Management of Elderly Patients with Focal Onset Seizures and Lymphocytic Leukocytosis
Diagnostic Evaluation
- The European Society for Medical Oncology recommends obtaining flow cytometry of peripheral blood immediately to diagnose chronic lymphocytic leukemia (CLL), as an absolute lymphocyte count of ~38,500 cells/mm³ strongly suggests lymphoproliferative disorder 1, 2
- Blood smear microscopy should be performed to confirm mature lymphocyte morphology characteristic of CLL 1, 2
- Screening for Del(17p) and/or TP53 mutations is recommended if CLL is confirmed and treatment is planned 1, 2, 3
- A complete blood count with differential, LDH, beta-2 microglobulin, and comprehensive metabolic panel should be performed 4, 5
Seizure Management and CLL Treatment
- If CLL with CNS involvement is confirmed, seizures may resolve with treatment of the underlying lymphoma 1, 3
- The International Workshop on Chronic Lymphocytic Leukemia recommends ibrutinib as the first-line therapy for patients with Del(17p)/TP53mut, regardless of fitness level 3, 9
- For fit elderly patients without Del(17p)/TP53mut, bendamustine plus rituximab or dose-attenuated FCR may be considered as first-line therapy 2, 3
Patient Assessment and Treatment Selection
- Geriatric assessment should be used to stratify patients as fit, vulnerable, or terminally ill, which determines treatment intensity 1, 2
- The European Society for Medical Oncology recommends assessing comorbidities, functional status, and treatment goals to determine the appropriate treatment approach 1, 2
- For vulnerable elderly patients without Del(17p)/TP53mut, obinutuzumab-chlorambucil, ofatumumab-chlorambucil, or rituximab-chlorambucil may be considered as first-line therapy 1, 3