Download chronic lymphocytic leukemia (cll)

CHRONIC LYMPHOCYTIC
LEUKEMIA (CLL)
Curs an IV – limba engleza
2012-2013
CLL - Definition
• CLL is a neoplastic disease characterized by
proliferation and accumulation (blood, marrow
and lymphoid organs) of morphologically
mature but immunologically dysfunctional
lymphocytes
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CLL - Definition
• Clonal B cell malignancy.
• Progressive accumulation of long lived mature
lymphocytes.
• Increase in anti-apoptotic protein bcl-2.
• In most cases, the cells are monoclonal B
lymphocytes that are CD5+
• Intermediate stage between pre-B and mature
B-cell.
• T cell CLL can occur rarely
CLL - Epidemiology
•
•
•
•
•
•
Most common leukemia of Western world.
Less frequent in Asia and Latin America.
Male to female ratio is 2:1.
Median age at diagnosis is 65-70 years.
Uncommon (10%) in patients under 50 years
In US population incidence is similar in
different races.
Cancer statastics 2000; CA J Clin 2000; 50:7-33
CLL - Etiology (1)
• The cause of CLL is unknown
• There is increased incidence in farmers, rubber
manufacturing workers, asbestos workers, and
tire repair workers
• Genetic factors have been postulated to play a
role in high incidence of CLL in some families
CLL - Etiology (2)
• Cytogenetics
– clonal chromosomal abnormalities are detected in
approximately 50% of CLL patients
– the most common clonal abnormalities are:
• trisomy 12
• structural abnormalities of chromosomes 13, 14 and 11
– patients with abnormal karyotypes have a worse
prognosis
• Oncogenes
– in most cases of CLL is overexpressed the protooncogene c-fgr 9a member of the src gene family of
tyrosine kinases
CLL – Initial symptoms
• Approximately 40% are asymptomatic at
diagnosis – discovered by a CBC
• In symptomatic cases the most common
complaint is fatigue
• Well’s syndrome – increase sensitivity to insects
bites
• B symptoms – fever, sweats, weight loss
• Less often the initial complaint are enlarged
nodes or the development of an infection
(bacterial)
CLL - Clinical findings
• Most symptomatic patients have enlarged lymph nodes
(more commonly cervical and supraclavicular) and
splenomegaly
• The lymph nodes are usually discrete, freely movable,
and nontender
• Hepatomegaly may occure
• Less common manifestation are infiltration of tonsils,
mesenteric or retroperitoneal lymphadenopathy, and
skin infiltration
• Patients rarely present with features of anemia, and
bruising or bleeding
CLL – Lab findings
a) Blood test
lymphocytosis ≥ 5G/l (4 weeks)
b) Morphology
monoconal population of small
mature lymphocyte
c) B-cell CLL phenotype
clonal CD5+/CD19+ population
of lymphocyte
d) Markers of clonality
κ/λ light chain restriction;
cytogenetical abnormalities
e) Bone marrow infiltrate
> 30% of nuceated cells on aspirate
f) Lymph node
diffuse infiltrate of small lymphocye
CLL - Laboratory findings (1)
• The blood lymphocyte count above 5.000/mmc
• Leukemic cells have the morphologic appearance of
normal small lymphocytes
• In the blood smears are commonly seen ruptured
lymphocytes (“basket” or “smudge” cells)
• Careful examination of the blood smear can usually
differentiate CLL, and the diagnosis can be confirmed
by immunophenotyping
CLL - Peripheral Blood
• Absolute lymphocytosis
• Lymphs = B cells
– Thin cytoplasm
– Dense nucleus
– Partially aggregated
chromatin
– No recognizable
nucleoli
• Smudge cells
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CLL - Laboratory findings (2)
• Clonal expansion of B (99%) or T(1%) lymphocyte
– In B-cell CLL clonality is confirmed by
• the expression of either  or  light chains on the cell surface
membrane
• the presence of unique idiotypic specificities on the
immunoglobulins produced by CLL cells
• by immunoglobulin gene rearrangements
• typical B-cell CLL are unique in being CD19+ and CD5+
CLL - Immunophenotype
• Detect antigens on surface of cells
– Specific antibodies
– Use flow cytometry or immunohistochemistry
• CLL = mature B cells
–
–
–
–
–
–
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CD5
CD19
CD20 - low
CD22 - low
CD23
Light chains (κ, λ)
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CLL - Immunophenotype scoring
system
Scoring system for B-CLL
Points
Membrane
marker
Smlg
1
0
Weak
Moderate/strong
CD5
Positive
Negative
CD23
Positive
Negative
FMC7
Negative
Positive
CD79b (SN8)
Negative
Positive
1. Matutes E, et al. Leukemia. 1994;8:1640-1645.
2. Moreau EJ, et al. Am J Clin Pathol. 1997;108:378-382.
CLL – Other lab tests
• Hypogammaglobulinemia
or
agammaglobulinemia are often observed
• 10 - 25% of patients with CLL develop
autoimmune hemolytic anemia, with a positive
direct Coombs’ test
• The marrow aspirates shows greater than 30%
of the nucleated cells as being lymphoid
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CLL - Bone Marrow
• Infiltrates of small lymphocytes
– Causes
neutropenia,
thrombocytopenia
anemia,
• Extramedullary expansion
– Splenomegaly
– Hepatomegaly
– Lymphadenopathy
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CLL – Lymph node
• Loss of nodal architecture
• Diffuse infiltration of
lymphocytes
• Lymphadenopathy
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small
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CLL - diagnostic criteria
1) A peripheral blood lymphocyte count of
greater than 5 G/L, with less than 55% of the
cells being atypical
2) The cell should have the presence of Bcellspecific differentiation antigens (CD19, CD20,
and CD24) and be CD5(+)
3) A bone marrow aspirates showing greater than
30% lymphocytes
CLL - Differential diagnosis
• Infectious causes
– bacterial (tuberculosis)
– viral (mononucleosis)
• Malignant causes
– B-cell
– T-cell
•
•
•
•
leukemic phase of non-Hodgkin lymphomas
Hairy-cell leukemia
Waldenstrom macroglobulinemia
large granular lymphocytic leukemia
Investigations
• Pretreatment studies of patients with CLL should
include examination of:
–
–
–
–
–
–
–
–
complete blood count
peripheral blood smear
reticulocyte count
Coomb’s test
renal and liver function tests
serum protein electrophoresis
immunoglobulin levels
plasma 2 microglobulin level
• If available immunophenotyping should be carried
out to confirm the diagnosis
• Bone marrow biopsy and cytogenetic analysis is not
routinely performed in CLL
CLL – Rai staging system
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CLL – Rai stages
CLL – Binet staging system
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CLL – Binet stages
Staging: Rai and Binet staging systems for CLL
Clinical staging systems for CLL
Stage
Value
Rai
Binet
Median survival
Lymphocytosis
(>15,000/mm3)
0
-
150 months
(12.5 years)
Lymphocytosis plus
nodal involvement
I
A
<3
node groups
101-108 months
(8.5-9 years)
Lymphocytosis plus
organomegaly
II
B
>3
node groups
60-71 months
(5-6 years)
Anemia (RBCs)
Lymphocytosis plus
thrombocytopenia
(platelets)
III
Hgb <11 g/dL
IV
PLT <100,000/mm3
Hgb <10 g/dL
C
PLT <100,000/mm3
19-24 months
(1.5-2 years)
CLL - Markers of poor prognosis
• Advanced Rai or Binet stage
• Peripheral lymphocyte doubling time <12
months
• Diffuse marrow histology
• Increased number of prolymphocytes or cleaved
cells
• Poor response to chemotherapy
• High 2- microglobulin level
• Abnormal karyotyping
Prognosis: histologic bone
marrow patterns
Nodular
(low risk)
Interstitial
(low risk)
Diffuse
(high risk)
• The different bone marrow patterns probably reflect
variations in amount of lymphoid accumulation during
the natural course of the disease
Randy Gascoyne, MD., Montserrat E, et al. Cancer. 1984;54:447-451.
Prognosis: lymphocyte doubling
time
Survival time according to LDT (all stages)
1.0
Probability of survival
0.9
0.8
Doubling time ≤12 months
Doubling time >12 months
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0.0
0
20
40
60
80
Months
1. Montserrat E, et al. Br J Haematol. 1986;62:567-575.
100
120
140
160
CLL - Genetic abnormalities
Genetic
abnormality
Incidence
(%)
Median
survival
(months)
13q14
55-62
133-292
Typical morphology
Mutated VH genes
Stable disease
+ 12
16-30
114-122
Atypical morphology
Progressive disease
del 11q23
18
79-117
Bulky lymphadenopathy
Unmutated VH genes
Progressive disease
Early relapse
post autograft
p53
loss/mutation
7
32-47
Atypical morphology
Unmutated VH genes
Advanced disease
Drug resistance
1. DÖhner H, et al. N Engl J Med. 2000;343:1910-1916.
2. Oscier DG, et al. Blood. 2002;100:1177-1184.
Clinical correlation
Effect of genetic abnormalities
on survival
1. Döhner H, et al. N Engl J Med. 2000;343:1910-1916.
CLL - VH Status
• “Variable” region of immunoglobulin gene
• H=heavy chain
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CLL - VH Mutation
• Naïve B cells have unmutated V regions
– Make initial IgM and IgG that bind Ag poorly
• Somatic hypermutation of V region creates
memory B cells
– Make Ab with higher affinity for Ag
CLL progression is dependent on mutation
status of B cells
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– Unmutated VH = rapid progression, short survival
– Mutated VH = slow progression, long survival
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CLL - VH Mutation
Naïve B cells
Unmutated VH
CLL
Fast progression
Short survival
Memory B cells
Mutated VH
CLL
Slow Progression
Long Survival
Prognosis: effect of VH gene
mutations on survival
Percent surviving (%)
100
Unmutated VH gene
Median = 117 months
Mutated VH gene
Median = 293 months
90
80
70
60
50
40
30
20
10
0
0
25
50 75 100 125 150 175 200 225 250 275 300 325
Months
1. Hamblin TJ, et al. Blood. 1999;94:1848-1854.
Clinical Course of CLL
• Disease has a variable course; however, it often progresses
from an indolent lymphocytosis without other evident
disease to one of generalized lymphatic enlargement with
concomitant pancytopenia
• Progression: bone marrow impairment,  susceptibility to
infection
• Complications of pancytopenia, including hemorrhage and
infection, represent a major cause of death in these patients
CLL - Immunologic Complications
• Autoimmune hemolytic anemia
– Coombs’ positive
– Clinical hemolysis
• Pure red cell aplasia
• Immune-mediated thrombocytopenia
• Depressed immunoglobin levels
• Granulocytopenia
• Hypogammaglobulinemia  with advanced disease
• Long-term complications: autoimmune phenomena,
Richter’s transformation
CLL - Complications
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Severe systemic infections
Bleeding
Richter’s transformation
Prolymphocytoid transformation
Secondary malignancies
Acute myeloid leukemia
Transforming the way we approach
CLL therapy
• Traditional treatment goal: Palliation
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–
–
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Age is a factor
Treat to relieve symptoms
Continuous/intermittent treatment
No survival advantage for any tested treatment to date
• New advances may allow treatment for remission
and survival
– Treat to complete remission (CR)
– Eliminate minimal residual disease
– Response predicts for survival: More CRs
CLL – treatment (1)
• Watch and wait
• Monotherapy
– glucocorticoids
– alkylating agents (Chlorambucil, Cyclophosphamide)
– purine analogues (Fludarabine, Cladribine, Pentostatin)
• Combination chemotherapy
– Chlorambucil/ Cyclophosphamide + Prednisone
– Fludarabine + Cyclophosphamide +/- Mitoxantrone
– CVP, CHOP
• Monoclonal antibodies (monotherapy and in combination)
– Alemtuzumab (anti-CD52)
– Rituximab (anti-CD20)
• Splenectomy
• Radiotherapy
CLL – treatment (2)
• Hematopoietic stem cell transplantation
– allogeneic with reduced intesity conditioning
– autologous
• New and novel agents
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–
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Oblimersen – bcl2-directed antisense oligonucleotide
Lenalidomide
Flavopiridol
Anti-CD23
Anti-CD40
• Vaccine strategies
• Supportive therapy (allopurinol, G-CSF, blood and platelet transfusion,
immunoglobulins, antibiotics)
NCI-WG: Indications to Initiate
Treatment for CLL
• Constitutional symptoms referable to CLL
(B-symptoms)
• Progressive marrow failure
• Autoimmune anemia and/or thrombocytopenia
poorly
responsive to corticosteroids
• Massive or progressive splenomegaly
• Massive or progressive lymphadenopathy
• Rapid lymphocyte doubling time
MoAbs citotoxic mechanisms
Effector cells/
Complement
Apoptosis
Radionuclide Toxin/Antibiotic
MoAbs for CLL
Antibody
Antigen
Alemtuzumab (Campath-1H)
Rituximab (Rituxan, Mabthera)
CD52
CD20
Epratuzumab (LymphoCide)
Hu-1D10 (Apolizumab)
IDEC-152 (Lumiliximab)
IDEC-114
Bevacizumab (Avastin)
BL-22
CD22
HLA-DR
CD23
CD80
VEGF
CD22( conjugate
with Pseudomonas)
MabThera®: a chimeric murine/human
MoAb
Variable murine regions bounding
CD20 on B cells
Human kappa costant regions
Human domain IgG1 Fc, synergistic
with human effector mechanisms
Chimeric IgG1
Rituximab as part of first-line
therapy for CLL: Rationale
• Rituximab monotherapy is moderately active in CLL1,2
– Activity is dose dependent (between 500–2250 mg/m2)1
• Rituximab acts synergistically with other cytotoxic
agents in vitro
– Increases fludarabine activity in NHL cell lines3
– Increases activity of bendamustine, mitoxantrone and other
chemotherapeutic agents in CLL cells4
• Rituximab combination therapies (e.g. R-F, R-FC, R-PC, R-FCM,
R-Bendamustine, R-Chlorambucil) are now being assessed
Alemtuzumab (anti-CD52) antibody
IgG1 humanised antibody:
Low immunogenicity
 CD52 antigen:
 Highly expressed on
 all lymphocytes
 monocytes and macrophages
 spermatozoa
 eosinophils
 Not expressed on haemopoietic stem
cells
 Does not modulate/shed
 Also expressed on the majority of
malignant lymphocytes
Treatment of CLL
CLL – Treatment strategy
Gribben J G Blood 2010;115:187-197