The Chronic Lymphocytic Leukemia (CLL)

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The Chronic Lymphocytic Leukemia (CLL)
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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

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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)

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Clinical stages of lymphomas according to Ann
Arbors classification
A no general symptoms B general symptoms such
as fever, night sweats, weight loss
Lister T, et al. J Clin Oncol 1989 71630
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(No Transcript)
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• Ann Arbors classification is specific for all
  lymphomas
• CLL is classified according to
• Rai and Binet classification

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WHO classification

• B-Cell neoplasms
• - Precursor B-cell neoplasm
• B-lymphoblastic leukemia/lymphoma
• - Mature (peripheral) B-cell neoplasms
• B-cell chronic lymphocytic leukemia/small
  lymphocytic lymphoma
• 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

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 Angioimmunob
lastic T-cell lymphoma Anaplastic large-cell
lymphoma, T/null cell, primary systemic type
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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

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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

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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 21 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

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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

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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

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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!

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B-CLL clinical symptoms (2)
Cervical and axillary limfadenopathy in 60-years
old patient with B-CLL
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B-CLL clinical symptoms (2)
Cervical and axillary limfadenopathy in 70-years
old patient with B-CLL
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B-CLL clinical symptoms (3)
Cervical limfadenopathy in patient with B-CLL
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B-CLL clinical symptoms (3)
The CLL patient can have splenomegaly
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B-CLL clinical symptoms (3)
The CLL patient has splenomegaly, which is visble
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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

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B-CLL laboratory features (2)

• Peripheral blood smear
• Lymphocytosis
• small, mature, morphologically
• normal
• Smudge cells
• Neutropenia
• Because of displacement
• and/or autoimmunologic

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B-CLL laboratory features (3)

• Bone Marrow smear (cytological examination)
• extensive replacement of marrow element by mature
  lymphocytes (more than 30)

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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)

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B-CLL laboratory features (5)

• Bone Marrow Biopsy
• Interstitial
• infiltration

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B-CLL laboratory features (6)

• lymph node finding (histopathological
  examination)
• - diffuse infiltration of small lymphocytes
  identical to low-grade, small lymphocytic
  lymphoma

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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)

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B-CLL features (8)

• Radiological examinations (X-ray,
  ultrasonography, CT, ...)
• Serological examinations (direct and indirect
  antiglobulin tests)
• Biochemical examinations (lactate dehydrogenase,
  ?2-microglobulin)

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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

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Diagnosis of B-CLL
Blood test lymphocytosis 5G/l (6 weeks)
Morphology monoclonal population of small mature lymphocyte
B-cell CLL phenotype clonal CD5/CD19 population of lymphocyte
Markers of clonality ?/? light chain restriction cytogenetical abnormalities
Bone marrow infiltration gt 30 of nucleated cells on aspirate
Lymph node diffuse infiltrate of small lymphocytes
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RAIs CLINICAL STAGING SYSTEM
Stage Clinical Features at Diagnosis Median Survival (years)
0 Low risk Blood lymphocytosisgt5G/l, Bone marrow lymphocytosisgt30 gt12,5
I Intermediate risk Blood lymphocytosisgt5G/l, Bone marrow lymphocytosisgt30 and enlarged lymph nodes 8
II Intermediate risk Blood lymphocytosisgt5G/l, Bone marrow lymphocytosisgt30 and enlarged spleen and/or liver 6
III High risk Blood lymphocytosisgt5G/l, Bone marrow lymphocytosisgt30 and anemia (Hb lt 11g/dl) 1,5-2
IV High risk Blood lymphocytosisgt5G/l, Bone marrow lymphocytosisgt30 and thrombocytopenia(lt 100 000 /ul) 1,5-2
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CLL Rai stages
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BINETs CLINICAL STAGING SYSTEM
Stage Clinical Features at Diagnosis Median Survival (month)
A Blood lymphocytosisgt5G/l, Bone marrow lymphocytosisgt30 and less than 3 areas of palpable lymphoid-tissue enlargement Without anemia (Hb gt 6,21 mmol/l, 10 g/dl) and thrombocytopenia gt 120 month
B Blood lymphocytosisgt5G/l, Bone marrow lymphocytosisgt30 and 3 and more areas of palpable lymphoid-tissue enlargement Without anemia (Hb gt 6,21 mmol/l, 10 g/dl) and thrombocytopenia 60 month
C Blood lymphocytosisgt5G/l, Bone marrow lymphocytosisgt30 with anemia (Hgb lt10g/dL) or thrombocytopenia (Plt lt100.000/uL) 24 month
An area cervical, axillary left, axillary right,
inquinofemoral left, inquinofemoral right lymph
nodes, spleen, liver
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CLL Binets stages
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New prognostic indicators in B-CLL (1)
Prognostic factor Good prognosis Bad prognosis
Clinical stage according to Binet Rai A 0 B, C I, II, III, IV
Bone marrow infiltration in - bone marrow biopsy - cytological examination Leucocytosis Prolymphocytes in peripheral blood Leukemia cell doubling time Non-Difussed infiltration lt80 lymphocytes lt 50 x 109/l lt 10 gt 12 months Difussed infiltration gt 80 lymphocytes gt 50 x 109/l gt10 lt 12 months
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New prognostic indicators in B-CLL (2)
Prognostic factor Good prognosis Bad prognosis
Serum markers lactate dehydrogenase activity (LDH) ß2-mikroglobulin activity lymphocytes thymidine kinase activity CD23 expression Normal range Elevated
Clonal chromosomal abnormalities Normal karyotype isolated del (13q) Del (11q) Del (17p)
CD 38 expression lt 30 gt 30
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New prognostic indicators in B-CLL (3)
Prognostic factor Good prognosis Bad prognosis
The mutational status of immunoglobulin variable region of heavy chain genes (IgvH) mutated unmutated
ZAP70 expression low (lt 20) high ( gt 20 )
Survivin absence presence
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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

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CLL ZAP-70 ZAP70 is an intracellular protein
which is strongly correlated with the VH status
in CLL
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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 patients condition
  
• Indications to treatment
• III/IV stage according to Rais classification
• Progressive disease (rapidly increasing
  lymphadenopathy, infections, general symptoms)
• leukemia cell doubling time lt6 (12) months
• rapidly increasing organomegaly
• Secondary anemia, neutropenia, thrombocytopenia
  because of bone marrow infiltration
• Richters syndrome

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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)

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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)

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Response criteria (NCI working group 1996)

• Complete response (for at least 2 months)
• clinical features normal
• morphology normal (Hbgt11 g/dl Ptgt100 000 /ul,
  lymphocytes lt4000 G/l neutrofiles gt1500 G/l))
• bone marrow - lymphocytosis less than 30
• Partial response
• Stable Disease
• Progressive Disease

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Richters Syndrome

• is always the transformation of CLL into an
  aggressive Lymphoma diffuse large cell lymphoma
  (DLCL) or Hodgkins lymphoma
• usually evolves after a long indolent course -
• can occur as 1st manifestation of CLL Primary
  Richters - but still CLL
• has a poor prognosis