Proposal of an algorithm for first- and second-line therapy of CLL.
| . | . | . | First-line treatment . | |
|---|---|---|---|---|
| Stage . | Fitness . | Molecular cytogenetics . | Standard . | Alternatives* . |
| Asymptomatic Binet A–B or Rai 0–II | Irrelevant | Irrelevant | None | Only in trials: treat high-risk patients |
| Binet C or Rai III–IV, or symptomatic disease (any stage) | Go Go | No del(17p) Del(17p) | FCR FCR, A or FA → Allo SCT | BR, FR, FA, FCA |
| Slow Go | No del(17p) Del(17p) | CLB A? | CLB+R, CLB+GA101, B, dose reduced F or FC or FCR | |
| . | . | . | First-line treatment . | |
|---|---|---|---|---|
| Stage . | Fitness . | Molecular cytogenetics . | Standard . | Alternatives* . |
| Asymptomatic Binet A–B or Rai 0–II | Irrelevant | Irrelevant | None | Only in trials: treat high-risk patients |
| Binet C or Rai III–IV, or symptomatic disease (any stage) | Go Go | No del(17p) Del(17p) | FCR FCR, A or FA → Allo SCT | BR, FR, FA, FCA |
| Slow Go | No del(17p) Del(17p) | CLB A? | CLB+R, CLB+GA101, B, dose reduced F or FC or FCR | |
| . | . | . | Relapse therapy . | |
|---|---|---|---|---|
| Relapse . | Fitness . | Molecular cytogenetics . | Standard . | Alternatives . |
| *In part tested in Phase III trials. | ||||
| Clb indicates chlorambucil; F, fludarabine; C, cyclophosphamide; A, alemtuzumab; R, rituximab; B, bendamustine; Allo SCT, allogeneic stem cell transplantation; GA101, novel anti-CD20 antibody. | ||||
| Early (< 1 year) = refractory disease | Go Go | No del(17p) Del(17p) | A or FA → Allo SCT A or FA → Allo SCT | BR, flavopiridol, lenalidomide Flavopiridol, lenalidomide |
| Slow Go | No del(17p) Del(17p) | A A | BR, B, lenalidomide Lenalidomide | |
| Late (> 1 year) | Go Go & Slow Go | Repeat first line | ||
| . | . | . | Relapse therapy . | |
|---|---|---|---|---|
| Relapse . | Fitness . | Molecular cytogenetics . | Standard . | Alternatives . |
| *In part tested in Phase III trials. | ||||
| Clb indicates chlorambucil; F, fludarabine; C, cyclophosphamide; A, alemtuzumab; R, rituximab; B, bendamustine; Allo SCT, allogeneic stem cell transplantation; GA101, novel anti-CD20 antibody. | ||||
| Early (< 1 year) = refractory disease | Go Go | No del(17p) Del(17p) | A or FA → Allo SCT A or FA → Allo SCT | BR, flavopiridol, lenalidomide Flavopiridol, lenalidomide |
| Slow Go | No del(17p) Del(17p) | A A | BR, B, lenalidomide Lenalidomide | |
| Late (> 1 year) | Go Go & Slow Go | Repeat first line | ||