Watch and Wait in Lebanese Chronic Lymphocytic Leukemia Patients: How Relevant is it?

  • Lutfallah, Antoine Abi (Hematology-Oncology Department, Hotel-Dieu de France University Hospital, Faculty of Medicine, Saint Joseph University) ;
  • Kourie, Hampig Raphael (Hematology-Oncology Department, Hotel-Dieu de France University Hospital, Faculty of Medicine, Saint Joseph University) ;
  • Eid, Roland (Hematology-Oncology Department, Hotel-Dieu de France University Hospital, Faculty of Medicine, Saint Joseph University) ;
  • Farhat, Fadi (Hematology-Oncology Department, Hotel-Dieu de France University Hospital, Faculty of Medicine, Saint Joseph University) ;
  • Ghosn, Marwan (Hematology-Oncology Department, Hotel-Dieu de France University Hospital, Faculty of Medicine, Saint Joseph University) ;
  • Kattan, Joseph (Hematology-Oncology Department, Hotel-Dieu de France University Hospital, Faculty of Medicine, Saint Joseph University)
  • Published : 2016.02.05


Background: Chronic lymphocytic leukemia (CLL) is the most frequent form of leukemia in Europe and North America, and it mainly affects older individuals. Many approaches are implemented in the management of CLL from a watch and wait (W&W) strategy to chemotherapeutic regimens. We here reviewed our clinical practice for the relevance of the W&W strategy in Lebanese CLL patients. Materials and Methods: A total of 95 patients with CLL diagnosed in four institutions in Lebanon, between 1992 and 2013, were selected and their files were reviewed. Characteristics of these patients were noted including age, sex, RAI and Binet scores, CBC values, presence of hepatomegaly or splenomegaly, performance of bone marrow biopsy or peripheral blood flux cytometry for diagnosis, adoption of W&W strategy, different chemotherapeutic regimens and the indications for treatment. Results: Some 38 patients (40%) diagnosed with CLL were women and 57 (60%) were men with a mean age of 65.1 years [36-89]. Of the total, 50.5%, 17.2%, 14%, 7.5% and 10.8% had an RAI score at diagnosis of 0, 1, 2, 3 and 4, respectively, while 65.6%, 17.2% and 17.2% had Binet scores of I, II and III. The mean lymphocyte count at diagnosis was $39885/mm^3$ [1596-290000], the mean hemoglobin level was 12.7 g/dl [6.2-17] and the mean platelet count was $191255/mm^3$ [14000-458000]. While 26.3% of patients with CLL had splenomegaly, only 7.4% had hepatomegaly. Some 33.7% had undergone a bone marrow biopsy, 66.3% flow cytometry of circulating blood and 5.3% a lymph node biopsy. Overall, the W&W was adopted in 62.4% (58) of patients with a mean duration of 37.7 months [3-216]. The W&W was used in 82.6%, 73.3%, 46.2%, 14.3% and 0% of patients having RAI scores of 0, 1, 2, 3 and 4, respectively, and, it was used in 80%, 46.7% and 6.25% with Binet scores of I, II and III. The most frequent indication for treatment was anemia and thrombocytopenia, accounting for 32.7% of cases. The most frequently used chemotherapeutical regimens were chlorambucil until the end of the last century and flufarabine-cyclophosphamide-rituximab during the last decade. Conclusions: This retrospective review of CLL clinical practice showed an important implementation of the W&W strategy with a long duration, especially in early stage cases with low RAI or Binet scores.


Watch and wait strategy;chronic lymphocytic leukemia;treatment;Lebanon


  1. Binet JL, Auquier A, Dighiero G, et al (1981) A new prognostic classification of chronic lymphocytic leukemia derived from a multivariate survival analysis. Cancer, 48, 198.<198::AID-CNCR2820480131>3.0.CO;2-V
  2. Chevallier P, Penther D, Avet-Loiseau H, et al (2002). CD38 expression and secondary 17p deletion are important prognostic factors in chronic lymphocytic leukaemia. Br J Haematol, 116, 142.
  3. Cheson BD, Bennett JM, Grever M, et al (1996). National Cancer Institute-sponsored Working Group guidelines for chronic lymphocytic leukemia: revised guidelines for diagnosis and treatment. Blood, 87, 4990.
  4. Chronic lymphocytic leukemia: recommendations for diagnosis, staging, and response criteria (1989). International Workshop on Chronic Lymphocytic Leukemia. Ann Intern Med, 110, 236.
  5. Durig J, Nuckel H, Cremer M, et al (2003). ZAP-70 expression is a prognostic factor in chronic lymphocytic leukemia. Leukemia, 17, 2426.
  6. Hallek M, Cheson BD, Catovsky D, et al (2008). Guidelines for the diagnosis and treatment of chronic lymphocytic leukemia: a report from the international workshop on chronic lymphocytic leukemia updating the national cancer institute-working group 1996 guidelines. Blood, 111, 5446.
  7. Hernández JA, Land KJ, McKenna RW (1995). Leukemias, myeloma, and other lymphoreticular neoplasms. Cancer, 75, 381.<381::AID-CNCR2820751320>3.0.CO;2-B
  8. Hess G, Chen C, Satram-Hoang S, Reyes C (2010). Characteristics and treatment patterns in patients newly diagnosed with chronic lymphocytic leukemia (CLL). Abstract e16561 in ASCO.
  9. Kermani IA, Dehdilani M, Dolatkhah R (2007). Chronic lymphocytic leukemia in the recent 10 years and treatment effects of Fludarabin. Asian Pac J Cancer Prev, 8, 367-71.
  10. Lin KI, Tam CS, Keating MJ, et al (2009). Relevance of the immunoglobulin VH somatic mutation status in patients with chronic lymphocytic leukemia treated with fludarabine, cyclophosphamide, and rituximab or related chemoimmunotherapy regimens. Blood, 113, 3168.
  11. Mhaskar AR, Quinn G, Vadaparampil S, et al (2010). Timing of first-line cancer treatments - early versus late - a systematic review of phase III randomized trials. Cancer Treat Rev, 36, 621-8.
  12. Pamuk ON, Pamuk GE, Soysal T, et al (2004). Chronic lymphocytic leukemia in Turkey: experience of a single center in Istanbul. South Med J, 97, 240-5.
  13. Rai KR, Sawitsky A, Cronkite EP, et al (1975). Clinical staging of chronic lymphocytic leukemia. Blood, 46, 219.
  14. Siegel RL, Miller KD, Jemal A (2015). Cancer statistics, 2015. CA Cancer J Clin, 65, 5.
  15. Rosenquist R, Cortese D, Bhoi S, et al (2013). Prognostic markers and their clinical applicability in chronic lymphocytic leukemia: where do we stand? Leuk Lymphoma, 54, 2351-64.
  16. Rossi D, Rasi S, Spina V, et al (2013). Integrated mutational and cytogenetic analysis identifies new prognostic subgroups in chronic lymphocytic leukemia. Blood, 121, 1403.
  17. Smith A, Howell D, Patmore R, et al (2011). Incidence of haematological malignancy by sub-type: a report from the Haematological Malignancy Research Network. Br J Cancer, 105, 1684.

Cited by

  1. Untreated chronic lymphocytic leukemia in Lebanese patients: an observational study using standard karyotyping and FISH vol.6, pp.4, 2017,