Features Of Chronic Lymphocytic Leukemia Research Articles

MiR-155 and miR-223 as markers of biological and clinical features of chronic lymphocytic leukemia

Introduction. Chronic lymphocytic leukemia (CLL) is a disease characterized by large individual differences both in the clinical course and in molecular patterns of expression of genes and regulatory RNAs, which can influence pathological changes. The involvement of regulatory microRNAs miR-155 and miR-223 in the pathogenesis of CLL is fairly well known, but there is insufficient information about possible fluctuations in the expression of miR-155 and miR-223 depending on the time course of pathology development and on parameters of medical treatment. Purpose – to investigate the expression of miR-155 and miR-223 in patients having CLL with different biological and clinical features and different characteristics of treatment in terms of peripheral-blood substrates (plasma, lymphocytes, and extracellular vesicles) and bone marrow. Material and Methods. This work involved samples of peripheral blood and bone marrow from 38 patients with a diagnosis of CLL from the City Hematology Center at the government-funded healthcare institution (Novosibirsk Oblast) City Clinical Hospital No. 2 from the years 2016 to 2017. Assessment of miR-155 and miR-223 expressions was carried out by reverse-transcription real-time PCR according to the TaqMan principle. Significance of differences between groups was evaluated either by the nonparametric Mann–Whitney test or by the nonparametric Kruskal–Wallis test with subsequent pairwise comparisons via the Mann–Whitney test. Results. High variation of the analyzed parameters was found. The expression levels of miR-155 and miR-223 in microvesicles of patients with unfavorable chromosomal anomalies were lower than those in patients with the chromosomal aberrations (or the normal karyotype) associated with a moderate effect on CLL prognosis. The expression level of miR-223 in peripheral blood lymphocytes of untreated patients with CLL was higher than that observed in treated patients. Conclusion. differences in the expression levels of miR-155 and miR-223 were identified depending on chromosomal aberrations and polychemotherapy. Our preliminary results will provide the basis for future larger studies on levels of microRNAs in CLL patients having specific features of the development, clinical course, and treatment of the disease.

Characteristics of chronic lymphocytic leukemia in Japan: Comprehensive analysis of the CLLRSG-01 study.

Chronic lymphocytic leukemia (CLL) is rare in Japan. We conducted the nationwide, prospective observational study CLLRSG-01 to clarify the current state of CLL in Japan and to make accurate international comparisons by preparing naturally air-dried smears like those used in other countries. Of the 201 untreated patients enrolled and evaluated, 119 were diagnosed with CLL and 82 with non-CLL mature B-cell neoplasms, based on the WHO classification. Of the 119 CLL patients, 90 were classified as typical and 29 as atypical according to FAB classification morphology, with the proportion of atypical CLL consistent with reports from other countries. Immunophenotypic analyses by flow cytometry showed that 55% of Japanese CLL patients had a Matutes score of 4 or higher, which is lower than the rate of about 90% in Europeans. Mutated IGHV was identified in 80% of Japanese CLL patients, which is a higher rate than in Western patients. The most frequent IGHV gene was VH3-30 (15%), followed by VH3-23 (12%) and VH4-34 (10%). VH1-69, the most common gene in Western countries, was identified in only one patient. These results indicate that the pattern of immunophenotypes and IGHV gene usage in Japanese CLL patients differs from that in Western patients.

Multifactorial Basis of T Cell Dysfunction in CLL: Disrupted Mitochondrial Metabolism Induces T Cell Senescence

Despite being a B-cell malignancy, dysfunction of the T-cell compartment is a key feature of chronic lymphocytic leukemia (CLL). This leads to complications in acquired immunity and low success rates in autologous T cell-based therapies in these patients, particularly chimeric antigen receptor T cells (CAR-T). Despite exhibiting features of exhaustion, T cells from CLL patients are not reinvigorated by immune checkpoint inhibitors. Although T-cell dysfunction in CLL is heterogeneous, a consistent feature among all CLL patients is T-cell subset skewing towards effector T cells at the expenses of the central memory compartment (Martens et al., Leukemia 2023) and intact ability to produce inflammatory cytokines. A common feature of senescent T cells includes this maintained ability to produce pro-inflammatory cytokines alongside dysfunctions such as cell-cycle arrest, a decline in proliferation, and reduced activation. Notably, senescence often coincides with impaired mitochondrial function which is known to play a crucial role in the development of memory phenotypes and the efficacy of CAR-T cells (Van der Windt et al., Immunity 2012; Van Bruggen et al., Blood 2019). Given these associations, our aim is to comprehensively investigate the interplay between T-cell dysfunction, senescence, and mitochondrial impairment in CLL patients through a multifaceted approach encompassing analysis of T-cell metabolism, (epi)genetics, and functional phenotyping. Metabolic profiling of T cells from CLL patients and age-matched healthy donors (HD) was performed by extracellular flux analysis, flow cytometry, metabolomics and 13C tracing. A decreased mitochondrial respiration upon T-cell receptor stimulation was observed in all CLL patients. On the other hand, glycolytic activity correlated with T-cell activation status, which varied among patients. We identified alterations in the utilization of the three main mitochondrial fuels in T cells from CLL patients: i) induction of pseudohypoxia by CLL cells, leading to a re-routing of glucose-derived pyruvate into lactate rather than into the mitochondria; ii) a reduced rate of conversion of glutamine into glutamate resulting in decreased utilization of this fuel within the mitochondria; and iii) impaired lipid uptake, along with diminished fatty acid oxidation. Accordingly, mitochondria from CLL T cells showed intrinsic features of dysfunction including depolarization and increased production of reactive oxygen species (ROS). So far, these findings strongly demonstrate a misbalance in metabolic fueling resulting in mitochondrial dysfunction, aligning more closely with senescence rather than classical T-cell exhaustion. To further reinforce this observation, we assessed the expression of cell-surface proteins that characterize senescent T cells (e.g., absence of CD27/CD28 and presence of PD1/CD57/KLRG1). Indeed, we found an increased proportion of senescent cells in the T-cell compartment of CLL patients, as compared to HD. In response to stimulation, CLL T cells showed a strikingly distinct cell-cycle pattern whereby a larger proportion of cells resided in S and G2/M phases, indicating cell-cycle arrest. Cell cycle arrest is often induced by DNA damage. Transcriptomic and epigenomic profiling of T cells of CLL patients indeed revealed a molecular profile consistent with inflammation and an increased p53/DNA damage response upon stimulation. These features are known to be induced by dysfunctional mitochondria and ROS in senescent cells, underscoring a direct link between mitochondrial metabolism and senescence. Altogether, our results strongly point towards senescence as the dominant dysfunctional T-cell state in CLL patients, with impaired mitochondrial metabolism at its basis. The distinctive mechanisms leading to T-cell senescence, as opposed to classical exhaustion, underscore the necessity for different strategies to reinvigorate T cells in the context of immunotherapy. Therefore, interventions aimed at ameliorating T-cell dysfunction in CLL should prioritize enhancement of mitochondrial metabolism to attenuate DNA damage and the induction of senescence. This would be especially beneficial to improve the fitness of autologous CAR-T cells for these patients.

Dysfunction of T Cells from Chronic Lymphocytic Leukemia (CLL) Patients Is Linked to Disturbed Lipid and Fatty Acid Homeostasis

Background: Successful T cell-based anti-cancer therapies require proliferation and longevity of effector cells, features that highly depend on metabolic processes. A key feature of chronic lymphocytic leukemia (CLL) is acquired T cell dysfunction, resulting in impaired proliferative capacity (van Bruggen, et al Blood Adv 2022). T cell lipid metabolism has only recently come into focus as an important source of energy production and at the same time as essential component for the formation of new membranes upon proliferation. Fatty acid (FA) and lipid uptake in T cells requires several membrane proteins, among which the scavenger FA transporter CD36 and the low-density lipoprotein receptor (LDL-R). Specifically CD36-mediated FA transport has been identified to modulate (intratumoral) Treg and cytotoxic CD8+ T cells (Kolonin, et al, 2021 Immunometab). Whether T cell lipid and FA metabolism are affected in CLL is currently unknown. Methods: Peripheral blood mononuclear cells (PBMCs) of untreated CLL patients and, as control, age-matched healthy donors (HD) were studied. T cells were analyzed by transcriptomics, lipidomics and flow cytometry, either directly after thawing or after a 2-day culture with or without αCD3/αCD28 antibodies. Results: Unbiased transcriptomic analyses of patient-derived T cells following αCD3/αCD28 activation showed reduced expression of the master regulators of FA and cholesterol biosynthesis SREBF1 and SREBF2 in the presence of autologous CLL cells. This was associated with significantly reduced protein abundance of downstream targets of the SREBP pathway, including the key enzymes in FA synthesis and saturation FASN and SCD. In accordance with these data, lipidomic analyses highlighted an altered lipid profile in T cells from CLL patients that clearly demarcated them from HD T cells. In short, unbiased analyses revealed disturbed lipid homeostasis in CLL T cells at multiple levels, which led us to investigate lipid and FA metabolic pathways and their related functional consequences. Studying lipid and FA uptake capacity revealed lower expression of the FA transporter CD36 on CLL T cells. Stimulation of HD T cells resulted in upregulation of CD36 and the main receptor for cholesterol uptake LDL-R, accompanied by increased uptake of long chain fatty acids (LCFA) and increased FA-oxidation, concomitantly with induced expression of the activation marker CD25. In contrast, CLL-derived T cells did not increase CD36 or LDL-R expression, LCFA uptake or oxidation (Fig 1 and 2). Because of a recently suggested role for CD36 in T cell function, we next specifically analyzed CD36-expressing T cells (CD36+), and found these to have higher ability for LCFA and glucose uptake, and higher expression of the glucose transporter GLUT-1 than CD36 negative T cells from the same HD. Accordingly, CD36+ cells were also more likely to increase their CD25 expression and mitochondrial mass upon a 48h stimulation. This CD36+ T cell subpopulation, with potential metabolic and functional advantage, was virtually absent in CLL PBMCs. Impact of FA and lipid metabolism on proliferation was further established by the observation that culturing of HD T cells in absence of exogenous lipids resulted in nearly absent proliferative capacity. However, despite decreased expression of lipid and FA transporters, we observed marked accumulation of lipid droplets (LD) in T cells from CLL patients, suggesting an impaired ability to mobilize lipids towards oxidation pathways or as building blocks for membranes. In line with this, we found that in contrast to HD T cells that increased the expression of the rate-limiting enzyme for lipolysis ATGL, CLL T cells failed to do so. Conclusions: We provide the first data showing a disturbed lipid and FA metabolism of CLL T cells that contributes to T cell dysfunction. This includes decreased expression of FA synthesis enzymes as well as FA and cholesterol transporters. CD36+ T cells are metabolically distinct and are largely absent in CLL. We are investigating strategies to increase FA and lipid metabolism in order to rebalance lipid homeostasis. This could ameliorate CLL T cell dysfunction and specifically proliferation defects in CLL. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

CLL-042 Clinical Characteristics of Chronic Lymphocytic Leukemia in Younger versus Older Patients in the Kurdistan Region, Iraq

Chronic lymphocytic leukemia is a common adulthood leukemic type, although the incidence rate in the Kurdistan region is low. It is well known that chronic lymphocytic leukemia is prevalent among older adults; however, frequent cases of chronic lymphocytic leukemia are newly diagnosed at a younger age. To analyze the difference in disease presentation, progression, and outcomes between younger and older patients with chronic lymphocytic leukemia in the Kurdistan region of Iraq. A retrospective cross-sectional review study was carried out in three oncology centers in the Kurdistan region (Nanakaly Hospital in Erbil, Hiwa Center in Sulaymaniyah, and Azadi Center in Duhok) for 10 years, from the 1st of January, 2010, to the 31st of December, 2019, on a convenient sample of 152 patients with chronic lymphocytic leukemia. Diagnosis of chronic lymphocytic leukemia was done by oncologists in Kurdistan tumor centers according to the International Workshop on Chronic Lymphocytic Leukemia. The age of patients at diagnosis was categorized into two groups and ranged from 25 to 94 years. The age cutoff value in the current study (55 years) depended on previous literature. The mean age of patients at diagnosis was 63 years; 28% were diagnosed at ≤50 years of age, and 72% were diagnosed at an age of more than 55 years. Older patients significantly presented with weight loss, whereas younger patients significantly presented with neck lumps. There was a highly significant association between the advanced ECOG performance scale and older age at diagnosis. A significant association was observed between the death outcome of chronic lymphocytic leukemia and older age at diagnosis. The mean survival duration of younger patients at diagnosis was significantly longer than that of patients who were older at diagnosis. Clinical presentation, physical status, death rates, and survival of patients with chronic lymphocytic leukemia in the Kurdistan region of Iraq are different between younger and older patients.

Characteristics of Chronic Lymphocytic Leukemia in Sudanese Patients

Objective: Our study aimed to characterize clinical, hematological and Immunophenotyping patterns in Sudanese patients with Chronic Lymphocytic Leukemia. Methods: A cross-sectional study was conducted in Khartoum state, Sudan, during the period from April 2017 to April 2018, involved 110 CLL patients. Physical examination, Complete Blood Count and Immunophenotyping were performed for all patients to confirm the diagnosis. Clinical staging such as Rai and Binet stages were applied. The statistical analysis was performed by using SPSS version 23.0. Results: In this study, 71.8% were males and 28.2% were females. Lymphadenopathy, splenomegaly, hepatomegaly, leukocytosis, thrombocytopenia, and anemia were seen in 71%, 49%, 13%, 60.9%, 39% and 34.5% of patients respectively. However, about 90% of patients displayed an advanced Rai risk stage and 70% were at Binet stage B or C. All CLL samples expressed CD45, CD19 and CD20. All the CLL cases were negative for the T-cell marker CD3.CD5 was expressed in 80% patients; CD23 was expressed in 92.7% patients. CD22, CD79b and FMC7 were negative in 91.8%, 77.3%, and 96.4% of patients respectively. Conclusions: CLL in Sudan is a disease of the elderly and more frequently in males than females. The incidence at young patients was higher than those reported by Western studies. Most of our patients presented advanced Rai and Binet stages. CD22 may be a highly specific marker for diagnosing CLL in Sudanese patients and should be included in all diagnostic panels used to differentiate CLL from other B cell lymphoproliferative disorders in Sudan.

B cell receptor signaling drives APOBEC3 expression via direct enhancer regulation in chronic lymphocytic leukemia B cells

Constitutively activated B cell receptor (BCR) signaling is a primary biological feature of chronic lymphocytic leukemia (CLL). The biological events controlled by BCR signaling in CLL are not fully understood and need investigation. Here, by analysis of the chromatin states and gene expression profiles of CLL B cells from patients before and after Bruton’s tyrosine kinase inhibitor (BTKi) ibrutinib treatment, we show that BTKi treatment leads to a decreased expression of APOBEC3 family genes by regulating the activity of their enhancers. BTKi treatment reduces enrichment of enhancer marks (H3K4me1 and H3K27ac) and chromatin accessibility at putative APOBEC3 enhancers. CRISPR-Cas9 directed deletion or inhibition of the putative APOBEC3 enhancers leads to reduced APOBEC3 expression. We further find that transcription factor NFATc1 couples BCR signaling with the APOBEC3 enhancer activity to control APOBEC3 expression. We also find that enhancer-regulated APOBEC3 expression contributes to replication stress in malignant B cells. In total we demonstrate a novel mechanism for BTKi suppression of APOBEC3 expression via direct enhancer regulation in an NFATc1-dependent manner, implicating BCR signaling as a potential regulator of leukemic genomic instability.

Real-world Clinical Outcomes of First-Line Ibrutinib or Chemoimmunotherapy in Patients with Chronic Lymphocytic Leukemia by Risk Status.

IntroductionCertain genetic features in chronic lymphocytic leukemia (CLL) are associated with inferior outcomes after chemoimmunotherapy (CIT). This retrospective study evaluated treatment patterns and clinical outcomes of patients with CLL, stratified into high-risk and non-high-risk groups, who received first-line ibrutinib or CIT therapy.MethodsHigh-risk group included confirmed presence of del(17p), del(11q), unmutated IGHV, TP53 mutations, or complex karyotype. Weighted high-risk ibrutinib and CIT groups were compared for treatment effects using inverse probability of treatment weighting. Hazard ratios [95% CI] (HR) for time to next treatment (TTNT) were analyzed using Kaplan–Meier curves.ResultsBendamustine/rituximab was the most common CIT regimen initiated for high-risk patients. During the available follow-up (median 34–35 months), 74.7% of the weighted high-risk ibrutinib group received only one line of treatment, compared with 47.2% of the weighted high-risk CIT group. The most common second-line treatment was ibrutinib for those in the CIT groups and venetoclax for the ibrutinib groups. The weighted high-risk ibrutinib group had a significantly longer TTNT (median not reached) than the weighted high-risk CIT group (median 34.4 months) and was 54% less likely to start a new treatment (HR 0.5 [0.3–0.6], P < 0.010). Among CIT-treated groups, high-risk patients had significantly shorter median TTNT than non-high-risk patients (P < 0.010). However, within the ibrutinib-treated groups, the median TTNT was similar between high-risk and non-high-risk patients (HR 2.2 [1.0–5.0]; P = 0.060).ConclusionThis study found that first-line single-agent ibrutinib therapy was associated with significantly longer TTNT than CIT regimens in real-world patients with high-risk CLL. The results support the use of ibrutinib in high-risk patients.Infographic Supplementary InformationThe online version contains supplementary material available at 10.1007/s12325-021-01991-5.

Distinct Age-Related Clinical Features and Risk Assessment in Chinese With Chronic Lymphocytic Leukemia.

The biological and clinical features of chronic lymphocytic leukemia (CLL) exhibited profound heterogeneity across Chinese and patients of predominately European descent. However, the age-related peculiarities and risk assessment of Chinese CLL patients remained ill-defined. The present study demonstrated that CLL patients were characterized by the earlier age at onset in China (median age at diagnosis: 63 years old) than in the United States (median age at diagnosis: 69 years old). Young patients from Shandong Provincial Hospital CLL database displayed prolonged overall survival than the Surveillance, Epidemiology, and End Results cohort. Furthermore, among Chinese CLL patients, young patients showed an increased relapse rate compared with elderly patients. To optimize the risk assessment of CLL patients, novel risk score models named PR-Score and HBG-Score were developed for predicting the outcomes of young and elderly CLL patients respectively. The neonatal survival prediction systems were superior to international prognostic index for CLL (CLL-IPI) and Binet stage in assessing the overall survival and progression free survival of CLL patients. The analyses highlighted refinement of risk evaluation for CLL patients in different age groups, providing insights into individualized diagnosis and treatment of CLL.

Impaired neutralisation of SARS-CoV-2 delta variant in vaccinated patients with B cell chronic lymphocytic leukaemia

BackgroundImmune suppression is a clinical feature of chronic lymphocytic leukaemia (CLL), and patients show increased vulnerability to SARS-CoV-2 infection and suboptimal antibody responses.MethodWe studied antibody responses in 500 patients following dual COVID-19 vaccination to assess the magnitude, correlates of response, stability and functional activity of the spike-specific antibody response with two different vaccine platforms.ResultsSpike-specific seroconversion post-vaccine was seen in 67% of patients compared to 100% of age-matched controls. Amongst responders, titres were 3.7 times lower than the control group. Antibody responses showed a 33% fall over the next 4 months. The use of an mRNA (n = 204) or adenovirus-based (n = 296) vaccine platform did not impact on antibody response. Male gender, BTKi therapy, prophylactic antibiotics use and low serum IgA/IgM were predictive of failure to respond. Antibody responses after CD20-targeted immunotherapy recovered 12 months post treatment. Post-vaccine sera from CLL patients with Spike-specific antibody response showed markedly reduced neutralisation of the SARS-CoV-2 delta variant compared to healthy controls. Patients with previous natural SARS-CoV-2 infection showed equivalent antibody levels and function as healthy donors after vaccination.ConclusionsThese findings demonstrate impaired antibody responses following dual COVID-19 vaccination in patients with CLL and further define patient risk groups. Furthermore, humoural protection against the globally dominant delta variant is markedly impaired in CLL patients and indicates the need for further optimisation of immune protection in this patient cohort.

Epidemiology of chronic lymphocytic leukemia in Chilean and Amerindian population in Chile

The study aim was to analyze incidence and presentation features of chronic lymphocytic leukemia (CLL) in Chile, in Amerindian population and in non-Native. Between 2012 and 2019, 912 patients were diagnosed, and 13 (1.4%) were Amerindian. The estimated incidence in Chilean population was 1.17/100,000 person per year, while in Amerindian, 0.09/100,000 person per year. Median age was 73 years. At diagnosis, 48, 27, and 25%, had low (0), intermediate (I/II) and high-risk (III/IV) disease on Rai classification. Diagnostic immunophenotypic Matutes score was ≥4 in 90%. Median follow-up was 37 months (range 2–87). 5-year OS was 56%, with median overall survival (OS) not reached. It was worse in men, ≥65 years, high-risk and those with increased prolymphocytes (CLL/PL). This study shows low incidence and worse OS in Chilean CLL patients, compared to those from European countries, despite similar clinical features. It also demonstrates that CLL is very uncommon in Amerindian population.

Comprehensive Profile of Young and Elderly Chronic Lymphocytic Leukemia Patients in China: The Younger Population Compared with Western Countries

IntroductionThe epidemiological features of chronic lymphocytic leukemia (CLL) are different in the United States (US) and China. In addition to variant incidence rates, the median age at diagnosis of CLL patients in the Shandong Provincial Hospital CLL (SPHCLL) database is younger than the Surveillance, Epidemiology, and End Results (SEER) database. However, investigations on the association between age at onset and other clinical characteristics of Chinese patients with CLL remain unclear. Hence, the aim of this study was to explore the clinical-pathological parameters and prognosis of Chinese patients with CLL which were divided into the young (<60 years) group and the elderly (≥60 years) group.MethodsThe clinical data of 510 Chinese CLL patients diagnosed between October 2010 and June 2020 were obtained from the SPHCLL database. Meanwhile, the survival data of 2580 CLL patients diagnosed between 2010 and 2018 were obtained with SEER*Stat 8.1.5 from the SEER database. Patients <60 years were divided into the young group and patients ≥60 years were divided into the elderly group. Clinical-pathological parameters were accessed from the hospital-based laboratory service within 24 hours after the first admission. SPSS 23 and R 4.0.5 were used in analyzing the data. Moreover, Kaplan-Meier survival analysis, univariate Cox regression analysis and multivariate Cox regression analysis were performed to evaluate the prognosis of CLL patients. Comparisons of clinical characteristics between young and elderly CLL patients were made using t test and Chi-square test. p < 0.05 was defined as the borderline of statistical significance.ResultsThe median age at diagnosis of Chinese patients, Asian American patients and patients of predominately European descent were 62, 66 and 69 years respectively (Figure 1A-C). After adjustments according to the population age distribution of China and the US, patients in the Chinese SPHCLL database presented earlier age at onset than the SEER database (Figure 1D).To further explore the clinical characteristics of young and elderly Chinese CLL patients, the general clinical data and laboratory parameters were analyzed among young and elderly CLL patients. Compared with elderly CLL patients, young CLL patients showed a higher percentage of cytogenetic aberrations detected by fluorescence in situ hybridization (p<0.05). The proportion of patients with combined diseases was higher in elderly patients than young patients, especially coronary heart disease and hypertension (p<0.05). The levels of prealbumin, albumin, Apolipoprotein A and Lp (a) were higher in young CLL patients, while the levels of β2-macroglobulin were lower in young CLL patients (p<0.05). Moreover, the proportion of young CLL patients who accepted CHOP/RCHOP treatment was significantly higher.The overall survival (OS) of young CLL patients was better than elderly patients in the SPHCLL cohort and the SEER cohort (Figure 1E-F). Intriguingly, young Chinese patients experienced improved OS compared with young patients of predominately European descent (Figure 1G-H). Furthermore, univariate Cox regression analysis presented that apolipoprotein A, hemoglobin, thrombocyte and total cholesterol were positive prognostic factors among young patients, while β2-microglobulin and ADA were negative prognostic factors. In elderly CLL patients, univariate Cox regression analysis showed that albumin, apolipoprotein A, hemoglobin and superoxide dismutasewere positive prognostic factors, while β2-microglobulin, ADA and cystatin were negative prognostic factors. Multivariate Cox regression analysis showed that cystatin was an independent prognostic factor in elderly CLL patients.ConclusionIn conclusion, Chinese CLL patients are characterized by earlier age at onset than patients of predominately European descent. The investigation presented a comprehensive profile of young and elderly CLL patients from China, contributing to the optimal management strategies of CLL patients in variant age groups. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Clinical characteristics of chronic lymphocytic leukemia in young versus old age patients in Kurdistan region- Iraq

Background: Chronic lymphocytic leukemia is the common adulthood leukemic type, although the incidence rate in the Kurdistan region is low. It is well known that chronic lymphocytic leukemia is prevalent among the elderly age group, however frequent cases of chronic lymphocytic leukemia are newly diagnosed at a younger age. Aim of the study: To analyze the difference in disease presentation, progression, and outcome between young and old age group patients with chronic lymphocytic leukemia in the Kurdistan region/Iraq. Patients &amp; Methods: A retrospective cross-sectional review study carried out in three oncology centers in the Kurdistan region (Nanakaly Hospital in Erbil city, Hiwa center in Sulaimani city, and Azadi center in Duhok city) for ten years through the period from 1st of January, 2010 to 31st of December, 2019 on a convenient sample of 152 patients with chronic lymphocytic leukemia. Diagnosis of chronic lymphocytic leukemia was done by the Oncologists in Kurdistan tumor centers according to the International Workshop on Chronic Lymphocytic Leukemia. The age of patients at diagnosis was categorized into two groups and ranged from 25 years to 94 years. The age cutoff value in the current study was (55 years) depending on previous kinds of literature. Results: The mean age at diagnosis of patients was (63 years); 28% of them were diagnosed at age of ≤50 years and 72% of them were diagnosed at age of more than 55 years. Older age patients were significantly presented with weight loss, while younger age patients were significantly presented with neck lumps. There was a highly significant association between the advanced ECOG performance scale and older age patients at diagnosis. A significant association was observed between the death outcome of chronic lymphocytic leukemia and older age patients at diagnosis. The mean survival duration of younger age patients at diagnosis was significantly longer than the mean survival duration of older age patients at diagnosis. Conclusions: clinical presentation, physical status, death rates, and survival of patients with chronic lymphocytic leukemia in Kurdistan region-Iraq are different between young and older age patients. Keywords: Chronic Lymphocytic Leukemia, age, death, Survival.

Hypogammaglobulinemia in Chronic Lymphocytic Leukemia: A Predictor of Outcome?

BACKGROUNDHypogammaglobulinemia (HYPO) is a typical feature of chronic lymphocytic leukemia (CLL), with an incidence of 20-60% at diagnosis and a relationship with infections occurrence. Predictive and prognostic factors are well known (IGHV, del11q, del17p, TP53); CLL-IPI score including age, clinical stage, beta2microglobulin, IGHV and deletion 17p and/or TP53 mutation has been recently validated. It identifies 4 risk groups with significantly different time to first treatment (TTFT) and overall survival (OS). Prognostic significance of HYPO at diagnosis has not been extensively evaluated in terms of OS and TTFT. Only IgG serum levels have been reported to be associated with TTFT but no data are available on other immunoglobulin classes (Ig).AIM To evaluate the impact of HYPO and single Ig classes on TTFT in a retrospective cohort of CLL patients and to assess the relationship between HYPO and CLL-IPI.METHODSWe retrospectively evaluated 698 consecutive CLL patients diagnosed at our Institution from 1983 till 2016. Data from laboratory, biological analysis and clinical stage were collected. We also evaluated immunoglobulin (Ig) status (i.e. IgG, IgM and IgA) at diagnosis and calculated CLL-IPI. HYPO was defined basing on our laboratory cut-offs (IgA 70 mg/dl, IgG 700 mg/dl, IgM 40 mg/dl). However, as no recognized prognostic/predictive Ig cut off has been reported to date, we aimed to identify a prognostic threshold for each Ig class.RESULTSFrom 698 patients assessed, 410 cases were evaluable for Ig values at diagnosis. IgA levels were lower than 70 mg/dl in 17,4%, IgG lower than 700 mg/dl in 22,2%, and IgM lower 40 mg/dl in 33.7%. Forty-six percent of patients presented deficit of at least one Ig class, while 7.8% of patients had all Ig low. Each Ig deficit was related with a shorter TTFT with the following hazard ratios (HRs): 2.09 (1.45-3.03) for IgA (P<0.0001), 1.58 (1.10-2.27) for IgG (P=0.008) and 1.52 (1.09-2.13) for IgM (P=0.01) (Figure 1, A-B-C). However, only IgA deficit maintains statistical significance in multivariate analysis [HR 1.59 (1.08-2.35)].A prognostic threshold for each Ig class was identified maximizing the differences in TTFT and the following values were obtained: 80 mg/dl for IgA, 410 mg/dl for IgG and 18 mg/dl for IgM (Figure 1, D-E-F).Considering CLL-IPI, 186 patients presented IPI 0-1, 99 had IPI 2-3, 32 patients IPI 4-6, and 12 patients had IPI 7-10. Even in our series, CLL-IPI separated four risk groups with different TTFT and OS, suggesting that our cohort may be suitable to evaluate new prognostic factors. As regards the relationship between HYPO and CLL-IPI, we observed a correlation with IgA levels, using our laboratory cut-off. Moreover, we found a relationship among CLL-IPI and both IgA and IgM values, when using the newly validated Ig cut-off. Finally, CLL-IPI was a stronger prognostic factor for TTFT than HYPO in our analysis. However, the addition of IgA deficit to CLL-IPI appears to further improve CLL prognostication.CONCLUSIONOur analysis supports the impact of HYPO on CLL prognosis. Although CLL-IPI has a stronger prognostic value for TTFT compared to HYPO, the inclusion of IgA deficit appears to further improve accuracy on CLL prognostication. [Display omitted] DisclosuresBarcellini:Alexion: Honoraria; Agios: Honoraria, Research Funding; Novartis: Honoraria.

NK Cells in Chronic Lymphocytic Leukemia and Their Therapeutic Implications.

Key features of chronic lymphocytic leukemia (CLL) are defects in the immune system and the ability of leukemic cells to evade immune defenses and induce immunosuppression, resulting in increased susceptibility to infections and disease progression. Several immune effectors are impaired in CLL, including T and natural killer (NK) cells. The role of T cells in defense against CLL and in CLL progression and immunotherapy has been extensively studied. Less is known about the role of NK cells in this leukemia, and data on NK cell alterations in CLL are contrasting. Besides studies showing that NK cells have intrinsic defects in CLL, there is a large body of evidence indicating that NK cell dysfunctions in CLL mainly depend on the escape mechanisms employed by leukemic cells. In keeping, it has been shown that NK cell functions, including antibody-dependent cellular cytotoxicity (ADCC), can be retained and/or restored after adequate stimulation. Therefore, due to their preserved ADCC function and the reversibility of CLL-related dysfunctions, NK cells are an attractive source for novel immunotherapeutic strategies in this disease, including chimeric antigen receptor (CAR) therapy. Recently, satisfying clinical responses have been obtained in CLL patients using cord blood-derived CAR-NK cells, opening new possibilities for further exploring NK cells in the immunotherapy of CLL. However, notwithstanding the promising results of this clinical trial, more evidence is needed to fully understand whether and in which CLL cases NK cell-based immunotherapy may represent a valid, alternative/additional therapeutic option for this leukemia. In this review, we provide an overview of the current knowledge about phenotypic and functional alterations of NK cells in CLL and the mechanisms by which CLL cells circumvent NK cell-mediated immunosurveillance. Additionally, we discuss the potential relevance of using NK cells in CLL immunotherapy.

Impaired Neutralisation of SARS-CoV-2 Delta Variant in Vaccinated Patients With B Cell Chronic Lymphocytic Leukaemia

Background: Immune suppression is a clinical feature of chronic lymphocytic leukaemia (CLL) and patients show increased vulnerability to SARS-CoV-2 infection and suboptimal antibody responses.Method: We studied antibody responses in 500 patients following dual COVID-19 vaccination to assess the magnitude, correlates of response, stability and functional activity of the spike-specific antibody response with 2 different vaccine platforms.Results: Spike-specific seroconversion post-vaccine was seen in 67% of patients compared to 100% of age-matched controls. Amongst responders, titres were 3.7 times lower than the control group. Antibody responses showed a 33% fall over the next 4 months. The use of an mRNA (n=204) or adenovirus-based (n=296) vaccine platform did not impact on antibody response. Male gender, BTKi therapy, prophylactic antibiotics use and low serum IgA/IgM were predictive of failure to respond. Antibody responses after CD20-targeted immunotherapy recovered 12 months-post treatment. Post-vaccine sera from CLL patients with Spike-specific antibody response showed markedly reduced neutralisation of the SARS-CoV-2 delta variant compared to healthy controls. Patients with previous natural SARS-CoV-2 infection showed equivalent antibody levels and function as healthy donors after vaccination.Interpretation: These findings demonstrate impaired antibody responses following dual COVID-19 vaccination in patients with CLL and further define patient risk groups. Furthermore, humoral protection against the globally-dominant delta variant is markedly impaired in CLL patients and indicates the need for further optimisation of immune protection in this patient cohort.Funding Information: This work was partially supported by the UK Coronavirus Immunology Consortium (UK-CIC) funded by DHSC/UKRI and the National Core Studies Immunity programme.Declaration of Interests: The authors declare no conflicts of interest.Ethics Approval Statement: Informed consent was obtained by remote consultation and work performed under the CIA UPH IRAS approval (REC 20\NW\0240) from North-West and Preston ethics committee and conducted according to the Declaration of Helsinki.

MODERN APPROACHES TO TREATMENT OF CHRONIC LYMPHOCYTIC LEUKEMIA

Purpose of the study: to systematize published data on the effectiveness of drugs used to treat patientswith chronic lymphocytic leukemia.Material and Methods. A literature search was conducted using Medline, Pubmed databases. 93 publications were selected to write this review.Results. General information about chronic lymphocytic leukemia (biological features, criteria for establishing diagnosis, staging, criteria for evaluating antitumor therapy response) was presented. The focus was made on antitumor drugs used as monotherapy and in combination with other anti-cancer agents. The use of drugs belonging to the classes of cytostatics, monoclonal antibodies, as well as drugs that affect the signaling pathways of the B-cell receptor, BCL -2 inhibitors, immunomodulators was discussed. The gold standard for first-line therapy remains the RFC scheme. With a positive Coombs test, bendamustine is an equivalent alternative to the FC regimen. The use of chlorambucil is limited in situations in which the goal of therapy is the palliative treatment of older people with serious comorbidity. In subsequent lines of therapy, molecular action drugs are beginning to take an increasingly important place.Conclusion. During the past twenty years, significant advances have been made in understanding biological features of chronic lymphocytic leukemia, the synthesis of several dozen new therapeutic drugs of targeted action, some of which are already undergoing clinical testing. These drugs may lead to serious complications. The review is devoted to new drugs, the efficacy and safety of which has already been tested in a clinical setting.

Raman spectroscopy-based biomarker screening by studying the fingerprint characteristics of chronic lymphocytic leukemia and diffuse large B-cell lymphoma

Raman spectroscopy (RS) can provide fingerprint-type information on biochemical molecules. RS-based blood plasma analysis of solid tumors has been reported in recent years; however, there are no studies on the use of this analysis for detecting blood diseases. We studied the features of blood plasma in patients with diffuse large B-cell lymphoma (DLBCL) and chronic lymphocytic leukemia (CLL) by RS with the aim of developing a simple blood test for noninvasive DLBCL and CLL detection. We analyzed blood plasma from 33 DLBCL patients, 39 CLL patients and 30 healthy volunteers. Orthogonal partial least squares discriminant analysis (OPLS-DA) could build two clusters with almost no overlap between DLBCL/CLL and the controls. We used the prediction set to test the model built by OPLS-DA. For the CLL model, the sensitivity was 92.86%, and the specificity was 100%, whereas for the DLBCL model, the sensitivity was 80% and the specificity was 92.31%. We found Raman bands specific to both DLBCL and CLL patients in comparison with the healthy volunteers. Most importantly, we found that the combination of the 1445 cm−1 and 1655 cm−1 Raman shifts could discriminate DLBCL from CLL and even the other solid tumors reported to date. Further analysis of the assignments of 1655 cm−1 also gave us a clue to find potential important variables hemoglobin and serum albumin related with the CLL prognosis. Our exploratory study primarily demonstrated the great potential of developing RS blood plasma analysis as a novel clinical tool for the noninvasive detection of DLBCL and CLL.

Chronic lymphocytic leukemia with TP53 gene alterations: a detailed clinicopathologic analysis.

TP53 alteration in chronic lymphocytic leukemia indicates a high-risk disease that is usually refractory to chemotherapy. It may be caused by deletion of 17p involving the loss of TP53 gene, which occurs in low percentage of patients at diagnosis but can be acquired as the disease progresses. Since patients may harbor TP53 mutation without chromosome 17p deletion, consensus recommendations call for both cytogenetic and PCR mutation analysis of TP53 in chronic lymphocytic leukemia. We conducted a single-institution retrospective study to investigate the clinicopathologic features of chronic lymphocytic leukemia with TP53 alterations as well as the utility of different diagnostic modalities to identify p53 alterations. Forty percent of chronic lymphocytic leukemia patients with TP53 alterations demonstrated atypical lymphocytes with cleaved/irregularly shaped nuclei and/or large atypical lymphoid cells with abundant cytoplasm in the peripheral blood. Progression was also observed in lymph node and bone marrow samples (21% with Richter transformation; 33% with findings suggestive of "accelerated phase" of chronic lymphocytic leukemia including prominent proliferation centers and/or increased numbers of prolymphocytes). However, the presence of the morphologic features suggestive of "accelerated phase" had no effect on overall survival within the chronic lymphocytic leukemia group with TP53 abnormalities (p > 0.05). As previously reported by others, a subset of patients with TP53 alterations were only identified by either PCR mutation analysis (12%) or cytogenetic studies (14%). p53 immunostain positivity was only identified in approximately half of the patients with TP53 alterations identified by either method, and it failed to identify any additional patients with p53 abnormalities. In summary, chronic lymphocytic leukemia patients with TP53 alterations frequently show atypical morphologic features. Use of multiple modalities to identify p53 abnormalities is recommended to ensure optimal sensitivity and specificity.

PS1160 PATTERNS OF DUVELISIB‐INDUCED LYMPHOCYTOSIS IN PATIENTS WITH RELAPSED/REFRACTORY CHRONIC LYMPHOCYTIC LEUKEMIA/SMALL LYMPHOCYTIC LEUKEMIA INCLUDING THOSE WITH HIGH‐RISK FACTORS TREATED IN THE DUO TRIAL

Background:Although lymphocytosis is a defining feature of chronic lymphocytic leukemia (CLL), it is also recognized as a class effect of treatment with B‐cell receptor pathway inhibitors. Duvelisib (DUV) is a first‐in‐class, oral, dual PI3K‐δ,γ inhibitor approved for the treatment of patients with relapsed/refractory (R/R) CLL or small lymphocytic leukemia (SLL) who have received ≥2 prior therapies. In the phase 3 multicenter DUO trial, DUV 25 mg twice daily (BID) showed a significant improvement in efficacy vs ofatumumab (mPFS, 13.3 vs 9.9 mo; HR, 0.5 [P &lt; .0001]; ORR, 74% vs 45% [P &lt; .0001]) with a manageable safety profile (Flinn et al. Blood. 2018). In preclinical studies using CLL cells from patients transferred into mice, dual PI3K‐δ,γ inhibition was more effective than PI3K‐δ inhibition alone in reducing CLL cell burden (Chen et al. ASH 2018). Herein we aim to characterize the clinical profile and kinetics associated with DUV‐related lymphocytosis.Aims:This post hoc analysis characterized response in patients with R/R CLL/SLL, including high‐risk subgroups—defined by unmutated IGHV (n = 110 [70%]), del(17p)/TP53 mutation (n = 48 [30%]), del(11q) (n = 38 [24%]), and bulky disease (n = 74 [47%])—who received DUV 25 mg BID in the DUO trial.Methods:Lymphocytosis was defined as an absolute lymphocyte count (ALC) of ≥5 × 109/L and a ≥50% increase of ALC from baseline (BL). ALC measured by local laboratories to determine peak ALC, median time to 50% reduction from BL ALC, and median time to onset and resolution of lymphocytosis. Median time to resolution was defined as ALC at or below BL value or ALC of &lt;5 × 109/L, whichever occurred first. Data were summarized using descriptive statistics, including medians for continuous variables and proportions for discrete variables.Results:Of 158 patients treated with DUV, 78% experienced lymphocytosis. Median ALC at BL was 41.1 × 109/L (range, 0.2–381.7). Median time to onset of lymphocytosis was 1 wk across all patients, including high‐risk patients. Median time to resolution of lymphocytosis (&lt;5 × 109/L or BL) was 14 wk (Figure; solid arrow), with a 50% reduction from BL ALC at 21 wk (Figure, dashed arrow). Similar results were observed regardless of high‐risk status: del(17p)/TP53, 14 wk; del(11q), 18 wk; bulky disease, 11 wk; unmutated IGHV, 13 wk. Rapid shrinkage of lymph nodes was noted, with 86% of patients achieving lymph node response. Among patients who achieved a response with DUV at first or second assessment, 78% and 86%, respectively, experienced lymphocytosis; median time to resolution of lymphocytosis in these patients was 12 and 18 wk, respectively. Prolonged lymphocytosis (for &gt;12 mo) occurred in 12 patients (8%). The ORR in patients with prolonged lymphocytosis was 83%. Of note, the median PFS was similar among patients with and those without prolonged lymphocytosis (22.1 mo [95% CI, 12.9–27.6]) vs [24 mo [95% CI, 20.5‐NE], respectively).Summary/Conclusion:DUV monotherapy induces rapid and transient lymphocytosis temporally associated with a reduction in lymphadenopathy in patients with R/R CLL/SLL. Notably, DUV resulted in a deep and prolonged resolution of lymphocytosis to &gt;50% below BL. The pattern of lymphocytosis in high‐risk patients was similar to that in the general patient population.image