquired hemostatic disorders pathophysiologically or statistically associated with higher risk of thrombosis. Their most important clinical manifestation is venous thromboembolism. In more than 50% of persons with non-induced thrombosis, some of the known thrombophilias can be found. Persons with congenital thrombophilias have, contrary to those without any thrombophilias, most of all an increased risk of an initial thromboembolic event while the impact of congenital thrombophilic conditions on their recurrence is not so clear. In patients with idiopathic thrombosis is the risk of recurrence 7-10% a year even at the absence of known thrombophilias. The risk of a recurrent event is influenced by a set of other factors (prevailing or undetected trigger factor, proximal thrombosis and pulmonary embolism, incomplete rechanneling of a thrombotic vein, presence of some thrombophilias, high level of D-dimers after discontinuation of the anticoagulant treatment). Their identification and consequent monitoring are decisive in the choice of an optimum treatment and the duration of their administration in secondary prevention of venous thromboembolism. In the primary venous thrombosis prevention, the knowledge of general trigger factors and the individual risk characteristics of the given patient is important, which means also timely detection of thrombophilic conditions in patients who profit from it, i.e. if they display at least medium probability of detection. A universal long-term prophylaxis in so far asymptomatic carriers of congenital thrombophilias is not indicated with regard to potential complications of anticoagulant treatment. Women with thrombophilic disorders are under an increased risk of a thromboembolic event when using hormonal contraceptives and during pregnancy. There is also a higher incidence of pregnancy complications connected with disorders in blood circulation of placental vascular tree.