The Chronic Lymphocytic Leukemia (CLL)

1. The Chronic Lymphocytic Leukemia (CLL)

2. The Chronic Lymphocytic Leukemias (1) • The group of clonal diseases characterized by proliferation and accumulation of small, mature lymphocytes in blood, bone marrow and lymphoid tissues (lymph nodes, spleen) • Neoplastic lymphocytes belong most often to B-cell lines and they have the special for B-cell antigenes on their surface; exceptionally neoplastic lymphocytes belong to T-cell lines or NK-cell • According to REAL (Revised European-American Lymphoma)/ /WHO classification CLLs belong to the group of: • lymphoproliferative diseases • lymphomas

3. Lymphoproliferative diseases • Primary lymphatic system (central) • bone marrow • thymus • Secondary lymphatic system (peripheral ) • spleen • lymph nodes • MALT (The mucosa-associated lymphoid tissue = also called mucosa-associated lymphatic tissue)

4. I II III IV Clinical stages of lymphomas according to Ann Arbor’s classification A: no general symptoms B: general symptoms such as fever, night sweats, weight loss Lister T, et al. J Clin Oncol1989; 7:1630

6. Ann Arbor’s classification is specific for all lymphomas • CLL is classified according to Rai and Binet classification

7. WHO classification T-cell and NK-cell neoplasms - Precursor T-cell neoplasm: T-lymphoblastic lymphoma/leukemia - Mature (peripheral) T-cell neoplasms: T-cell prolymphocytic leukemia T-cell granular lymphocytic leukemia Aggressive NK-cell leukemia Adult T-cell lymphoma/leukemia (HTLV1 +) Extranodal NK/T-cell lymphoma, nasal type Enteropathy-type T-cell lymphoma Hepatosplenic gamma-delta T-cell lymphoma Subcutaneous panniculitis-like T-cell lymphoma Mycosis fungoides/Sezary syndrome Anaplastic large-cell lymphoma, T/null cell, primary cutaneous type Peripheral T-cell lymphoma, not otherwise characterized Angioimmunoblastic T-cell lymphoma Anaplastic large-cell lymphoma, T/null cell, primary systemic type B-Cell neoplasms - Precursor B-cell neoplasm: B-lymphoblastic leukemia/lymphoma - Mature (peripheral) B-cell neoplasms: B-cell chronic lymphocytic leukemia/small lymphocyticlymphoma B-cell prolymphocytic leukemia Lympfioplasmacytic lymphoma Splenic marginal zone B-cell lymphoma (+ /- villous lymphocytes) Hairy cell leukemia Plasma cell myeloma/plasmacytoma Extranodal marginal zone B-cell lymphoma of MALT type Nodal marginal zone B-cell lymphoma (+/— monocytoid B cells) Follicular lymphoma Mantle-cell lymphoma Diffuse large B-cell lymphoma Mediastinal large B-cell lymphoma Primary effusion lymphoma Burkitts lymphoma/Burkitt cell leukemia

8. The Chronic Lymphocytic Leukemia (1) • Chronic lymphocytic leukemias are derived from: • B-cell line • B-cell chronic lymphocytic leukemia • B-cell chronic prolymphocytic leukemia • Hairy cell leukemia • Splenic marginal zone B-cell lymphoma ( + /- villous lymphocytes) • T-cell line • T-cell chronic lymphocytic leukemia • T-cell chronic prolymphocytic leukemia • T-cell granular lymphocytic leukemia • Chronic lymphocytic leukemias differ form each other in biology, morphology, antigen structure of the cell and in clinical course

9. The B-CLL - definition • B-CLL is a neoplastic disease characterized by proliferation and accumulation of small, mature, long-living lymphocytes in blood, marrow and lymphoid tissues (lymph nodes, spleen) • This lymphocytosis leads to specific clinical and laboratory symptoms of B-CLL • The neoplastic lymphocytes have on their surface the special for B-cell line antigens – CD19, CD20 and also CD5, CD23, and a very weak expression of surface immunoglobulin

10. B-CLL epidemiology • Most common adult leukemia in Europe and North America (in USA incidence of about 3/100.000 population) • predominantly, CLL is a disease of elderly (50-55 years) • 40% of leukemias in patients over 60 years old • Morbidity: • Men 2,2-3,69 / 100 000 / year • Women 0,9-1,59 / 100 000 / year /men affect twice as often as women; 2:1 ratio of male to female / • CLL morbidity rapidly increases with age (especially between 50 and 60 years of age) • in 98% of patients the leukemic cells are a monoclonal population of mature B lymphocytes with low-density surface immunoglobulin • death from infections, BM failure, high-grade transformation (Richter's syndrome), kachexia

11. B-CLL etiology & pathogenesis (1) • the cause of CLL is unknown • there is increased incidence in farmers, rubber manufacturing workers and tire repair workers • genetics factors have been postulated to play a role in high incidence of CLL in some families

12. B-CLL etiology & pathogenesis (2) • Cytogenetics- clonal chromosomal abnormalities are detected in approximately 50% of CLL patients • Immunoglobulin genes - monoclonal surface immunoglobulin is expressed by over 90% of patients (60% kappa and 40% lambda light chains) • nearly half of all cases have leukemia cells that express mutated immunoglobulin variable region genes (Ig VH genes) - associated with more indolent disease • Immunologic abnormalities • autoimmune disease (hemolytic anemia and thrombocytopenia, pure red cell aplasia) • hypogammaglobulinemia • cellular immune defects

13. B-CLL clinical symptoms (1) • often none! - 25% of patients are asymptomatic and the diagnosis is typically accidental • unspecific: night sweats, fever, weakness (many patients have fatigue, reduced exercises tolerance or malaise, weight loss) • recurrent infections (bacterial, viral – Herpes Zoster, fungal) – they are the most common cause of death • bleeding and symptoms of anemia and thrombocytopenia • Lymphadenopathy (lymph node enlargement) • at diagnosis - nontender in 80% of patients • later - may become very large • splenomegaly - mild to moderate in 50% of patients • hepatomegaly • some organs infiltration (lungs, pleura, skin and soft tissue) Blood lymphocytosis does not cause symptoms!

14. B-CLL clinical symptoms (2) Cervical and axillary limfadenopathy in 60-years old patient with B-CLL

15. B-CLL clinical symptoms (2) Cervical and axillary limfadenopathy in 70-years old patient with B-CLL

16. B-CLL clinical symptoms (3) Cervical limfadenopathy in patient with B-CLL

17. B-CLL clinical symptoms (3) The CLL patient can have splenomegaly

18. B-CLL clinical symptoms (3) The CLL patient has splenomegaly, which is visble

19. B-CLL laboratory features (1) • Morphology: • Leucocytosis with monoclonal lymphocytosis of greater than 5.000/ul. • anemia • Because of „displacement ” • and/or autoimmunohemolic (10-20% of patients have a positive direct antiglobulin test; AIHA is commonly connected with the presence of warm auto- antibodies IgG class – rapidly increasing fatigue, skin getting yellow, anemia with enlarged reticulocytosis, higher level of bilirubin) • pure red cell aplasia is very rare (selective aplasia of red cell line in bone marrow) • thrombocytopenia • Because of „displacement ” • and/or immunologic (about 5% of B-CLL patients have anty-platelet antibodies) • protein electrophoresis–Hipogammaglobulinemia, monoclonal protein in 5% of patients

20. B-CLL laboratory features (2) • Peripheral blood smear: • Lymphocytosis • small, mature, morphologically normal • Smudge cells • Neutropenia • Because of „displacement ” • and/or autoimmunologic

21. B-CLL laboratory features (3) • Bone Marrow smear (cytological examination) • extensive replacement of marrow element by mature lymphocytes (more than 30%)

22. B-CLL laboratory features (4) • Bone Marrow Biopsy (histological examination): Lymphocyte infiltration • nodular infiltration, • interstitial infiltration, • difussed infiltration • mixed infiltration Difussed infiltration (unfavourable prognostic factor)

23. B-CLL laboratory features (5) • Bone Marrow Biopsy Interstitial infiltration

24. B-CLL laboratory features (6) • lymph node finding(histopathological examination) - diffuse infiltration of small lymphocytes identical to low-grade, small lymphocytic lymphoma

25. B-CLL laboratory features (7) • Immunophenotype: • CD5+/CD19+/CD23+/CD20+, • sometimes also CD38+, • low expression of CD22; • lack expression of CD 10-, CD 103-, • 90% of the patient have a very weak expression of surface immunoglobulin (kappa or lambda light chain, IgM, IgD)

26. B-CLL features (8) • Radiological examinations (X-ray, ultrasonography, CT, ...) • Serological examinations (direct and indirect antiglobulin tests) • Biochemical examinations (lactate dehydrogenase, 2-microglobulin)

27. B-CLL laboratory features (9) • Cytogenetic examinations - clonal chromosomal abnormalities are detected in approximately 50% of CLL patients • deletion 13 (13q14.3) • trisomy 12 • structural abnormalities of chromosomes 11 (11q-), 14, 17 Genomic aberrations found in approximately 50% of CLL

28. Diagnosis of B-CLL

29. RAI’s CLINICAL STAGING SYSTEM

30. CLL – Rai stages

31. BINET’s CLINICAL STAGING SYSTEM An area: cervical, axillary left, axillary right, inquinofemoral left, inquinofemoral right lymph nodes, spleen, liver

32. CLL – Binet’s stages

33. New prognostic indicators in B-CLL (1)

34. New prognostic indicators in B-CLL (2)

35. New prognostic indicators in B-CLL (3)

36. New prognostic indicators in B-CLL (4) - summary • clinical stage • bone marrow histology (diffuse replacement carries worst prognosis) • leukemia cell doubling time (less than 1 year - worse prognosis) • percentage of prolymphocyte • high cell-surface expression of CD38 • ZAP-70 expression • serum level of: B2-microglobulin; thymidine kinaze, LDH, sCD23 • IgVH mutational status • genetic features - FISH cytogenetic • low-risk: normal kariotype; isolated del(13q) • high-risk: del(17p0, del(11q), trisomy 12

37. CLL : ZAP-70ZAP70 is an intracellular protein which isstrongly correlated with the VH status in CLL

38. CLL – treatment (1) • We have to remember: • B-CLL – indolent lymphoma, but incurable • Elderly patients – risk of additional diseases • Course of the disease can be very long, indolent for many years, patient can die because of another reason which is not connected to B-CLL. • Decision about treatment depends on clinical stage, prognostic factors and patient’s condition • Indications to treatment: • III/IV stage according to Rai’s classification • Progressive disease (rapidly increasing lymphadenopathy, infections, general symptoms) • leukemia cell doubling time <6 (12) months • rapidly increasing organomegaly • Secondary anemia, neutropenia, thrombocytopenia because of bone marrow infiltration • Richter’s syndrome

39. CLL – treatment (2) • Watch and wait • Monotherapy • Glucocorticoids (autoimmunological complications) • alkylating agents (Chlorambucil, Cyclophosphamide) • purine analogues (Fludarabine, Cladribine, Pentostatin) • Combination chemotherapy • Chlorambucil/Cyclophosphamide + Prednisone • purine analog (Fludarabine) + Cyclophosphamide +/- Mitoxantrone • CVP, CHOP (Cyclophosphamide, Doxorubicin, Vincristin, Prednisone) • Monoclonal antibodies (monotherapy and in combination) • Alemtuzumab (anti-CD52) = CAMPATH • Rituximab (anti-CD20) = Mabthera • antiCD23 etc. • monoclonal antibodies conjugated with radionuclides =Ibritumomab tiuxetan= Zevalin • Splenectomy (hypersplenism) • Radiotherapy (massive lymphadenopathy)

40. CLL – treatment (3) • Hematopoietic stem cell transplantation • autologous - still no cure with auto-SCT • allogenic with reduced intensity conditioning • Even RIC-SCT is still a risky procedure - indicated only in high-risk disease • Can allo-SCT cure CLL? - YES • 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)

41. Response criteria (NCI working group 1996) • Complete response (for at least 2 months) • clinical features – normal • morphology – normal (Hb>11 g/dl; Pt>100 000 /ul, lymphocytes <4000 G/l; neutrofiles >1500 G/l)) • bone marrow - lymphocytosis less than 30% • Partial response • Stable Disease • Progressive Disease

42. Richter’s Syndrome • is always the transformation of CLL into an aggressive Lymphoma – diffuse large cell lymphoma (DLCL) or Hodgkin‘s lymphoma • usually evolves after a long indolent course - • can occur as 1st manifestation ofCLL: Primary Richter‘s - but still CLL • has a poor prognosis