How best to manage patients with chronic lymphocytic leuekmia with 17p deletion and/or TP53 mutation?

Patients with chronic lymphocytic leukemia (CLL) carrying deletion of 17p (17p-) or mutations of TP53 have a uniquely poor prognosis related to increased propensities to progress to symptomatic disease, poor responses to chemo(immuno) therapy and high rates of Richter transformation. Both traditional fludarabine, cyclophosphamide and rituximab (FCR)-based chemoimmunotherapy and alemtuzumab-based regimens are inadequate in controlling 17p- CLL durably, and allogeneic stem cell transplant holds the only prospect for long-term survival. Recent advances in targeted therapies have resulted in novel agents such as B-cell receptor pathway and BCL2 antagonists yielding high response rates in 17p- CLL, but these patients continue to relapse at an increased rate when compared to patients without 17p-. In this review, we discuss the current evidence base for making therapeutic decisions in this difficult disease.