The Chronic Lymphocytic Leukemia (CLL). The group of clonal diseases characterized by proliferation and accumulation of small, mature lymphocytes in blood,

The Chronic Lymphocytic Leukemia

(CLL)

• 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

The Chronic Lymphocytic Leukemias (1)

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)

I II III IV

Clinical stages of lymphomas according to Ann Arbor’s classification

A: no general symptomsB: general symptoms such as fever, night sweats, weight loss

Lister T, et al. J Clin Oncol 1989; 7:1630

• Ann Arbor’s classification is specific for all lymphomas

• CLL is classified according to

Rai and Binet 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 leukemiaLympfioplasmacytic lymphomaSplenic marginal zone B-cell lymphoma

(+ /- villous lymphocytes)Hairy cell leukemiaPlasma cell myeloma/plasmacytomaExtranodal marginal zone B-cell

lymphoma of MALT typeNodal marginal zone B-cell lymphoma

(+/— monocytoid B cells)Follicular lymphomaMantle-cell lymphomaDiffuse large B-cell lymphoma

Mediastinal large B-cell lymphoma Primary effusion lymphoma

Burkitts lymphoma/Burkitt cell leukemia

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 leukemiaLympfioplasmacytic lymphomaSplenic marginal zone B-cell lymphoma

(+ /- villous lymphocytes)Hairy cell leukemiaPlasma cell myeloma/plasmacytomaExtranodal marginal zone B-cell

lymphoma of MALT typeNodal marginal zone B-cell lymphoma

(+/— monocytoid B cells)Follicular lymphomaMantle-cell lymphomaDiffuse large B-cell lymphoma

Mediastinal large B-cell lymphoma Primary effusion lymphoma

Burkitts lymphoma/Burkitt cell leukemia

WHO classification

T-cell and NK-cell neoplasms- Precursor T-cell neoplasm: T-lymphoblastic lymphoma/leukemia - Mature (peripheral) T-cell neoplasms:

T-cell prolymphocytic leukemiaT-cell granular lymphocytic leukemiaAggressive NK-cell leukemiaAdult T-cell lymphoma/leukemia (HTLV1 +)

Extranodal NK/T-cell lymphoma, nasal typeEnteropathy-type T-cell lymphomaHepatosplenic gamma-delta T-cell lymphomaSubcutaneous panniculitis-like T-cell lymphomaMycosis fungoides/Sezary syndromeAnaplastic large-cell lymphoma, T/null cell, primary cutaneous typePeripheral T-cell lymphoma, not otherwise characterizedAngioimmunoblastic T-cell lymphomaAnaplastic large-cell lymphoma, T/null cell, primary systemic type

T-cell and NK-cell neoplasms- Precursor T-cell neoplasm: T-lymphoblastic lymphoma/leukemia - Mature (peripheral) T-cell neoplasms:

T-cell prolymphocytic leukemiaT-cell granular lymphocytic leukemiaAggressive NK-cell leukemiaAdult T-cell lymphoma/leukemia (HTLV1 +)

Extranodal NK/T-cell lymphoma, nasal typeEnteropathy-type T-cell lymphomaHepatosplenic gamma-delta T-cell lymphomaSubcutaneous panniculitis-like T-cell lymphomaMycosis fungoides/Sezary syndromeAnaplastic large-cell lymphoma, T/null cell, primary cutaneous typePeripheral T-cell lymphoma, not otherwise characterizedAngioimmunoblastic T-cell lymphomaAnaplastic large-cell lymphoma, T/null cell, primary systemic type

• 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

The Chronic Lymphocytic Leukemia (1)

• 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

The B-CLL - definition

• 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

B-CLL epidemiology

• 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

B-CLL etiology & pathogenesis (1)

• 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

B-CLL etiology & pathogenesis (2)

• 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!

B-CLL clinical symptoms (1)


Cervical and axillary limfadenopathy in 60-years old patient with B-CLL


Cervical and axillary limfadenopathy in 70-years old patient with B-CLL


Cervical limfadenopathy in patient with B-CLL


The CLL patient can have splenomegaly


The CLL patient has splenomegaly, which is visble

• 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

B-CLL laboratory features (1)

B-CLL laboratory features (2)• Peripheral blood smear:

– Lymphocytosis • small, mature, morphologically normal

– Smudge cells– Neutropenia

• Because of „displacement ”• and/or autoimmunologic


• Bone Marrow smear (cytological examination) – extensive replacement of marrow element by mature

lymphocytes (more than 30%)

• Bone Marrow Biopsy (histological examination): Lymphocyte infiltration

– nodular infiltration, – interstitial infiltration, – difussed infiltration– mixed infiltration

Difussed infiltration (unfavourable prognostic factor)


• Bone Marrow Biopsy

Interstitial

infiltration


• lymph node finding (histopathological examination)

- diffuse infiltration of small lymphocytes identical to low-grade,

small lymphocytic lymphoma


• 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)


• Radiological examinations (X-ray, ultrasonography, CT, ...)

• Serological examinations (direct and indirect antiglobulin tests)

• Biochemical examinations (lactate dehydrogenase, 2-microglobulin)

B-CLL features (8)

• 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


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 κ/λ light chain restriction; cytogenetical abnormalities

Bone marrow infiltration > 30% of nucleated cells on aspirate

Lymph node diffuse infiltrate of small lymphocytes

RAI’s CLINICAL STAGING SYSTEMStage Clinical Features at Diagnosis Median

Survival (years)

0

Low risk

Blood lymphocytosis>5G/l,

Bone marrow lymphocytosis>30%

>12,5

I

Intermediate risk



and enlarged lymph nodes

8

II

Intermediate risk



and enlarged spleen and/or liver

6

III

High risk



and anemia (Hb < 11g/dl)

1,5-2

IV

High risk



and thrombocytopenia(< 100 000 /ul)

1,5-2

CLL – Rai stages

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BINET’s CLINICAL STAGING SYSTEMStage Clinical Features at Diagnosis Median

Survival

(month)

A Blood lymphocytosis>5G/l,


and less than 3 areas of palpable lymphoid-tissue enlargement

Without anemia (Hb >= 6,21 mmol/l, 10 g/dl) and thrombocytopenia

> 120 month

B Blood lymphocytosis>5G/l,


and 3 and more areas of palpable lymphoid-tissue enlargement

Without anemia (Hb >= 6,21 mmol/l, 10 g/dl) and thrombocytopenia

60 month

C Blood lymphocytosis>5G/l,


with anemia (Hgb <10g/dL) or thrombocytopenia (Plt <100.000/uL)

24 month

An area: cervical, axillary left, axillary right, inquinofemoral left, inquinofemoral right lymph nodes, spleen, liver

CLL – Binet’s stages

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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

<=80% lymphocytes

<= 50 x 109/l

<= 10%

> 12 months

Difussed infiltration

> 80% lymphocytes

> 50 x 109/l

>10%

<= 12 months

New prognostic indicators in B-CLL (1)


Serum markers:- lactate dehydrogenase activity (LDH)- ß2-mikroglobulin activity- lymphocyte’s thymidine kinase activity - CD23 expression

Normal range Elevated

Clonal chromosomal abnormalities Normal karyotype isolated del (13q)

Del (11q)

Del (17p)

CD 38 expression <= 30 % > 30%



The mutational status of immunoglobulin variable region of heavy chain genes (IgvH)

mutated unmutated

ZAP–70 expression low (< 20%) high ( > 20 %)

Survivin absence presence


• 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

New prognostic indicators in B-CLL (4) - summary

CLL : ZAP-70 ZAP70 is an intracellular protein which is strongly correlated with the

VH status in CLL

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• 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

CLL – treatment (1)

• 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)


• 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)


• 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

Response criteria (NCI working group 1996)

• 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 of CLL: Primary Richter‘s - but still

CLL • has a poor prognosis

Richter’s Syndrome

The Chronic Lymphocytic Leukemia (CLL). The group of clonal diseases characterized by proliferation and accumulation of small, mature lymphocytes in blood,

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