Transcript Slide 1

Chronic Lymphocytic Leukemia
• CLL lymphocytes are clonal B-cells arrested in the
B-cell differentiation pathway at some
intermediate stage between the pre-B-cell and
mature B-cell, perhaps in the "activated, antigenexperienced" B-cell subset
• ONLY T– Cell CLL (2 – 5 % )
B cell chronic lymphocytic
leukemia
Lymphocytes have a very sparse cytoplasm, round to slightly
oval nuclei, and no evident nucleoli. Damaged lymphocytes
("smudge cells") are present (arrows)
Peripheral smear from a patient with chronic lymphocytic leukemia, small
lymphocytic variety.
Peripheral smear from a patient with chronic lymphocytic leukemia, large
lymphocytic variety. Smudge cells are also observed; smudge cells are the artifacts
produced by the lymphocytes damaged during the slide preparation.
CLL
PB and BM
CLL Bone marrow
Low power view of a bone marrow aspirate in a patient with chronic lymphocytic leukemia
shows a monotonous infiltration with small round cells having only a thin rim of cytoplasm.
Bone Marrow
CLL lymph node
At low magnification (A), there is a vaguely nodular (pseudofollicular) pattern. Higher
magnification (B) shows a predominance of small lymphocytes with scattered larger cells
known as prolymphocytes and paraimmunoblasts.
Symptoms include the following
i.
Enlarged lymph nodes, liver, or spleen
ii. Recurring infections
iii. Loss of appetite or early satiety
iv. Abnormal bruising (late-stage symptom)
v. Fatigue
vi. Night sweats
Prolymphocytic leukemia
Peripheral blood smear from a 71-year-old male patient with splenomegaly and a white blood
cell count of 50,000/µL, with a preponderance of prolymphocytes. The prolymphocytes shown
here are large cells with a moderate amount of clear to lightly basophilic cytoplasm, coarse
nuclear chromatin, and a prominent single nucleolus (arrows).
Lymphoplasmacytic cells in
WM
The marrow consists largely of lymphoplasmacytic cells that have the nuclear spoke-wheel
pattern of a plasma cell but the low cytoplasmic volume that is more characteristic of a small
lymphocyte
Hairy cell leukemia
Panel A: normal view of five hairy cells. The cells have abundant, irregularly distributed
cytoplasm. The nuclei vary from round to oval to slightly lobulated.
Panel B: same view but with the contrast adjusted to show the irregular cytoplasmic outlines,
giving the cells their "hairy" appearance (arrows). Wright-Giemsa stain
Flow cytometry of chronic
lymphocytic leukemia
Typically, the cells express dim CD20, dim CD5, and CD23. This figure displays flow cytometry
results for CD5 and CD20 expression. The CLL cells are shown in red and demonstrate weak
expression of both CD5 and CD20
Immunophenotype
• CD19+, CD20+, and CD23+ (CD20 is usually weak)
• CD21 and CD24 can be seen, but is not required for diagnosis
• Expression of CD5, a T-cell associated antigen.
• CLL cells are usually negative for cyclin D1 and CD10
• FMC7, CD22, CD79b commonly negative or weakly expressed
• Low levels ( SmIg weak). The immunoglobulin is most often IgM or both
IgM and IgD, and only a single immunoglobulin light chain is expressed (ie,
either kappa or lambda but not both), confirming the clonal nature of
these cells.
Phenotype of B-CLL lymphocytes
Three phenotypic features are characteristic of B-cell CLL (B-CLL)
Extremely low levels of surface membrane immunoglobulin (SmIg or sIg).
The immunoglobulin is most often IgM or both IgM and IgD, and only rarely IgG Only
a single light Ig chain is expressed (ie, either kappa or lambda).
Expression of one or more B-cell associated antigens as demonstrated by CD19,
CD20, CD21, CD23, and CD24
Expression of CD5, a T-cell associated antigen
Variant forms : Some cases of CLL are CD11c positive , suggesting an
immunophenotypic overlap between CLL and hairy cell leukemia.
IMMUNOBIOLOGY
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Initially it was felt that the majority of CLL cells were in the G(0) phase of
the cell cycle, with less than 1 percent spontaneous mitoses in vitro,
suggesting that CLL was a disease of accumulation of long-lived
lymphocytes.
• Indeed, malignant cells accumulate in CLL at least partly due to their
inability to undergo apoptosis. Mechanisms of apoptosis resistance in CLL
include overexpression of B-cell leukemia/lymphoma 2 (bcl2) and Fasinhibitory molecules such as TOSO
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However, in vivo kinetic studies have uncovered a wide range of cellular
proliferation and death rates among individual patients.
• Those patients with cellular birth rates >0.35 percent/day were much more
likely to exhibit active disease or develop progressive disease than those
with lower cellular birth rates
Bone marrow aspirate and biopsy
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BM not required for the diagnosis of CLL.
Cellularity (normal to increased )
Lymphocytes >30 % of all nucleated cells.
Types of BM infiltrative patterns :
. Nodular, Interstitial, and Diffuse
Sometimes mixture of nodular and interstitial, or nodular and diffuse
infiltrative patterns
Diffuse infiltration ( advanced disease and a poorer prognosis)
Nodular and interstitial "non-diffuse“ prognostically better
Lymph node biopsy
• SLL : Lymphadenopathy but without peripheral lymphocytosis
• CLL peripheral blood and bone marrow lymphocytosis
• SLL absolute peripheral lymphocyte count that does not
exceed 5000/microL [5 x 109/L] and no evidence of
neutropenia, anemia, or thrombocytopenia related to the
disease .
• The histopathologic lymph node findings in SLL and CLL are
identical and consist of a diffusely effaced nodal architecture
with occasional residual naked germinal centers
• The infiltrate is composed of mostly mature-appearing, small
lymphocytes, with an admixture of prolymphocytes and
paraimmunoblasts
NCI guidelines CLL Criteria
CLL two criteria must be met
• Absolute B lymphocyte count(ALC )in PB ≥5000/microL [5 x
109/L], with a preponderant population of morphologically
mature-appearing small lymphocytes
• Clonality B lymphocytes by flow cytometry PB . A majority of
the population should express the following pattern of
monoclonal B-cell markers: extremely low SmIg and either
kappa or lambda (but not both) light chains; (CD19+, CD20+,
CD23+); CD5 +
DIFFERENTIAL DIAGNOSIS
• Non-neoplastic lymphocytosis :
Infections (eg, infectious mononucleosis, pertussis,
toxoplasmosis)
• Neoplastic conditions other than CLL eg,
(leukemic phase of lymphomas, hairy cell
leukemia, prolymphocytic leukemia, and large
granular cell lymphocyte leukemia)
Infectious causes of lymphocytosis
• Lymphocytosis transientcan , not sustained
(lymphocyte counts rise and then typically return
to normal after a few weeks ).
• Lymphocytosis does not occur in the bone marrow
• Lymphocytosis is not clonal
Monoclonal B-cell lymphocytosis (MBL)
• Monoclonal B-cell lymphocytosis ( Absolute increase peripheral blood clonal B
lymphocytes that does not exceed 5000/microL [5 x 109/L] and who have no
lymphadenopathy, organomegaly, cytopenias, or disease-related symptoms
• MBL with a CLL-phenotype can be detected using high sensitivity flow cytometry in
approximately 5 percent of patients over the age of 60 with normal blood counts
and 14 percent of patients over age 60 with lymphocytosis
• Patients with CLL-phenotype MBL progress to CLL requiring treatment at a rate of
approximately 1 to 2 percent per year . The rate of progression may be even lower
among persons with low-count MBL, as defined as a clone size of 50/microL or less
• Chromosomal analysis demonstrated that the CLL-phenotype lymphocytes in
patients with MBL have the same genetic abnormalities as CLL cells, occurring at
similar rates.
• Conversely, a monoclonal B-cell population appears to be present years prior to the
diagnosis in virtually all patients with CLL.
• As only a small minority of these persons develop CLL it is important not to cause
undue anxiety among them
Normal counterpart of B-CLL lymphocytes
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A number of studies have been performed to determine the pathophysiologic implications of the
combination of cell surface markers seen in B-CLL. CD5+ B-cells (with many or all of the characteristics of
B-CLL cells listed above, including monoclonality) can be found in the lymph nodes and spleen of the
normal human fetus, and at the edge of germinal centers of lymph nodes , as well as in the peripheral
blood of normal adults , The most frequent B-CLL phenotype corresponds to one or more cellular
subsets within the mantle zone of lymph nodes. In addition, approximately 15 percent of normal B-cells
in the peripheral blood express CD5 .
CD5 positive B-cells are increased in patients with autoimmune disorders, such as rheumatoid arthritis .
This observation is relevant to CLL, since the pathophysiologic explanation for the increased frequency
of Coombs' positivity and other autoimmune phenomena in CLL has remained unresolved. In
approximately 25 percent of CLL cases bearing kappa light chains on the lymphocyte surface, the
leukemic cells react against an anti-idiotype antibody to a highly conserved region of one specific kappa
gene (cross reactive idiotype) . Analysis of kappa gene rearrangement showed considerable sequence
homology in the rearranged regions.
These observations suggest that specific subsets of CD5+ B-cells may be the normal counterparts of BCLL . Evaluation of a naturally occurring CD5+ B-cell subset that resembled autoantibody-producing BCLL cells showed a restricted expression of Ig V genes , raising the possibility that B-CLL may arise from a
normal B-cell subset engaged in autoantibody production . A minor subpopulation of normal human
CD5+ cells is considered to be a long-lived population circulating between blood and lymph nodes,
mostly located in the inner layer of mantle zones; these cells may be the normal counterpart of the
neoplastic B-CLL cells
T cells and natural killer cells in CLL
Because B-cells account for almost 90 percent of all lymphocytes in BCLL, the percentages of T-cells and natural killer (NK) cells are
invariably decreased. Since the number of T-cells is a function of the
absolute lymphocyte count, the absolute T-cell count may be high,
normal or low. In addition, natural killer cells are usually decreased in
number as well as function in CLL.
Patients with B-CLL also may have an unusual T-cell subpopulation
expressing lower CD4 or CD8 levels than classic T-cells, which may
derive from nonclassic pathways of T-cell development or through
direct interaction with the malignant B-cell population . Similar cells
have been described in human and murine autoimmune disease
Hypogammaglobulinemia in CLL
• is a common finding in CLL
• CLL patients have defective antibody responses to
specific infections and immunizations .
• Infections with gram-negative as well as encapsulated
organisms are the most frequent cause of morbidity
and mortality in CLL .
• B-CLL cells may inhibit autologous production of
immunoglobulin by interaction with CD95 on normal
bone marrow plasma cells
Autoimmune disorders in CLL
• occur in up to 25 percent of CLL patients
• Coombs' positive autoimmune hemolytic anemia (AIHA),
idiopathic thrombocytopenic purpura (ITP), and pure red cell
aplasia (PRCA)
• AIHA occurred in 11 percent of patients with CLL, primarily in
advanced disease
• ITP ( 2 to 3 ) and PRCA (6 percent), primarily occurring in
early disease .
• Autoantibodies produced by the leukemic clone .
Prolymphocytic leukemia
• Both (PLL) and CLL can present with lymphocytosis and splenomegaly,
and have circulating prolymphocytes in the blood.
• Prolymphocyte large cells with somewhat immature-appearing
nuclear chromatin, a prominent vesicular nucleolus, and a moderate
amount of cytoplasm
• Prolymphocytes can be of either B or T lineage, express normal
amounts of SmIg and do not express CD5
• While prolymphocytes can be seen in CLL, they typically comprise
over 90 percent of the neoplastic cells in PLL
Mantle cell lymphoma
• Have a leukemic phase that may mimic CLL
• Such patients have circulating small lymphocytes with irregular or
cleaved nuclei. Like the malignant cells of CLL
• MCL coexpress CD5 and CD20
• MCL stain strongly for cyclin D1 and (SmIg)
• MCL have a t(11;14) chromosomal abnormality
• MCL are negative for CD23
Lymphoplasmacytic lymphoma LPL
•
Both lymphoplasmacytic lymphoma (LPL) and CLL are lymphoproliferative
disorders of small cells that usually have an indolent course
• LPL is the lymphomatous counterpart to Waldenstrom disease (ie, LPL
leukemia)
• Peripheral blood involvement in LPL is usually less prominent than in CLL;
circulating malignant cells often have a plasmacytoid appearance
• LPL can be distinguished from CLL by its lack of CD23 expression, the
presence of strong staining for surface IgM and CD20, and the presence of
cytoplasmic Ig.
Hairy cell leukemia HCL
• Both hairy (HCL) and CLL can be associated with an
elevated lymphocyte count in the peripheral blood.
• HCL is often suspected based upon the presence of
circulating lymphocytes with cytoplasmic projections
(hairy cells)
• HCL is frequently distinguished from CLL based upon its
immunophenotype that is usually CD5 and CD21 negative,
and positive for CD25, CD11c, and CD103
Follicular lymphoma ( FL )
• (FL) similar to CLL/SLL ( diffuse painless peripheral adenopathy,
often waxing and waning over long periods of time )
• FL has a nodular growth pattern on lymph node biopsy which is not
seen in CLL/SLL; however, on occasion, involved lymph nodes in
CLL/SLL tumors can have prominent proliferation centers that take
on a mottled "pseudo-nodular" appearance that mimics that of FL.
• FL demonstrate bright surface immunoglobulin (SmIg), express
CD10 and lack CD5 expression.
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FL has a t(14;18) translocation which is not seen in CLL/SLL
Splenic marginal zone lymphoma MZL
• (MZL) and CLL present with splenomegaly and peripheral blood
lymphocytosis
• CLL and splenic MZL can express CD23, CD43, CD5, and IgD, although
expression of these is much more typical of CLL.
• Unlike CLL/SLL, MZL may have bright SmIg and CD20
• In difficult cases, pathologic evaluation of the bone marrow, spleen,
and hilar lymph nodes may be used in concert to determine the most
likely diagnosis.
• Bone marrow morphology in MZL may show notched nuclei
• Cytogenetic changes typically seen in CLL are not usually seen with
MZL
CLL VARIANTS
• T-cell CLL
• B-cell PLL
• T-cell PLL
 Low risk
 Intermediate risk
 High risk
Rai stage O
Rai stages I and II combined
Rai stages III and IV combine
Binet staging system
 Stage A — Fewer than three involved lymphoid sites
 Stage B — Three or more involved lymphoid sites
 Stage C — Presence of anemia and/or thrombocytopenia.
At the time of initial diagnosis, the breakdown
into the various stages is approximately:
• Stage 0 (lymphocytosis)
25%
• Stages I to II (lymphadenopathy, organomegaly)
50 %
• Stages III to IV (anemia, thrombocytopenia)
25 %
The median survival from the time of
diagnosis
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Stage 0
Stage I
Stage II
Stages III and IV
150 months
101 months
71 months
19 months
Median survival for the prognostic
groups studied by Binet
 Stage A — comparable to age-matched controls
 Stage B — 84 months
 Stage C — 24 months
Patients with autoimmune cytopenias have better
prognosis than patients with cytopenias due to
bone marrow failure
Prognostic features CLL
Bone marrow histologic pattern
 Lymphocyte infiltration pattern is an independent
prognostic marker
 Diffuse pattern predicts a progressive course and
a non-diffuse (interstitial and nodular) pattern
predicts a more indolent course
Prognostic features CLL
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Lymphocyte doubling time
Cytogenetic abnormalities
Extent of blood lymphocytosis
Morphologic features of blood lymphocytes
(relative proportion of prolymphocytes )
• Presence of normal or abnormal chromosomal
karyotype
• Phenotypic profile of B-lymphocytes
• Levels of serum immunoglobulins
Age, sex, performance status
Prognostic features CLL
Lymphocyte doubling time LTD
• LDT in untreated patients <12 months predicts a
progressive course and a longer LDT predicts an
indolent course
• In early stage disease, short LDT may favor more
aggressive therapy
Prognostic features CLL
CLL Survival stratified by beta-2 microglobulin levels
Prognostic features CLL
Beta-2 microglobulin levels
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B2M correlate with disease stage and tumor burden in patients with
CLL, with increasing levels associated with a poorer prognosis
B2M may be regulated, at least in part, by exogenous cytokines
The source of these elevated cytokines in CLL is unclear, although IL6, which inhibits apoptosis in CLL cells, may be released from vascular
endothelium
B2M levels also rise with worsening renal dysfunction leading some
investigators to suggest a measure of B2M adjusted for the
glomerular filtration rate (GFR-adjusted B2M).
This GFR-adjusted B2M requires validation in prospective
confirmatory studies
Prognostic features CLL
IgVH mutation status
• Mutated immunoglobulin variable heavy chain (IgVH) genes are
defined in most studies as having a greater than 2 percent difference
in nucleotide sequence compared with germline DNA
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Approximately half of CLL clones will demonstrate unmutated
immunoglobulin variable heavy chains, a finding associated with
shorter overall survival and a higher risk of relapse following
treatment, including hematopoietic cell transplantation .
• This is a technically difficult study to perform and is not widely
available.
Prognostic features CLL
CD38
• CD38 positivity correlate with the presence of unmutated
immunoglobulin variable heavy chains
• CD38 independently associated with adverse prognosis
• This may be due to specific changes in the expression of
certain genes, particularly HEM1 (associated with
fludarabine resistance) and the ataxia telangiectasia
mutated gene (which interferes with apoptosis)
Prognostic features CLL
(ZAP 70 ) Zeta-associated peptide of 70 kilodaltons
• (ZAP 70), a tyrosine kinase normally expressed by NK and T cells, is required for
normal T cell receptor signaling.
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ZAP 70 is not normally expressed in B lymphocytes, but has been found in a subset
of patients with CLL and appears to correlate with survival.
• The best cutoff value for determining ZAP 70 positivity is unclear and levels appear
to change over time .
• Despite the uncertainty concerning normal threshold values, increased levels of
ZAP-70 detected by flow cytometry denote a poor prognosis
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Abnormal expression of ZAP-70 in CLL B cells is strongly associated with the
presence of an unmutated Ig heavy chain variable region gene (IgVH), another poor
prognostic factor (as previously noted)
Prognostic features CLL
Expression of ZAP-70 in CLL and immunoglobulin
(IgVH) mutational status
Open circles ( mutated Vh genes ) closed circles ( unmutated Vh genes )
Two groups were almost completely separable when the threshold for categorizing ZAP-70 positivity was set
at 20 percent (dashed line)
Prognostic features CLL
Age, sex, performance status
Prognostic features CLL
Other markers
• Low vitamin D levels (<25 ng/mL) as a marker of poor prognosis , shorter
time to initiation of treatment (hazard ratio 1.47; 95% CI 1.11 to 1.96) and a
trend towards shorter survival (hazard ratio 1.47; 95% CI 0.97 to 2.23)
• CLL who have low levels of vitamin D should be considered for vitamin D
• Elevated cellular levels of (VEGFR-2, KDR) have elevated lymphocyte
counts, severe anemia, elevated levels of B2M, advanced-stage disease, and
significantly shorter survival
• Elevated plasma levels of (TNF-alpha) had more advanced Rai and Binet
stages, higher B2M levels, and a greater percent of cells expressing CD38
• (TNF-alpha) also higher in the small subgroup of patients with 11q
deletion, trisomy 12, or any chromosome 17 aberration.
• Higher levels of TNF-alpha were an independent prognostic factor
correlating more strongly with shorter survival than B2M or Rai stage
Prognostic features CLL
Other markers
• IL-8 levels (>26.2 pg/mL) have been correlated with reduced survival
(9 versus 63 months for those with IL-8 levels below this value; relative risk
7.4, 95% CI: 3.8-14.7) IL-8 levels were predictive of survival independent of
B2M levels as well as Rai stage.
• B-cell marker CD20 ≥1875 nM/L correlated with reduced survival
(relative risk 3.5) , this finding was independent of Rai stage or hemoglobin
level. Whether dosing of the anti-CD20 antibody rituximab should be
adjusted according to plasma CD20 levels is not known at this time.
• Abnormality in free light chain assays (eg, monoclonal, polyclonal, or
kappa/lambda ratio abnormalities) had a shorter time to initial therapy than
those with normal free light chain assays
• Patients with either monoclonal or polyclonal abnormalities had inferior
overall survival when compared with those with normal or kappa/lambda
only abnormalities.
Prognostic features CLL
Other markers
• High plasma levels of thrombopoietin (TPO) and B2M
were associated with shorter survival
• Adverse effect of high levels of TPO on survival was
independent of VH gene mutation status, B2M, and Rai
stage.
• MicroRNAs (miRNAs) small noncoding RNAs that modulate
the expression of genes at the posttranscriptional level.
• Decreased expression of microRNAs (eg, miR-223 and
miR-29c) associated with reduced overall survival
High-risk genetic features and markers
• Germline immunoglobulin variable heavy chain
(IgVH)
• IgVHV3-21 gene usage
• Increased CD38 expression
• Increased Zap70 expression
• Elevated serum beta-2-microglobulin levels
• Increased serum thymidine kinase activity
• Short lymphocyte doubling time (< 6 mo)
• Increased serum levels of soluble CD23
CYTOGENETICS
• Patients with complex genomic changes appear to have more aggressive disease
• The most frequently observed abnormalities were trisomy 12 and 14q+.
• With (FISH) techniques, chromosomal abnormalities were noted in 69 to 82
percent, chromosomes 11, 12, and 13 abnormalities most commonly seen
• Five categories were defined with a statistical model: 17p deletion, 11q deletion,
12q trisomy, normal karyotype, and 13q deletion as the sole abnormality; median
survival times for patients in these five groups were 32, 79, 114, 111, and 133
months, respectively
• Karyotypic abnormalities are often acquired over time:
• In a five-year prospective study of 45 patients with CLL, in whom sequential
karyotypic studies were performed every 6 to 12 months, karyotypic evolution
occurred in 38 percent and was significantly associated with progressive disease
.Deletions of 11q were the most commonly detected change.
• In a second prospective sequential study in 159 patients with CLL, the rate of clonal
evolution was 1.4 percent during the first two years of follow-up and 27 percent
among those tested after five or more years .Clonal evolution occurred among 10
versus 42 percent of those who were ZAP-70 negative or positive, respectively.
Trisomy 12
Prognostic value of trisomy 12 detected by
FISH is not clear
• One study found an association of trisomy 12 with
advanced disease and higher proliferative activity , while
another study found that median survival in patients with
CLL and trisomy 12 detected by FISH was similar to that of
patients with CLL and a normal karyotype
del(13q14)
• del(13q14) found in 45 to 55 of patients(often
associated with inactivation of the Rb gene .
• Lack of Rb gene expression occurs in both the early
and late stages of CLL
• The 13q abnormalities appear to be associated
with a favorable outcome
Other deletions
• 17p deletions were found in 7 to 10 percent
• 17p deletion stronge predictor of poor survival
• Chromosomal translocations involving the MYC
gene located on chromosome 8 at band q24.1,
although rare in CLL, are associated with a worse
prognosis
Other deletions
• 11q deletions are the most common type of karyotypic evolution over time
• 11q deletions are associated with extensive adenopathy, progressive
disease and shorter survival, particularly in patients under the age of 55
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11q also contains the ataxia telangiectasia mutated (ATM) gene.
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Patients who have loss or mutation of both copies of this gene have an
even worse overall survival associated with impaired cellular response to
irradiation and cytotoxic drug exposure in vitro .
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However, the poor prognosis associated with this abnormality may be
overcome with the use of certain chemotherapy regimens such as FCR
(fludarabine,cyclophosphamide, and rituximab)
MOLECULAR GENETICS
• While these gene mutations have been found to affect tumor suppression
genes, oncogenes, DNA damage repair, RNA splicing, and cellular signaling
pathways, the prognostic significance of such mutations is not well
characterized
• Nine genes were mutated at a rate significantly higher than the background
mutation rate.
These nine genes are key components of four major cellular signaling pathways:
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DNA damage and cell-cycle control (eg, ATM, p53)
Notch signaling (eg, NOTCH1, FBXW7)
Inflammatory pathways (eg, MYD88, DDX3X, MAPK1)
RNA splicing and processing (eg, SF3B1, DDX3X)
Other point mutations were commonly identified, but at a lower mutation
rate, within these pathways and within the Wnt signaling pathway.
Bcl-2 protooncogene
• bcl-2 expression is elevated in approximately 95 percent of patients
• Bcl-2 is expressed in CD5+ B-CLL cells, but not in normal CD5+ B-cells
• Bcl-2 higher levels seen in CLL cells derived from lymph nodes than in
CLL cells derived from the peripheral blood or bone marrow
• Bcl-2 is suppressor of programmed cell death (apoptosis), resulting in
prolonged survival of the involved cells
• Ligation of CD23, expressed on B-CLL cells , results in increased
expression and activity of iNOS ( functional and inducible nitric oxide
synthase )
• The nitric oxide produced exerts an antiapoptotic effect.
p53 tumor suppressor gene
•
p53 is a tumor-suppressor gene located on short arm of chromosome 17
• p53 inactivated by deletion and/or point mutation in many human
malignancies.
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The wild-type p53 gene protein helps trigger apoptosis and acts as a check
point regulator of cells entering into S phase.
• p53 gene mutations identified in 10 to 47 percent of patients with CLL
• There is generally a poorer survival among CLL patients with p53 gene
deletion or mutation as compared with those without a deletion or mutation
p53 tumor suppressor gene
• In one study of 181 patients with B-CLL, for example, expression of
p53 (as compared with p53 negative patients) was strongly
associated with the presence of p53 gene mutations, a significantly
shortened overall survival, and a poorer response to therapy .
• In another report, a response to chemotherapy
with chlorambucil and/or CHOP and/or fludarabine occurred in
only one of eight patients (13 percent) with p53 mutations
compared with 80 percent of 36 patients without such mutations .
• In this regard, gene expression studies have suggested that
treatment of CLL patients with fludarabine has the potential to
select for induction of p53 mutant subclones .
Notch1 mutations
• Notch proteins are transmembrane receptors that are involved in regulating
hematopoietic cell development.
• Mutations in Notch can be found in a subset of patients with
lymphoproliferative disorders, such as CLL.
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A whole-genome sequencing study that compared samples from four
patients with CLL and normal paired germ line control material identified
recurrent somatic mutations in NOTCH1, XPO1, MYC88, and KLHL6 .
• Analysis in larger cohorts identified NOTCH1 mutations in 4 to 12 percent
of CLL patients
• NOTCH1 mutations were associated with unmutated immunoglobulin
variable heavy chain genes and a poor clinical outcome.
SF3B1 gene mutations
• SF3B1 gene encodes for part of a nuclear
ribonucleoprotein that complexes with other nuclear
ribonucleoproteins to create the spliceosome that is
responsible for splicing messenger RNA.
• SF3B1 mutations can be identified in a subset of
patients with CLL .
• As an example, recurrent somatic point mutations
(most commonly K700E) were seen in 14 of 91 patients
(15 percent) with CLL in one study
MicroRNAs (miRNAs)
• MicroRNA — are a novel class of small noncoding RNAs that modulate the
expression of genes at the post-transcriptional level, and are involved in cancer,
apoptosis, and cell metabolism . They may have particular relevance to CLL
• Mutations in miRNA transcripts are frequent, some of them germ-line, and may
predispose to CLL and to a spectrum of associated malignancies
• In a study of 56 patients with CLL, marked overexpression of two microRNAs (miR21 and miR-155) was seen in almost every sample analyzed
• MicroRNA-15a and miR-16-1 have been shown to interact directly with and result
in the upregulation of the B-cell leukemia/lymphoma 2 (BCL2) antiapoptotic
protein in many cases of CLL . These two mRNAs are not present in CLL with 13q
deletion, a genetic finding associated with a favorable outcome.
• Tumor suppressor genes may regulate the expression of microRNA. As an example,
the expression of a microRNA cluster located at 11q (miR34b/miR-34c) appears to
be directly activated by TP53 .
• It is unknown how microRNA and other regulatory systems interact to produce CLL
and/or determine its aggressiveness. One proposal is that there is a complex
interaction between miR-15a/miR-16-1, miR-34b/miR-34c, BCL2, ZAP70, and TP53
Indolent or smoldering CLL
• In the low-risk group, several investigators have discovered clinical criteria that may
identify patients whose disease will remain indolent or smoldering, as distinct from
those whose disease will progress to higher risk groups
• In one report of Spanish patients in Binet stage A, a lymphocyte count
<30,000/microL, a blood lymphocyte doubling time >12 months, hemoglobin ≥13
g/dL, and bone marrow biopsy showing a non-diffuse (interstitial or nodular)
pattern of lymphoid infiltration was associated with "smoldering" CLL, with survival
statistics similar to those of an age and sex-matched Spanish population
• In a series from France, Binet stage A patients with a hemoglobin concentration
>12 g/dL and blood lymphocytosis of <30,000/microL had a survival time equal to
that of an age and sex matched French population
• An Italian study found that Binet stage A patients with low serum concentrations of
vascular endothelial growth factor (VEGF) had a median progression-free survival
(PFS) that was not reached at 40 months, significantly longer than patients with
higher serum VEGF concentrations (median PFS 33 months)
• CLL cells have been shown to produce VEGF, which may be important for expansion
of lymphoid tissues, migration of CLL cells from blood to tissues, and/or
prolongation of the survival of these cells
Defining good and poor prognostic
groups
• Postgerminal center memory B-cells CLL:
with mutated immunoglobulin heavy chain variable-region (VH)
genes. In multiple studies, mutated VH gene status has, in general,
correlated with the presence of more favorable chromosomal
abnormalities, lowered expression of CD38 and ZAP-70, lower
clinical stage, greater disease stability, and excellent survival.
• Pregerminal Center B-cells CLL :
CLL developing from pregerminal center B-cells, with unmutated VH
genes. This finding correlated, in general, with the presence of less
favorable chromosomal abnormalities, higher expression of CD38
and ZAP-70, higher clinical stage, greater tendency to disease
progression, a poor response to treatment, and shorter survival.
Nomogram
•
Predicts which asymptomatic patients are more likely to progress to symptomatic disease
within two to four years .
A multivariable model evaluated time to first treatment and identified the
following factors as significant:
•
•
•
•
•
•
Number of lymph node sites involved
Size of largest lymph node in the neck
Serum LDH
VH gene mutation status,
del(11q)
del(17p)
•
Using these six factors, the two-year treatment-free probability ranged from 10 percent to
95 percent and the median treatment-free survival ranged from 10 to 60 months.
CLL nomogram for time to first treatment
Nomogram used by totaling points identified at top scale for each of four independent variables .This summed point score then identified on
total point scale to identify two- and four-year treatment-free probability and estimate treatment-free survival. FISH was categorized by Dohner
hierarchic categorization.IGHV: immunoglobulin heavy chain variable gene; FISH: fluorescent in situ hybridization; prob: probability.
Role of CD38, ZAP-70, and VH gene
mutation status
The relationships among lymphocyte developmental stage and morphology, CD38 and ZAP-70
positivity, genetic studies (eg, chromosomal changes, gene expression profiling, VH gene
mutation status, microRNA signatures), and other cellular variables as important prognostic
features are complex and the subject of considerable ongoing interest
• In a study of 325 consecutive patients with CLL, the presence of unmutated variable region
immunoglobulin heavy chain (VH) genes (ie, ≥97 percent homology to the nearest germline
gene) was associated with a hazard ratio of death of 5.3 (95 % CI 2.7-10), as compared with
those with lesser degrees of VH homology (ie, mutated VH genes)
• In a report including 205 patients with CLL and known VH mutation status, deletion of
chromosome 11q23, absence of a deletion of chromosome 13q14, atypical lymphocyte
morphology, and >30 percent expression of CD38 were significantly associated with
unmutated VH genes . The median survivals of patients with mutated VH genes, unmutated
VH genes, and loss or mutation of the p53 gene (regardless of VH gene status) were 310,
119, and 47 months, respectively. Patients with unmutated VH genes may have better
outcomes with hematopoietic cell transplantation
Role of CD38, ZAP-70, and VH gene
mutation status
In other reports, positivity for the zeta chain-associated protein (ZAP)-70 has been highly
correlated with the presence of unmutated VH genes and an inferior clinical outcome . In
our retrospective study, ZAP-70 positivity was a stronger predictor of the need for treatment
in B-cell CLL (hazard ratio 4.9; 95% CI 3.2-7.6) than was the presence of unmutated VH genes
(HR 2.5; 95% CI 1.6-3.9) . The adverse prognostic significance of ZAP-70 may not be seen in
patients treated with hematopoietic cell transplantation
• An Intergroup phase III trial of fludarabine versus fludarabine plus cyclophosphamide in 235
previously untreated CLL patients investigated the prognostic value of many of the abovenoted disease markers . Complete remission and overall response rates were not
significantly different based on cytogenetics, VH mutation status, CD38 expression, or p53
mutational status.
• However, the occurrence of del(17p) or del(11q) was associated with reduced progressionfree survival after an initial response, suggesting that patients with these high risk
cytogenetic features should be considered for alternative non-fludarabine-based therapy
that act independently of p53 (eg, alemtuzumab, flavopiridol)
HISTOLOGIC TRANSFORMATION
• CLLPatients, compared with general population, have a two- to
fivefold increased risk of second lymphoid malignancy .
• In 60 % of cases, the transformed cells are clonally related to the
original B-CLL cells while, in the remaining 40 %, they appear to be
derived from a separate cell of origin
•
•
•
•
The following are the most commonly reported transformations:
Prolymphocytic leukemia — 10 percent
Aggressive or highly aggressive lymphoma (Richter's
transformation) — 3 percent
Hodgkin lymphoma — 0.5 percent
Multiple myeloma — 0.1 percent
second lymphoid malignancy
• Limited data suggest that treatment with either a purine
nucleoside analogue or an anthracycline significantly increases the
risk of a second lymphoid malignancy.
• An observational cohort study from the Mayo Clinic followed 962
patients with CLL for a median of 3.3 years (range 0.1 to 21.0
years)
• Twenty-six patients (2.7 percent) developed a second lymphoid
malignancy with a median time of 4.4 years from CLL diagnosis
• There was no association between the development of a second
lymphoid malignancy and patient age, stage at diagnosis, absolute
lymphocyte count at diagnosis, or other known prognostic
parameters including IgVH gene mutation status, ZAP-70 status,
CD38 status, cytogenetic abnormalities by FISH, or beta-2
microglobulin level at diagnosis. These results require
confirmation from prospective trials
Prolymphocytoid transformation
In approximately 10 % of patients, the terminal event is a
morphological transformation of blood lymphocytes from the
typical small, mature-appearing cell to somewhat larger cells
with distinct nucleoli and a less dense nuclear chromatin.
Prolymphocytoid transformation, occurs slowly over years and is
associated with refractoriness to the usual chemotherapeutic
agents.
It is clinically and immunophenotypically distinct from de novo
prolymphocytic leukemia
Richter's transformation ( RT )
Richter's syndrome
• Transformation to a highly aggressive non-Hodgkin
lymphoma1 to 10 percent
• This transformation is heralded by sudden clinical
deterioration, characterized by increasing
lymphadenopathy, splenomegaly, worsening "B"
symptoms (ie, fever, night sweats, weight loss), a rapidly
progressive downhill clinical course, and a median survival
of 5 to 8 months.
Richters transformation
Lymph node from a patient with (B-cell CLL) undergoing Richter's transformation. The
monotonous infiltrate of small lymphocytes on the left side, representing the pre-existing Bcell CLL, contrasts with the large B-cells on the right, representing transformation to BCLCL
Hodgkin lymphoma
• In a number of cases of histologic transformation of B-CLL to Hodgkin lymphoma
(HL), single cell analysis indicated that the CLL cells and the isolated Reed-Sternberg
(RS) cells belonged to the same clonal population . A relationship with Epstein-Barr
virus infection and treatment with fludarabine has been suggested for these cases.
• In three other cases, RS-like cells were found in otherwise typical B-CLL in the
absence of clinical transformation to HL . The RS-like cells were derived from the
original B-CLL clone in one patient, but not in the other two, both of whose RS-like
cells were infected with Epstein-Barr virus.
• In a retrospective review of 4121 patients with CLL/small lymphocytic leukemia
(SLL) seen at the M D Anderson Cancer center, 18 developed HL (0.4 percent) at a
median time of 4.6 years after the diagnosis of CLL/SLL .
•
The most common presenting symptoms of HL in this group included
lymphadenopathy (79 percent), B-symptoms (67 percent), splenomegaly (43
percent), and hepatomegaly (29 percent). Fourteen patients received
chemotherapy for HL, with an overall response rate of 44 percent (19 percent
complete remission rate) and an extremely short median overall survival duration
of 0.8 years, similar to that seen in patients with CLL and Richter's transformation
Acute leukemic transformation
• Acute leukemia is a rare terminal event in CLL and,
when it does occur, is usually one of the myeloid
variants (ie, acute myeloid leukemia, AML)
• Prior therapy with alkylating agents has not been
clearly implicated in causation of terminal leukemia.
• AML developing in patients known to have CLL is
treated with any of the acute leukemia therapy
regimens, but with almost invariably poor outcome
Second malignancies
•
•
•
•
•
•
Bone cancer — 4.3
Skin cancer — 3.6
Thyroid cancer — 2.6
Kidney cancer — 1.8
Cancer of the buccal cavity and pharynx — 1.8
Lung cancer — 1.6
• Although skin cancers occur with considerably greater
frequency than among the general population, they do
not result in higher mortality.
INFORMATION FOR PATIENTS
• Basics patient education pieces are written in plain language,
at the 5th to 6th grade reading level, and they answer the four or
five key questions a patient might have about a given condition.
These articles are best for patients who want a general overview
and who prefer short, easy-to-read materials.
• Beyond the Basics patient education pieces are longer, more
sophisticated, and more detailed. These articles are written at the
10th to 12th grade reading level and are best for patients who
want in-depth information and are comfortable with some medical
jargon.
• Here are the patient education articles that are relevant to this
topic. We encourage you to print or e-mail these topics to your
patients. (You can also locate patient education articles on a
variety of subjects by searching on “patient info” and the
keyword(s) of interest.)
SUMMARY AND
RECOMMENDATIONS
•
•
•
•
Patients are grouped prognostically according to the Rai and Binet staging
systems based on physical examination and complete blood counts .
Computed tomography of the chest, abdomen, and pelvis is not routinely
performed outside of a clinical trial, but may be indicated based upon the
patient's symptoms
The variability in disease course suggests the need for prospective
treatment protocols stratifying for combinations of the Rai or Binet clinical
staging systems, along with study of important biologic markers, as
described above]. Such studies should improve the clinician's ability to
more reliably assess appropriate initial therapy and prognosis in all newly
diagnosed patients with CLL].
We do not recommend studies for CD38, ZAP-70, or VH gene mutation
status at this time outside of a clinical trial.
These studies will be of special importance, since retrospective analyses
have suggested a survival benefit for hematopoietic cell transplantation
over conventional chemotherapy in patients with CLL and unmutated VH
genes]. However, treatment based on prognostic markers alone in
asymptomatic patients with early stage disease cannot be recommended
outside of a clinical trial
INDICATIONS FOR
TREATMENT
• CLL is an extremely heterogeneous disease with certain
subsets of patients having survival rates without treatment
that are similar to the normal population
• With the possible exception of allogeneic hematopoietic
cell transplantation (HCT), CLL cannot be cured by current
treatment options
• Prospective, randomized trials evaluating immediate versus
delayed treatment strategies have found no improvement
in long-term survival with early treatment.
• Spontaneous regression of variable duration is a rare
occurrenc
Therapy is indicated for patients with the
following disease-related complications
•
Weakness, night sweats, weight loss, painful lymphadenopathy, or fever.
•
Symptomatic anemia and/or thrombocytopenia (Rai stages III or IV; Binet stage C)
•
Autoimmune mediated anemia or thrombocytopenia is treated with therapy directed at
the autoimmune process before treatment of the underlying CLL is initiated.
•
Autoimmune hemolytic anemia and/or thrombocytopenia poorly responsive to
corticosteroid therapy.
•
Progressive disease, as demonstrated by increasing lymphocytosis with a lymphocyte
doubling time less than six months, and/or rapidly enlarging lymph nodes, spleen, and
liver.
•
Transient localized lymphadenopathy, occurring in response to localized infections, is not
necessarily an indication for treatment.
•
Repeated episodes of infection. Hypogammaglobulinemia without repeated episodes of
infection is not a clear indication for therapy.
Karnofsky Performance Status
ECOG performance scale
•
CBC , diff , RFT , LFT, electrolytes, alkaline phosphatase, (LDH), beta-2 microglobulin, and direct
antiglobulin test (DAT).
•
Testing for HIV, hepatitis B and hepatitis C.
•
CMV Serology (IgM and IgG). For patients being treated with agents associated with
cytomegalovirus (CMV) reactivation (eg, alemtuzumab or allogeneic hematopoietic cell
transplantation)
•
Unilateral BMA &BMB ( who have cytopenias of unknown cause ).
•
BM pathologic review, immunophenotyping, IHC , (FISH) for del17p, del11q, trisomy 12, and
del13q.
•
Men and women with childbearing potential should receive counseling about the potential effect
of treatment on their fertility and options for fertility-preserving measures.
•
chest x-ray should be obtained to evaluate for hilar and mediastinal adenopathy.
•
CT should be performed in any patient in whom enlarged abdominal or pelvic nodes are suspected
based upon evidence of complications such as obstructive jaundice, or obstruction of the inferior
vena cava or ureters.
TREATMENT OF
SYMPTOMATIC CLL
• Purine analogs
(eg, fludarabine, pentostatin)
• Alkylating agents(eg, chlorambucil, bendamustine)
• Monoclonal antibodies(eg,rituximab, alemtuzumab)
• Combinations of these agents
Fludarabine-based therapy
• Chlorambcil
• Fludarabine + rituximab (FR)
• Fludarabine + cyclophosphamide + rituximab (FCR)
• Fludarabine + cyclophosphamide + ofatumumab
(O-FC)
• Alemtuzumab (Anti-CD52 monoclonal antibody)
• Fludarabine + rituximab (FR)
•
alemtuzumab
Fludarabine + cyclophosphamide+ rituximab +
alemtuzumab (CFAR)
• Bendamustine
• Pentostatin + cyclophosphamide + rituximab
High-risk disease
• Patients with del(17p) or del(11q) are at high risk of
either not responding to initial treatment, or
relapsing soon after achieving remission
RESPONSE CRITERIA
Complete remission
All of the following (at least two months after completion of therapy)
•
Absence of constitutional symptoms :
•
No LN >1.5 cm in diameter on physical examination
•
No hepatomegaly or splenomegaly by physical examination
•
Absolute neutrophil count >1500/microL [1.5 x 10(9)/L]
•
Platelet count >100,000/microL [100 x 10(9)/L]
•
Untransfused hemoglobin concentration >11 g/dL (110 g/L)
•
No clonal lymphocytes in the peripheral blood by immunophenotyping
≥10% unintentional weight loss within the previous 6 months, fatigue that interferes with work or
usual activities, fevers greater than (>38ºC) for ≥2 weeks, or night sweats for >1 month.
CR with incomplete BM recovery
• All criteria of CR + persistent neutropenia,
anemia, or thrombocytopenia unrelated to
their disease, but likely related to drug
toxicity
• These patients must have a normal bone
marrow aspirate and biopsy with no
evidence of clonal infiltrates
Partial remission
(PR) at least one of the following criteria has been met along with one of the specific
hematologic parameters described below. At least one of these criteria must be documented
for a minimal duration of two months after the completion of therapy:
• A decrease in the peripheral absolute lymphocyte count by at least 50 percent from the level
prior to therapy.
• A reduction in previously enlarged nodes by at least 50 percent with no increase in the size
of any single lymph node and no new enlarged lymph nodes. For these purposes, the size of
previously enlarged nodes is defined by the sum of the products of up to 6 lymph nodes. An
increase of <25 percent in a lymph node <2cm is not considered significant.
• If enlarged prior to therapy, the liver and spleen should be reduced in size by at least 50
percent based upon palpation or ultrasound.
• One of the following hematologic parameters must be met in addition to one of the above
criteria in order to qualify for a PR:
• Absolute neutrophil count ≥1500/microL [1.5 x 10(9)/L] or greater than 50 percent
improvement over baseline (if this value was abnormally low at baseline) without GCSF
support.
• Plt ≥100,000/microL [100 x 10(9)/L] or at least 50 percent improvement over baseline (if this
value was abnormally low at baseline).
• Hb ≥11 g/dL (110 g/L) or 50 percent improvement over baseline (if this value was
abnormally low at baseline) without red blood cell transfusions or erythropoietin support.
Progressive disease
(PD) is defined by the presence of one or more of the following:
•
•
•
•
•
The appearance of a newly enlarged lymph node (>1.5 cm), splenomegaly, or hepatomegaly.
An increase of 50 percent or more in size of a previously involved site (eg, lymph nodes,
spleen, or liver). Lymph node enlargement is measured by the sum of the product of
diameters of up to six involved nodes. A lymph node that was 1 to 1.5 cm previously must
increase by 50 percent or more to a size greater than 1.5 to 2 cm in the longest axis.
An increase of 50 percent or more in the total circulating lymphocyte count with at least
5000 lymphocytes per microL.
Development of neutropenia, anemia, or thrombocytopenia attributable to CLL. Cytopenias
cannot be used to determine disease progression during active therapy since they may be
due to administered cytotoxic agents. Cytopenias that occur at least three months after the
completion of therapy and are accompanied by an infiltrate of clonal CLL cells on bone
marrow biopsy can be used to define disease progression. Specific values that define
progression include a decrease in hemoglobin level by more than 2 g/dL (20 g/L) or to less
than 10 g/dL (100 g/L) or a decrease in platelet count by more than 50 percent or to less
than 100,000/microL [100 x 10(9)/L].
Richter's transformation (the development of an aggressive large-cell lymphoma) as
documented by lymph node biopsy.
Stable disease
• Patients who do not meet the criteria for
a complete remission, partial remission,
or progressive disease, have stable
disease.
• Stable disease is therapeutically
equivalent to a nonresponse (ie,
refractory disease).
Complete remission
on clinical trials
•
•
•
•
•
•
•
•
•
on a research protocol, a complete remission (CR) requires all of the following to be present
at least two months after completion of therapy :
Absence of constitutional symptoms attributable to CLL (ie, ≥10 percent unintentional
weight loss within the previous 6 months, fatigue that interferes with work or usual
activities, fevers greater than 100.5ºF (>38ºC) for ≥2 weeks, or night sweats for >1 month).
No lymph nodes >1.5 cm in diameter on computed tomography.
No hepatomegaly or splenomegaly by computed tomography.
Absolute neutrophil count >1500/microL [1.5 x 10(9)/L].
Platelet count >100,000/microL [100 x 10(9)/L].
Untransfused hemoglobin concentration >11 g/dL (110 g/L).
No clonal lymphocytes in the peripheral blood by immunophenotyping.
A unilateral bone marrow aspirate and biopsy performed at least two months after the
completion of therapy and before six months have elapsed is required to confirm the CR. If a
hypocellular marrow is found, the bone marrow aspirate and biopsy should be repeated in 4
to 6 weeks provided the peripheral blood counts have recovered. The marrow should be free
of clonal CLL cells by conventional flow cytometry and/or immunohistochemistry. If nodules
(lymphoid aggregates) are found on bone marrow biopsy, these may represent residual
disease (ie, nodular PR) and so should be assessed by immunohistochemistry to determine if
they are principally comprised of CLL cells or of lymphocytes other than CLL cells or T cells.
CR with incomplete BM recovery
• A separate category is used for patients who fulfill
all of the criteria for a complete remission yet have
persistent neutropenia, anemia, or
thrombocytopenia unrelated to their disease, but
likely related to drug toxicity. These patients must
have a normal bone marrow aspirate and biopsy
with no evidence of clonal infiltrates.
Minimal residual disease
•
— Laboratory tests based on multicolor flow cytometry and real time
quantitative polymerase chain reaction (PCR) have demonstrated that most
patients who achieve a complete remission following chemotherapy still
have a detectable malignant clone . These studies can reliably detect
approximately one CLL cell per 10,000 leukocytes
• As such, patients in some clinical trials are being evaluated for minimal
residual disease (MRD). Those with less than one CLL cell per 10,000
leukocytes are considered in complete remission without MRD. At this time,
studies for MRD are only recommended for patients enrolled in clinical
trials. Prospective trials are necessary to determine whether additional
therapy to convert a response from a complete remission to a clinical
remission with MRD is of significant clinical benefit.
Partial remission
•
•
•
•
•
•
•
•
(PR) is defined when at least one of the following general criteria has been met along with
one of the specific hematologic parameters described below. At least one of these criteria
must be documented for a minimal duration of two months after the completion of therapy:
A decrease in the peripheral absolute lymphocyte count by at least 50 percent from the level
prior to therapy.
A reduction in previously enlarged nodes by at least 50 percent with no increase in the size
of any single lymph node and no new enlarged lymph nodes. For these purposes, the size of
previously enlarged nodes is defined by the sum of the products of up to six lymph nodes.
An increase of <25 percent in a lymph node <2cm is not considered significant.
If enlarged prior to therapy, the liver and spleen should be reduced in size by at least 50
percent based upon computed tomography.
One of the following hematologic parameters must be met in addition to one of the above
criteria in order to qualify for a PR:
Absolute neutrophil count ≥1500/microL [1.5 x 10(9)/L] or greater than 50 percent
improvement over baseline (if this value was abnormally low at baseline)
without granulocyte colony-stimulating factor support.
Platelet count ≥100,000/microL [100 x 10(9)/L] or at least 50 percent improvement over
baseline (if this value was abnormally low at baseline).
Hemoglobin concentration ≥11 g/dL (110 g/L) or 50 percent improvement over baseline (if
this value was abnormally low at baseline) without red blood cell transfusions or
erythropoietin support.
Nodular partial remission
• Persistent bone marrow nodules on bone marrow
biopsy in patients achieving a CR or PR are classified
separately as a nodular PR (PR-Nod).
• Lymphoid aggregates should be evaluated with
immunohistochemistry to determine whether they
are comprised of CLL cells, lymphocytes other than
CLL cells, or T cells .
Progressive disease
•
•
•
•
•
•
Progressive disease (PD) is defined by the presence of one or more of the following:
The appearance of a newly enlarged lymph node (>1.5 cm), splenomegaly, or hepatomegaly.
An increase of 50 percent or more in size of a previously involved site (eg, lymph nodes,
spleen, or liver). Lymph node enlargement is measured by the sum of the product of
diameters of involved nodes. A lymph node that was 1 to 1.5 cm previously must increase by
50 percent or more to a size greater than 1.5 to 2 cm in the longest axis.
An increase of 50 percent or more in the total circulating lymphocyte count with at least
5000 lymphocytes per microL.
Richter's transformation (the development of an aggressive large-cell lymphoma) as
documented by lymph node biopsy.
Development of neutropenia, anemia, or thrombocytopenia attributable to CLL. Cytopenias
cannot be used to determine disease progression during active therapy since they may be
due to administered cytotoxic agents. Cytopenias that occur at least three months after the
completion of therapy and are accompanied by an infiltrate of clonal CLL cells on bone
marrow biopsy can be used to define disease progression. Specific values that define
progression include a decrease in hemoglobin level by more than 2 g/dL (20 g/L) or to less
than 10 g/dL (100 g/L) or a decrease in platelet count by more than 50 percent or to less
than 100,000/microL [100 x 10(9)/L].
Stable disease
• Patients who do not meet the criteria for a
complete remission, partial remission, or
progressive disease, have stable disease.
• Stable disease is therapeutically equivalent to a
nonresponse.
RELAPSED DISEASE
• Relapsed disease occurs in patients who have
previously achieved either a complete or partial
remission by the above criteria but then develop
progressive disease after a period of six months or
more.
REFRACTORY DISEASE
• Patients who fail to achieve either a partial or
complete remission with therapy or those who
develop disease progression within six months of
therapy have refractory disease.
• These treatment failures include patients with
stable disease, nonresponsive disease, progressive
disease, or death from any cause.
complications of CLL
INFECTION
• Immune defects — Patients with CLL have abnormal cellular
and humoral-mediated immune responses
• Infections account for up to 50 percent of all deaths in
patients with CLL
• Infection increases with disease stage and active treatment.
• Bone marrow infiltration and therapy-induced immune
dysfunction .
• Encapsulated organisms , Streptococcus pneumoniae,
Staphylococcus aureus, and Haemophilus influenzae.
• Reactivation of herpes viruses is also common, with Herpes
zoster being more frequent than Herpes simplex..
complications of CLL
INFECTION
•
Patients treated with purine analogs (eg, fludarabine) are at increased risk of infections due
to Listeria, mycobacterial species, Nocardia, Candida, Aspergillus, Cryptococcus, herpes
viruses (cytomegalovirus, Herpes zoster, Herpes simplex), and Pneumocystis jirovecii
(previously Pneumocystis carinii). .
•
Patients treated with alkylator-based regimens (eg, chlorambucil) have frequent infections
of the respiratory tract, most commonly due to Staphylococcus aureus, Streptococcus
pneumoniae, Haemophilus influenzae, Escherichia coli, Klebsiella pneumoniae, and
Pseudomonas aeruginosa
When such patients also demonstrate neutropenia and hypogammaglobulinemia, they are
at increased risk of becoming infected with encapsulated gram positive and gram negative
organisms such as those seen in patients treated with purine analogs.
Patients treated with alemtuzumab are at increased risk of infections due to herpes viruses
(cytomegalovirus, Herpes zoster, Herpes simplex), Candida, Aspergillus, and Pneumocystis
jirovecii.
Patients treated with rituximab have no definitive change in the spectrum of infection, but
are at increased risk for the reactivation of hepatitis B and/or hepatitis C.
•
•
•
complications of CLL
ANEMIA
• GI blood loss secondary to the use of
corticosteroids, thrombocytopenia, mucositis or
coagulopathy
• Hypersplenism
• Marrow suppression secondary to the use of
chemotherapy
• Marrow infiltration by advanced disease
• Hemolytic anemia
• Red blood cell aplasia
complications of CLL
THROMBOCYTOPENIA
• Suppression of platelet production in the presence
of extensive tumor burden
• Autoimmune destruction
• Hypersplenism
• Infection (particularly sepsis and associated
disseminated intravascular coagulation)
• Chemotherapy
complications of CLL
• PSYCHOLOGICAL DISTRESS
• SECOND CANCERS
• 5- 10 % transform into (Richter's transformation) or
PLL
• Treated CLL develop therapy-related MDS or AML
• Kaposi's sarcoma, malignant melanoma, cancers of
the larynx, and cancers of the lung.
complications of CLL
LEUKOSTASIS
• Leukostasis is a medical emergency characterized by
an extremely elevated white blood cell (WBC) count
and symptoms of decreased tissue perfusion
• While a significant proportion of patients with CLL
present with a high WBC count, symptoms of
leukostasis are rare unless the WBC count exceeds
400x10(9)/L (400,000/microL).
complications of CLL
TUMOR LYSIS SYNDROME TLS
• (TLS) (hyperphosphatemia, hypocalcemia, hyperkalemia, and RF)
• The inciting cause seems to be release of large amounts of
phosphate from lysed blasts, which coprecipitates with calcium in the
kidneys, leading to hypocalcemia and sometimes to oliguric renal
failure.
• Hyperuricemia further contributes to this problem.
• TLS incidence in CLL varies with the treatment given. Some regimens
require prophylaxis for TLS while others do not.
• Investigational cyclin-dependent kinase inhibitor flavopiridol is highly
active in refractory CLL, associated with dramatic instances of
hyperacute TLS
Hairy Cell Leukemia
Hairy Cell Leukemia
Lymphocytosis and pancytopenia
The characteristic cytoplasmic projections are already visible
Lymphocytosis and an absence of any other type of blood cell
(pancytopenia). The characteristic cytoplasmic projections are already
visible
Hairy Cell Leukemia
Clonal B-cell malignancy
Identified by immunoglobulin gene rearrangements that
result in a phenotype B-cell expression of surface antigens
which reflect the differentiation between the immature Bcell of chronic lymphocytic leukemia and the plasma cell
of multiple myeloma
Bone marrow failure or pancytopenia
Organomegaly
This image demonstrates tartrate-resistant acid phosphatase (TRAP) activity of
lymphocytes.
Etiology
• Benzene, organophosphorus insecticides, or other solvents may be related to
disease development ?
• Occupational pesticide exposures may involved in hairy cell leukemia, and
multiple myeloma, NHL, HD ?
• Exposure to radiation, agricultural chemicals, and wood dust, and a previous
history of infectious mononucleosis have been suggested as etiologic associations
in previous reports.
• Overexpression of cyclin D1 protein, an important cell-cycle regulator, has been
observed in hairy cell leukemia and may play a role in the molecular pathogenesis
of the disease.
• Accumulation of hairy cells in the bone marrow,
liver, and spleen, with very little lymph node
involvement, is characteristic of hairy cell
leukemia.
• This pattern probably results from the expression
of the integrin receptor alpha4-beta1 by the hairy
cells and the interaction of the receptor with the
vascular adhesion molecule-1 (VCAM-1) found in
splenic and hepatic endothelia, bone marrow, and
splenic stroma.
Epidemiology
• Mortality/Morbidity :
Anemia (fatigue and weakness)
Thrombocytopenia (bleeding or easy bruising)
Neutropenia (infections)
• Abdominal discomfort :
hepatosplenomegaly.
Epidemiology
• Race
: This disease is observed more commonly in
whites. It has been reported to occur in Ashkenazi Jewish
males, and it is rare in Japan and in those of African
descent
• Sex : M / F
• Age :
4:1 to 5:1
middle-aged men, with a median age of 52 years.
History
•
•
•
•
•
Weakness and fatigue due to anemia
One third have bleeding from thrombocytopenia
One third have fever and infections from neutropenia.
Spleenomegaly 25 %
Weight loss, fever, and night sweats
•
Infections with gram-positive and gram-negative bacterial, as well as
atypical mycobacterial and invasive fungal infections , Pneumocystis
carinii, Legionella, toxoplasmosis, and listeriosis, have been reported.
History
• HCL is associated with scleroderma, polymyositis,
polyarteritis nodosa, erythematous maculopapules, and
pyoderma gangrenosum.
• Other conditions may be associated with HCL ( acquired
factor VIII antibodies, paraproteinemia, and systemic mast
cell disease)
Physical
• Splenomegaly is massive in more than 80% of patients.
• Hepatomegaly with mild LFT abnormalities is found in 20%
• Lymphadenopathy is found in 10%.
• A low-grade fever is part of the disease
• Peripheral lymphadenopathy is uncommon with fewer than 10% of patients
presenting with peripheral nodes larger than 2 cm in diameter.
• Internal adenopathy may develop after a prolonged disease course and was
found in 75% of patients at autopsy.
Differential Diagnoses
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Agnogenic Myeloid Metaplasia With Myelofibrosis
Anemia
Aplastic Anemia
Chronic Lymphocytic Leukemia
Myelodysplastic Syndrome
Myelophthisic Anemia
Myeloproliferative Disease
Laboratory Studies
• Hairy cells express single or multiple immunoglobulin light chains and
pan–B-cell antigens, such as CD19, CD20, CD22, and CD79b, but not
CD21 (late B-cell marker). The cells also typically express CD103,
CD11c, and CD25 but usually not CD5, CD10, or CD23.
• Hairy cells strongly express CD45, seen as a bright signal, with
increased forward and side scatter resembling large lymphocytes and
monocytes. Immunophenotypic analysis helps distinguish hairy cell
leukemia from other low-grade B-cell malignancies.
• A study confirmed that CD123 and CD103 are useful in the
differential diagnosis of B-cell lymphoproliferative disorders.
Laboratory Studies
• Monoclonal BLy-7 has high sensitivity and specificity for HCL.
• CD22 stains at higher intensity in hairy cells than in normal B cells.
• HCL can be identified immunophenotypically in 92% of cases, even
when the cells represent less than 1% of the circulating lymphocytes.
• HCL demonstrate strong (TRAP) staining
• A positive TRAP stain in conjunction with a characteristic bone
marrow biopsy is essentially diagnostic of hairy cell leukemia
Laboratory Studies
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Anemia is usually severe and normochromic-normocytic in character.
Neutropenia and monocytopenia are usually present in HCL
Elevated white blood cell count (hairy cells) is found in 20% of cases.
Thrombocytopenia is found in more than 80% of patients.
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Bone marrow aspirate is usually unsuccessful "dry tap.”
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Bone marrow biopsy shows hairy cell infiltration with a single round or oval nucleus
separated by abundant cytoplasm in a fine fibrillar network . The cell appears separated,
resulting in the characteristic fried-egg appearance
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Clonal cytogenetic abnormalities are present in 1/3 of patients, and the involvement of
chromosomes 1, 2, 5, 6, 11, 14, 19, and 20 have been described. Chromosome 5
abnormality is most frequent (in 40% of patients) with trisomy 5 and pericentric inversions
and interstitial deletions of band 5q13.
Laboratory Studies
• Difficult cases can be confirmed by using immunophenotypic analysis
of the buffy coat cells or by performing electron microscopy on
suspected cells.
• Soluble interleukin-2 receptor levels are elevated in patients with
hairy cell leukemia and may provide additional supportive data for
the diagnosis.
• The somatically acquired V600E mutation of the BRAF gene is present
in all patients with hairy cell leukemia and represents a reliable
marker.
Histologic Findings
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Pancytopenia
Splenomegaly
Circulating cells that are TRAP positive
Bone marrow aspirate dry Tap
BMB infiltration with a mononuclear cells that
have a fried-egg appearance are diagnostic of hairy
cell leukemia.
Medical Care
Chemotherapeutic approaches
• The first-line therapy for hairy cell leukemia is 2-chlorodeoxyadenosine (2-CdA) 0.1
mg/kg/d (Cladribine, Leustatin) by continuous intravenous infusion for 7 days,
which can be performed on an outpatient basis with a pump, using a percutaneous
intravenous central catheter (PICC).
• Growth factors are not routinely given but may be added in patients with febrile
neutropenia.
• The response is usually first observed in the platelet counts (in 2-4 wk) followed by
white blood cell counts and neutrophils and, finally, hemoglobin levels.
• Bone marrow biopsy is repeated in 3 months, but minimal residual disease does
not need therapy.
• With one course of therapy of 2-CdA, 80% of patients obtain a complete remission
(CR), and the remainder obtains a partial remission (PR).
Medical Care
Chemotherapeutic approaches
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Several long-term studies have been reported. Chadha et al reported that, although the
overall survival rate at 12 years was 87%, the progression-free survival at 12 years was
only 54%.In addition, 17% of patients had developed another malignancy during that
time.
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For increased convenience, some groups have given 2-CdA as a 2-hour infusion (0.14
mg/kg/d) for 5 days. Zinzani et al reported a CR rate of 81% and a PR rate of 19% using
this schedule.The 13-year overall survival rate was 96%, and the relapse-free survival
rate was 52%.No randomized study comparing the 24-hour infusional versus the 2-hour
infusional schedules is available.
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A current trend is the significance of minimal residual disease following treatment with
2-CdA. Ravandi et al administered rituximab to patients with residual disease following
2-CdA.Eleven of 12 patients had eradication of minimal residual disease with this
treatment. Whether this will alter the natural history of hairy cell leukemia or prevent
relapse is unclear. Currently, the standard therapy for patients with minimal residual
disease is observation.
Relapsed hairy cell leukemia
• For patients who have previously been treated with
splenectomy, interferon, or 2-deoxyformycin (2'-DCF,
Pentostatin), retreatment with 2-CdA in the same manner
is indicated, especially
• If their disease had previously responded to 2-CdA. In
patients previously treated with 2-CdA, response rates of
50% are typical.
• Rituximab is a monoclonal antibody against CD20. In
patients with relapsed or refractory hairy cell leukemia,
response rates of 50% are reported.
Hairy cell leukemia may behave as a chronic leukemia without causing
any symptoms. Approximately 10% of cases, usually in elderly men with
moderate splenomegaly and mild decrease in blood counts, never
require therapy.
The standard criteria for initiating therapy include the
following: Symptoms or blood transfusion requirement
I. Significant anemia with hemoglobin of 8-10 g/dL or less
II. Thrombocytopenia with platelet counts of 50,000-100,000/mL or less
III. Neutropenia with an absolute neutrophil count (ANC) of 500-1000/mL or less
Less common indications for therapy
include the following:
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Leukocytosis with a high proportion of hairy cells
Repeated life-threatening infections
Symptomatic splenomegaly
Bulky or painful lymphadenopathy
Vasculitis
Bony involvement
Surgical Care
Splenectomy
 Splenectomy was the first standard treatment modality and was used
commonly in the past, but this propcedure has been replaced by the
newer agents available.
 Cytopenia improved rapidly in most patients.
 Splenectomy does not produce pathologic remissions in the BM, the
PB cell improve in all 3 cell lines in approximately 40-70% of patients.
This response usually lasts for a median of 20 months in approximately two thirds of
patients, with an overall survival rate of 70% in 5 years.
Surgical Care
Splenectomy
 Splenic size does not predict response to splenectomy.
 Effective medical therapy has replaced splenectomy as the first-line
treatment for hairy cell leukemia.
 Splenectomy is currently reserved for patients whose conditions fail
to respond to systemic therapy or for those with bleeding from
thrombocytopenia. Patients undergoing splenectomy require
appropriate vaccination.
 Laparoscopic splenectomy has decreased the morbidity and duration
of the postsurgical recovery period
Relapsed HCL
• For patients with hairy cell leukemia that is refractory to 2-CdA, or if
relapse occurs after 2 cycles of 2-CdA, the authors recommend
treatment with 2'-deoxycoformycin (2'DCF, Pentostatin) 4 mg/m2
intravenously every 2 weeks for 3-6 months
• Alpha interferon at 2 million U/m2 subcutaneously 3 times a week
for 12-18 months can be used to salvage relapsed or refractory hairy
cell leukemia.
Purine Analogues
 Patients with severe combined immunodeficiency (SCID)
were deficient in the purine catabolic enzyme adenosine
deaminase.
 This deficiency causes intracellular accumulation of
deoxyadenosine triphosphate and results in
lymphocytotoxicity.
 Purine analogues mimic this condition by irreversibly
binding to adenosine deaminase or by fostering resistance
to deamination in the purine salvage pathway.
Cladribine or 2-chlorodeoxyadenosine
(Leustatin)
• Synthetic antineoplastic agent for continuous IV infusion. The enzyme
deoxycytidine kinase phosphorylates this compound into active 5'triphosphate derivative. This, in turn, breaks DNA strands, inhibits
DNA synthesis, disrupts cell metabolism, and causes death to resting
and dividing cells.
• Most active among the purine analogues in the treatment of hairy
cell leukemia. Has a 94% overall response and 84% complete
response in hairy cell leukemia.
• Patients whose disease does not respond to the initial regimen likely
will not have a response to retreatment.
Pentostatin or 2-deoxycoformycin (Nipent)
• Approved by the FDA for hairy cell leukemia but is
less active than 2-CDA for this disease.
• Treatment results in a 79% overall response rate
and a 64% complete response rate in patients with
hairy cell leukemia.
• Response rates (CR + PR) of more than 90% have
been reported.
Interferons
Naturally produced proteins with antitumor and
immunomodulatory effects.
Interferon alfa 2a (Roferon)
• Roferon and Intron A differ from the natural product only in amino acid residue at
position 23 and achieve similar results in hairy cell leukemia. Response rates are
65% overall, with 10% of patients achieving a complete remission.
Interferon alfa-2b (Intron A)
 Manufactured by recombinant DNA technology.
 First systemic drug shown to partially eradicate hairy cells from bone
marrow, and first approved indication was for this disease.
 The mechanism of antitumor activity is not clearly understood;
however, direct antiproliferative effects against malignant cells and
modulation of the host immune response may play important roles.
Further Inpatient Care
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Hyperuricemia may occur during therapy in patients with hairy cell leukemia with
leukocytosis and high tumor burden. Add allopurinol at 300 mg per day orally.
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The risk of second malignancies has been observed in affected patients either through
hairy cell leukemia disease itself or secondary from the immunosuppressive effects of the
therapy, including melanoma, prostate cancers, gastrointestinal malignancies, non-Hodgkin
lymphomas, and nonmelanomatous cancers.
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A 20-year follow-up in 117 patients in British Columbia showed 31% developed a second
malignancy, of which 30% were diagnosed before hairy cell leukemia was found.
On the other hand, MD Anderson reported no excess of second malignancies among 350
patients with hairy cell leukemia who were treated with interferon, 2'-CdA, or 2'-DCF
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Further Outpatient Care
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Hairy cell leukemia is usually indolent and protracted; late relapses occur.
Long-term outpatient follow-up is often necessary in most patients.
The overall survival rate with 2'DCF up front or after alpha interferon failure 80-85% at 10
years.
Evaluation of minimal residual disease by posttreatment bone marrow biopsies using antiCD20 by flow cytometry reveals that 13-51% of patients in apparent CR had minimal residual
disease and appears to predict clinical relapse.
Because a majority respond very well to retreatment (92% response) or salvage treatment
(80% response), no evidence supports treatment of minimal residual disease.
Newer therapies, such as anti-CD20 monoclonal antibody rituximab, had been tested in
patients with hairy cell leukemia that was refractory to standard treatment. Several studies
with small numbers of patients who received rituximab showed an overall response of 64%,
with a median duration of response of 14 months, to 100% response and a duration of 73
months, indicating that this form of therapy is active against hairy cell leukemia.
Prognosis
 Hairy cell leukemia behaves like a chronic leukemia.
 With new therapies, most patients achieve clinical
remissions and, sometimes, long-term cures.
 Although relapses are known to occur after 5-10 years, they
are usually responsive to the same treatment.
 Most of the difficulty is in making the diagnosis.