How we approach the perioperative management of patients with chronic lymphocytic leukaemia receiving continuous cancer‐directed therapies

Historically, invasive procedures and surgeries were deferred in patients with haematological malignancies including advanced stage chronic lymphocytic leukaemia (CLL) because of limited life expectancy. However, novel, and often continuous, treatments have markedly improved outcomes in CLL. Some patients may expect years of treatment response and disease control, overcoming the short life expectancy that deters interventionalists. Such patients now often undergo various invasive procedures including major surgery. To inform peri-operative management, we summarize the relevant side effects and drug interactions of continuous CLL therapies, highlight potential surgical risks, and provide recommendations on withholding specific CLL drugs around invasive procedures.

[1]  P. Ganly,et al.  CLL-115 First Interim Analysis of ALPINE Study: Results of a Phase 3 Randomized Study of Zanubrutinib vs Ibrutinib in Patients With Relapsed/Refractory (R/R) Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma (CLL/SLL). , 2022, Clinical lymphoma, myeloma & leukemia.

[2]  P. Benharash,et al.  Impact of Chronic Lymphocytic Leukemia on Outcomes and Readmissions following Cardiac Operations. , 2021, The Annals of thoracic surgery.

[3]  A. Warner,et al.  Bleeding Risk of Direct Oral Anticoagulants in Patients With Heart Failure And Atrial Fibrillation. , 2021, Circulation. Cardiovascular quality and outcomes.

[4]  Chakradhar M. Reddy,et al.  Major gastrointestinal bleeding risk with direct oral anticoagulants: Does type and dose matter? – A systematic review and network meta-analysis , 2021, European journal of gastroenterology & hepatology.

[5]  J. Connors,et al.  Cancer and thrombosis: new insights to an old problem. , 2020, Journal de medecine vasculaire.

[6]  P. Ganly,et al.  Zanubrutinib monotherapy for patients with treatment-naïve chronic lymphocytic leukemia and 17p deletion , 2020, Haematologica.

[7]  D. Spain,et al.  Mortality After General Surgery Among Hospitalized Patients With Hematologic Malignancy. , 2020, The Journal of surgical research.

[8]  M. Dimopoulos,et al.  A RANDOMIZED PHASE 3 TRIAL OF ZANUBRUTINIB VERSUS IBRUTINIB IN SYMPTOMATIC WALDENSTRÖM MACROGLOBULINEMIA:THE ASPEN STUDY. , 2020, Blood.

[9]  J. Berger,et al.  Perioperative Cardiovascular Risk Assessment and Management for Noncardiac Surgery: A Review. , 2020, JAMA.

[10]  G. Gaidano,et al.  Precision Medicine Management of Chronic Lymphocytic Leukemia , 2020, Cancers.

[11]  J. Byrd,et al.  Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma, Version 4.2020, NCCN Clinical Practice Guidelines in Oncology. , 2020, Journal of the National Comprehensive Cancer Network : JNCCN.

[12]  M. Konopleva,et al.  Percutaneous coronary intervention and in‐hospital outcomes in patients with leukemia: a nationwide analysis , 2019, Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions.

[13]  D. Jackson,et al.  Ibrutinib, but not zanubrutinib, induces platelet receptor shedding of GPIb-IX-V complex and integrin αIIbβ3 in mice and humans. , 2019, Blood advances.

[14]  P. Libby,et al.  Clonal haematopoiesis: connecting ageing and inflammation in cardiovascular disease , 2019, Nature Reviews Cardiology.

[15]  Andrew J. Toth,et al.  Cardiac Surgery Outcomes in Patients With Chronic Lymphocytic Leukemia. , 2018, The Annals of thoracic surgery.

[16]  S. Mulligan,et al.  Atrial fibrillation, anticoagulant stroke prophylaxis and bleeding risk with ibrutinib therapy for chronic lymphocytic leukaemia and lymphoproliferative disorders , 2016, British journal of haematology.

[17]  M. Šimkovič,et al.  Venous thromboembolism in patients with chronic lymphocytic leukemia. , 2015, Thrombosis research.

[18]  G. Marti,et al.  Partial reconstitution of humoral immunity and fewer infections in patients with chronic lymphocytic leukemia treated with ibrutinib. , 2015, Blood.

[19]  Deborah A. Bowen,et al.  Hypogammaglobulinemia in newly diagnosed chronic lymphocytic leukemia: Natural history, clinical correlates, and outcomes , 2015, Cancer.

[20]  Jeffrey A Jones,et al.  Three-year follow-up of treatment-naïve and previously treated patients with CLL and SLL receiving single-agent ibrutinib. , 2015, Blood.

[21]  D. Roberts,et al.  Rituximab-associated hypogammaglobulinemia: incidence, predictors and outcomes in patients with multi-system autoimmune disease. , 2015, Journal of autoimmunity.

[22]  C. Tam,et al.  Ibrutinib treatment affects collagen and von Willebrand factor-dependent platelet functions. , 2014, Blood.

[23]  M. Keating,et al.  Ibrutinib increases the risk of atrial fibrillation, potentially through inhibition of cardiac PI3K-Akt signaling. , 2014, Blood.

[24]  Biykem Bozkurt,et al.  2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. , 2014, Circulation.

[25]  P. Ravaud,et al.  Safety of Surgery After Rituximab Therapy in 133 Patients With Rheumatoid Arthritis: Data From the AutoImmunity and Rituximab Registry , 2013, Arthritis care & research.

[26]  Audrey S. Wang,et al.  Corticosteroids and wound healing: clinical considerations in the perioperative period. , 2013, American journal of surgery.

[27]  D. Borde,et al.  Management of patients with hematological malignancies undergoing coronary artery bypass grafting. , 2013, Annals of cardiac anaesthesia.

[28]  J. Douketis,et al.  How I treat anticoagulated patients undergoing an elective procedure or surgery. , 2012, Blood.

[29]  P. Baade,et al.  Second cancer incidence and cancer mortality among chronic lymphocytic leukaemia patients: a population-based study , 2011, British Journal of Cancer.

[30]  D. Allsup,et al.  Chronic lymphocytic leukaemia is a risk factor for venous thromboembolism. , 2011, Leukemia research.

[31]  L. Leibovici,et al.  Immunoglobulin prophylaxis in hematological malignancies and hematopoietic stem cell transplantation. , 2008, The Cochrane database of systematic reviews.

[32]  M. P. Dixon,et al.  Bleeding complications in skin cancer surgery are associated with warfarin but not aspirin therapy , 2007, The British journal of surgery.

[33]  F. Rosendaal,et al.  Incidence of venous thrombosis in a large cohort of 66 329 cancer patients: results of a record linkage study , 2006, Journal of thrombosis and haemostasis : JTH.

[34]  H. Scheld,et al.  Impact of Malignant Hematological Disorders on Cardiac Surgery , 2000, Cardiovascular surgery.

[35]  M. Jetté,et al.  Metabolic equivalents (METS) in exercise testing, exercise prescription, and evaluation of functional capacity , 1990, Clinical cardiology.