Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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 4/30/2017 2 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 4/30/2017 11 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 – – – – – – 4/30/2017 CD5 CD19 CD20 - low CD22 - low CD23 Light chains (κ, λ) 13 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 4/30/2017 15 CLL - Bone Marrow • Infiltrates of small lymphocytes – Causes neutropenia, thrombocytopenia anemia, • Extramedullary expansion – Splenomegaly – Hepatomegaly – Lymphadenopathy 4/30/2017 16 CLL – Lymph node • Loss of nodal architecture • Diffuse infiltration of lymphocytes • Lymphadenopathy 4/30/2017 small 17 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 4/30/2017 21 CLL – Rai stages CLL – Binet staging system 4/30/2017 23 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 4/30/2017 32 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 4/30/2017 – Unmutated VH = rapid progression, short survival – Mutated VH = slow progression, long survival 33 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 • • • • • • 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 – – – – 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 – – – – – 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