Chronic Lymphocytic Leukemia/small Lymphocytic Lymphoma Research Articles

RAS/RAF Pathway Mutations Define a Distinct Subset of Chronic Lymphocytic Leukemia

Widespread use of next-generation sequencing (NGS) based mutational analysis has identified recurrent mutations of prognostic significance in chronic lymphocytic leukemia/ small lymphocytic lymphoma (CLL/SLL). In addition to novel genes such as NOTCH1 and SF3B1, targetable mutations in genes involved in RAS-MAPK pathway such as KRAS and BRAF including V600E have been reported. However, the detailed clinicopathologic, cytogenetic and molecular genetic features of KRAS/NRAS/BRAF mutated CLL/SLL (CLLrasmut) are not known. We describe the clinicopathologic findings in 44 cases of CLLrasmut.NGS analysis targeting 53 cancer-related genes was performed on Miseq Illumina on CLL/SLL cases on bone marrow (BM) and/or peripheral blood (PB) samples. ZAP70 expression was assessed by immunohistochemistry/ flow cytometry. Somatic hypermutation was performed by Sanger sequencing. Deviation from the germline above 2% was considered mutated. Interphase multi-color FISH studies were performed using probes targeting regions 11q22.3 (ATM), centromeric region of chromosome 12, 13q14.3 (D13S319 locus),13q34 (LAMP1) and 17p13.1 (TP53), Clinical data were correlated with molecular and cytogenetic findings.We reviewed 503 CLL cases in our laboratory database that underwent next-generation sequencing based multi-gene profiling. 44 (8.8%) patients had mutations including BRAF alone (n=18), KRAS alone (n=14), NRAS alone (n=8) and dual BRAF +KRAS/NRAS (n=4), respectively. We compared these 44 cases with 75 consecutive CLL/SLL cases without mutations in KRAS/NRAS/BRAF (CLLraswt). CLLrasmut showed a male predilection compared to the CLLraswt (M:F=3.9:1 versus 1.2:1, p =0.01) with a median age of 62 years (range, 42-80). There were no significant differences between CLLrasmut and CLLraswt in the median age of disease onset, PB counts, PB/BM tumor burden. Studies for somatic hypermutation showed unmutated IGHV in 79.4% of CLLrasmutversus 55.4% in CLLraswt (p =0.03). ZAP70 was positive in 73% of CLLrasmut compared to 42.9% in CLLraswt (0.05). TP53 was the most frequent concurrently mutated gene, noted in 22.7% (10/44) of CLLrasmut cases. CLLrasmut showed higher frequency of trisomy 12 (54.6% versus 30.7%, p =0.0001) and lower frequencies of D13S319 deletions (31.8% vs. 82.7%, p =0.0001) compared to CLLraswt. In a significant proportion of cases, the mutant allelic frequencies of RAS/RAF mutations were disproportionately lower than predicted based on the tumor burden. Interestingly, 15 out of 22 (69%) BRAF mutations involved codons other than V600.We conclude that BRAF/KRAS/NRAS mutations are seen in about 9% of CLL and could represent a distinct subset of CLL due to their frequent association with male gender, trisomy 12 and unmutated IGHV. These findings may provide additional insight into oncogenesis and guide design of potential targeted therapies in CLL. DisclosuresKeating:Celgene Corp.: Consultancy; Glaxo-Smith-Kline Inc.: Other: Advisory board. Wierda:Glaxo-Smith-Kline Inc.: Research Funding; Celgene Corp.: Consultancy.

Prevalence of Multiple Primary Hematologic Malignancies Seen at a Tertiary Care Center

Background: There is a paucity of data regarding patients who develop multiple unrelated hematologic malignancies. This study aims to determine the prevalence of two or more hematologic malignancies in the same patient at Loyola University Medical Center (LUMC) over a period of 7 years and to explore associations with certain clinical risk factors.Methods: After obtaining IRB approval, the electronic medical record was queried for various hematologic malignancies according to ICD-9 codes from 2007-2014. Chemotherapy-associated and transformed malignancies were excluded. In addition, the following data were collected: age at first and second diagnoses, gender, ethnicity, HIV, EBV, CMV, hepatitis B or C, JAK2 mutation, or autoimmune disorders. Survival outcomes and presence of coexisting solid tumors were assessed.Results: Of 5902 patients diagnosed with any hematologic malignancy, 27 were found to have more than one. Two patients had three hematologic malignancies (Hodgkin lymphoma, cutaneous t-cell lymphoma, diffuse large B-cell lymphoma; chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL), MALT lymphoma, diffuse large B-cell lymphoma). The most common first hematologic malignancy was CLL/SLL (10) followed by chronic myeloid leukemia (CML) (5) and Hodgkin lymphoma (4). The most common second primary hematologic malignancy was Hodgkin lymphoma (5), followed by multiple myeloma or plasmacytoma (4), acute myeloid leukemia (3) and CLL or monoclonal B-cell lymphocytosis (3). Thirty-seven of all malignancies were lymphoid, 16 myeloid and one Kaposi's sarcoma. Fifteen had both a myeloid and lymphoid malignancy; the remaining 12 patients had either two myeloid or two lymphoid malignancies. Seven cases were diagnosed synchronously and 20 metachronously. The median interval between the first and second diagnosis was 3 years (range: 0.19 - 6.26). The average age at diagnosis of the first and second disease was 62.4 and 67.2 years. Although not tested for statistical differences, the median survival after first and second diagnosis was 4.9 and 0.8 years, respectively. Seven patients also had at least one solid tumor malignancy; three had two different solid tumors. One patient had rheumatoid arthritis and hypothyroidism (SLL followed by Hodgkin lymphoma). Two patients had hypothyroidism, and four had type two diabetes. One patient had hepatitis B, and another had hepatitis B and C. Males were five times more likely to die after the first malignancy diagnosis compared to females, irrespective of the type of malignancy (p=0.04). No association was seen between survival and type of first malignancy or whether the second diagnosis was of lymphoid or myeloid lineage.Conclusion: These data show that in patients presenting with a hematologic malignancy, the risk of developing a second hematologic malignancy over a 7 year period was low at 0.005% (27 out of 5902). In about half (15 out of 27) the second hematologic malignancy belonged to a separate lineage and about a quarter (7/27) developed solid tumors. About one fourth of the patients (7/27) had an autoimmune disorder. Males in this cohort had a five-fold increased risk of death compared to females. The second hematologic malignancy was an ominous development and was associated with a median survival of 0.8 years. These observations should be confirmed in a prospective study. DisclosuresNo relevant conflicts of interest to declare.

Chronic Lymphocytic Leukemia with Bi-Nucleated Lymphocytes

Introduction: B-cell chronic lymphocytic leukemia is one of the common lymphoproliferative disorders in the adult patient population. It is very uncommon to find bi-nucleated lymphocytes as a morphological feature in this disorder. Our patient was diagnosed with CLL and was found to have bi-nucleated lymphocytes in the peripheral smear. The mechanism behind this type of morphological feature of lymphocytes is unknown in CLL, and whether it has prognostic value on disease outcome is undetermined.Case Description: 62 y/o man was referred to hematology oncology after diagnosis of small cell lymphocytic leukemia was made s/p a right inguinal lymph node biopsy. His CBC revealed a wbc count of 14,000, Rbc count of 4,360, Absolute lymphocyte count of 11,500 and Platelet count of 125,000. The patient did not have any B-symptoms. On physical exam, a pertinent finding was palpable right axillary adenopathy. The CT of abdomen /pelvic to evaluate these findings. This revealed extensive axillary, abdominal/pelvic lymphadenopathy, hepatosplenomegaly and cardio phrenic lymphadenopathy.The patient had a biopsy of the right inguinal lymph node as well as bone marrow biopsy. Biopsy results showed small lymphocytic cells, some of which show occasional large nucleoli were consistent with small lymphocytic lymphoma/chronic lymphocytic leukemia, and morphologic characteristics of the lymphocytes showed bi-nucleated lymphocytes in peripheral blood smear (figure A). Flow cytometric analysis confirmed a lymphocytic population with lambda light chain restriction, expressing CD5, CD19, CD20, and CD23 consistent with chronic lymphocytic leukemia/small lymphocytic lymphoma. Bone marrow biopsy showed a hypercellular marrow with 75 % cellularity mainly composed of mature lymphocytes with scattered macrophages and eosinophils, Flow cytometric analysis (Clarient FI11-041053) of the bone marrow is interpreted as chronic lymphocytic leukemia/small cell lymphoma with the abnormal B cells representing 56% of the viable white cells. FISH study showed deletion of the ATM gene (11q22-23), D13S319 (13q14) and TP53 (p53) were observed in 29%, 71% and 35.5% of the cells analyzed, respectively. A subset of cells with the 13q deletion (20.5% of the total cells) showed homozygous deletion of D13S319 (13q14). ATM deletion is associated with progressive disease and poor prognosis in cases of chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL).He did not have any other previous history of malignancy or hematologic disorder.Discussion:B-cell chronic lymphocytic leukemia is one of the common lymphoproliferative disorders in the adult patient population. To make a diagnosis requires absolute lymphocyte count >4x10 9 and lymphoid cell morphology. In CLL, leukemic cells are small and mature appearing lymphocytes, which have regular nuclear and cytoplasmic outlines and scant weakly basophilic cytoplasm. Surface markers that define a CLL cell are proteins such as antibody light chains (kappa or lambda) and CD proteins (CD5, CD19, CD20, and CD23). In our patient absolute lymphocyte count was 11.5x109 and lymphocytic population showed surface marker lambda light chain and CD proteins CD5, CD19, CD20 and CD23 which was consistent with CLL/SLL on inguinal lymph node biopsy, but morphology of lymphocytes was small and mature bi-nucleated lymphocytes, which is very uncommon. Although bi-nucleated lymphocytes are described in a disorder "Polyclonal chronic B-cell lymphocytosis with bi-nucleated lymphocytes". Detection of an extra chromosome for the long arm of chromosome 3 +i(3)(q10) has been considered a specific marker of Polyclonal B-cell lymphocytosis with binucleated lymphocytes (PPBL),which was not present in our case. One case study by Amouroux et al, included four patients with B-cell CLL who were found to have bi-nucleated lymphocytes. Disease course was stable in one patient, one patient had an indolent course and only one required treatment due to rapid doubling time of lymphocytes. Our patient initiated chemotherapy with Rituxan and Fludara, as he had progressive disease with hepatosplenomegaly, lymph nodes and bone marrow involvement.Conclusion:Bi -nucleated lymphocytes in B-cell CLL are very rare. Explanations as to the etiology of this morphological feature in B-cell CLL is unknown. There is no sufficient evidence that bi-nucleated lymphocytes in CLL has any impact on disease progression. DisclosuresNo relevant conflicts of interest to declare.

Composite Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma and Follicular Lymphoma

Introduction: Composite lymphoma is defined as the co-occurrence of two or, rarely, more than two morphologically and/or immunophenotypically different types of lymphoma in the same anatomic site. These lymphomas can arise synchronously or metachronously, and can be clonally related or unrelated. Different combinations of lymphomas have been reported, of which chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) and follicular lymphoma …

Occupation and Risk of Non-Hodgkin Lymphoma and Its Subtypes: A Pooled Analysis from the InterLymph Consortium.

Background:Various occupations have been associated with an elevated risk of non-Hodgkin lymphoma (NHL), but results have been inconsistent across studies.Objectives:We investigated occupational risk of NHL and of four common NHL subtypes with particular focus on occupations of a priori interest.Methods:We conducted a pooled analysis of 10,046 cases and 12,025 controls from 10 NHL studies participating in the InterLymph Consortium. We harmonized the occupational coding using the 1968 International Standard Classification of Occupations (ISCO-1968) and grouped occupations previously associated with NHL into 25 a priori groups. Odds ratios (ORs) adjusted for center, age, and sex were determined for NHL overall and for the following four subtypes: diffuse large B-cell lymphoma (DLBCL), follicular lymphoma (FL), chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL), and peripheral T-cell lymphoma (PTCL).Results:We confirmed previously reported positive associations between NHL and farming occupations [field crop/vegetable farm workers OR = 1.26; 95% confidence interval (CI): 1.05, 1.51; general farm workers OR = 1.19; 95% CI: 1.03, 1.37]; we also confirmed associations of NHL with specific occupations such as women’s hairdressers (OR = 1.34; 95% CI: 1.02, 1.74), charworkers/cleaners (OR = 1.17; 95% CI: 1.01, 1.36), spray-painters (OR = 2.07; 95% CI: 1.30, 3.29), electrical wiremen (OR = 1.24; 95% CI: 1.00, 1.54), and carpenters (OR = 1.42; 95% CI: 1.04, 1.93). We observed subtype-specific associations for DLBCL and CLL/SLL in women’s hairdressers and for DLBCL and PTCL in textile workers.Conclusions:Our pooled analysis of 10 international studies adds to evidence suggesting that farming, hairdressing, and textile industry–related exposures may contribute to NHL risk. Associations with women’s hairdresser and textile occupations may be specific for certain NHL subtypes.Citation:‘t Mannetje A, De Roos AJ, Boffetta P, Vermeulen R, Benke G, Fritschi L, Brennan P, Foretova L, Maynadié M, Becker N, Nieters A, Staines A, Campagna M, Chiu B, Clavel J, de Sanjose S, Hartge P, Holly EA, Bracci P, Linet MS, Monnereau A, Orsi L, Purdue MP, Rothman N, Lan Q, Kane E, Seniori Costantini A, Miligi L, Spinelli JJ, Zheng T, Cocco P, Kricker A. 2016. Occupation and risk of non-Hodgkin lymphoma and its subtypes: a pooled analysis from the InterLymph Consortium. Environ Health Perspect 124:396–405; http://dx.doi.org/10.1289/ehp.1409294

Insecticide exposure and farm history in relation to risk of lymphomas and leukemias in the Women's Health Initiative observational study cohort

PurposeRelationships of farm history and insecticide exposure at home or work with lymphohematopoietic (LH) neoplasm risk were investigated in a large prospective cohort of US women. MethodsIn questionnaires, women self-reported history living or working on a farm, personally mixing or applying insecticides, insecticide application in the home or workplace by a commercial service, and treating pets with insecticides. Relationships with non-Hodgkin lymphoma (NHL), chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL), diffuse large B-cell lymphoma (DLBCL), follicular lymphoma, plasma cell neoplasms, and myeloid leukemia were investigated using Cox proportional hazard models. Age and farming history were explored as effect modifiers. ResultsThe analysis included 76,493 women and 822 NHL cases. Women who ever lived or worked on a farm had 1.12 times the risk of NHL (95% confidence interval [CI] = 0.95–1.32) compared to those who did not. Women who reported that a commercial service ever applied insecticides in their immediate surroundings had 65% higher risk of CLL/SLL (95% CI = 1.15–2.38). Women aged less than 65 years who ever applied insecticides had 87% higher risk of DLBCL (95% CI = 1.13–3.09). ConclusionsInsecticide exposures may contribute to risk of CLL/SLL and DLBCL. Future studies should examine relationships of LH subtypes with specific types of household insecticides.

Risk Factors for Melanoma Among Survivors of Non-Hodgkin Lymphoma

Previous studies have reported that survivors of non-Hodgkin lymphoma (NHL) have an increased risk of developing cutaneous melanoma; however, risks associated with specific treatments and immune-related risk factors have not been quantified. We evaluated second melanoma risk among 44,870 1-year survivors of first primary NHL diagnosed at age 66 to 83 years from 1992 to 2009 and included in the Surveillance, Epidemiology, and End Results-Medicare database. Information on NHL treatments, autoimmune diseases, and infections was derived from Medicare claims. A total of 202 second melanoma cases occurred among survivors of NHL, including 91 after chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) and 111 after other NHL subtypes (cumulative incidence by age 85 years: CLL/SLL, 1.37%; other NHL subtypes, 0.78%). Melanoma risk after CLL/SLL was significantly increased among patients who received infused fludarabine-containing chemotherapy with or without rituximab (n=18: hazard ratio [HR], 1.92; 95% CI, 1.09 to 3.40; n=10: HR, 2.92; 95% CI, 1.42 to 6.01, respectively). Significantly elevated risks also were associated with T-cell activating autoimmune diseases diagnosed before CLL/SLL (n=36: HR, 2.27; 95% CI, 1.34 to 3.84) or after CLL/SLL (n=49: HR, 2.92; 95% CI, 1.66 to 5.12). In contrast, among patients with other NHL subtypes, melanoma risk was not associated with specific treatments or with T-cell/B-cell immune conditions. Generally, infections were not associated with melanoma risk, except for urinary tract infections (CLL/SLL), localized scleroderma, pneumonia, and gastrohepatic infections (other NHLs). Our findings suggest immune perturbation may contribute to the development of melanoma after CLL/SLL. Increased vigilance is warranted among survivors of NHL to maximize opportunities for early detection of melanoma.

Abstract LB-184: Risk factors for lung cancer among survivors of non-Hodgkin lymphoma

Abstract Background: Previous studies have reported that non-Hodgkin lymphoma (NHL) survivors have increased risk of developing lung cancer; however, risks associated with specific treatments and immune-related risk factors have not been quantified. Methods: We assessed second lung cancer risk among 44,870 1-year survivors of first primary NHL diagnosed at ages 66-84 years during 1992-2009 from the Surveillance, Epidemiology, and End Results (SEER)-Medicare data linkage. Information on potential risk factors, including NHL treatments, infections, and immune-related medical conditions, was derived from Medicare claims. Results: A total of 700 second lung cancers were diagnosed among NHL survivors, including 259 after chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL), 127 after follicular lymphoma (FL), 116 after diffuse large B-cell lymphoma (DLBCL), and 137 after other NHL subtypes. Lung cancer risks were significantly increased among CLL/SLL survivors who received fludarabine-containing chemotherapy without rituximab (Cox regression hazard ratio [HR] = 2.28, 95% confidence interval [CI] = 1.48-3.52). Elevated risks were also seen among DLBCL survivors who received cyclophosphamide-containing chemotherapy (without rituximab HR = 2.13, 95%CI = 1.01-4.47; with rituximab HR = 1.82, 95%CI = 0.87-3.80). After adjusting for history of smoking, lower airway respiratory infections, particularly pneumonia, were associated with increased risks of second lung cancer after CLL/SLL (HR = 2.21, 95%CI = 1.65-2.96), DLBCL (HR = 1.90, 95%CI = 1.26-2.87), and FL (HR = 1.98, 95%CI = 1.31-3.00). The pattern of lung cancer risks associated with autoimmune conditions was complex, with increased risks seen for B-cell activating autoimmune conditions among DLBCL survivors (HR = 1.63, 95%CI = 1.00-2.66) and T-cell activating autoimmune conditions among survivors of other NHL subtypes (HR = 1.56, 95%CI = 1.07-2.27). In contrast, T-cell activating autoimmune conditions were significantly inversely associated with lung cancer among FL survivors (HR = 0.57, 95%CI = 0.34-0.96), and no associations with autoimmune disease were identified among CLL/SLL survivors. Conclusion: We report for the first time that chemotherapy used in treatment of NHL, infections, and autoimmune diseases are associated with the risk of developing lung cancer after NHL. Further research is needed to confirm the observed associations and understand the underlying carcinogenic mechanisms. Citation Format: Clara Lam, Rochelle Curtis, Graca Dores, Eric Engels, Neil Caporaso, Aaron Polliack, Joan Warren, Heather Young, Paul Levine, Angelo Elmi, Joseph Fraumeni, Margaret Tucker, Lindsay Morton. Risk factors for lung cancer among survivors of non-Hodgkin lymphoma. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr LB-184. doi:10.1158/1538-7445.AM2015-LB-184

Abstract 867: Reproductive factors and risk of B-cell non-Hodgkin lymphoma among women in Los Angeles

Abstract Background: Overall, non-Hodgkin lymphoma (NHL) incidence is higher in men than women, and the male to female ratio differs by NHL subtype. Historically, female reproductive characteristics and patterns have been inconsistently linked to NHL risk, though studies on this topic remain limited. Because a woman experiences changes in immune function during pregnancy, that permit her to establish and maintain a successful pregnancy, we hypothesize that such pregnancy-associated changes in immune function could affect the risk of NHL, a cancer of the immune cells. Methods: We conducted a population-based case-control study among women in Los Angeles County comprising 998 histologically confirmed B-cell NHL patients diagnosed 2004-2008 from the Los Angeles Cancer Surveillance Program and 998 individually matched controls (matched on age, race and socioeconomic status). Conditional logistic regression was used to calculate the associations [odds ratios (OR) and 95% confidence intervals (CI)] between female reproductive factors (e.g., ever pregnant; number of full-term pregnancies; breastfeeding) with B-cell NHL overall and unconditional logistic regression was used to calculate the associations with major NHL subtypes. Results: Compared to women who had never been pregnant, women who had full-term pregnancies had 17% decreased risk of B-cell NHL (OR = 0.83, 95% CI = 0.64-1.08); the decreased risk was most pronounced for the diffuse large B-cell lymphoma (DLBCL) subtype (OR = 0.68, 95% CI = 0.47-0.98). Increasing number of full-term pregnancies was inversely associated with B-cell NHL overall (P-trend = 0.02), DLBCL (P-trend = 0.03) and follicular lymphoma (P-trend = 0.04). Women who had reported breastfeeding also had decreased risk of B-cell NHL overall (OR = 0.80, 95% CI = 0.64-1.00) and follicular lymphoma (OR = 0.71, 95% CI = 0.50-1.00). Among women who had full-term pregnancies, women who breastfed for 60 weeks or more had 30% decreased risk of B-cell NHL overall (OR = 0.70, 95% CI = 0.52-0.93; P-trend = 0.06), which was consistent for follicular lymphoma and chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL). Conclusions: Our results provide evidence for an association between female reproductive factors and decreased risk of B-cell NHL, supporting a role for hormonal factors in B-cell NHL etiology. Citation Format: Yani Lu, Jianning Luo, Sophia Wang, Jane Sullivan-Halley, Wendy Cozen, Leslie Bernstein. Reproductive factors and risk of B-cell non-Hodgkin lymphoma among women in Los Angeles. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 867. doi:10.1158/1538-7445.AM2015-867

Non-Hodgkin Lymphoma, Body Mass Index, and Cytokine Polymorphisms: A Pooled Analysis from the InterLymph Consortium.

Excess adiposity has been associated with lymphomagenesis, possibly mediated by increased cytokine production causing a chronic inflammatory state. The relationship between obesity, cytokine polymorphisms, and selected mature B-cell neoplasms is reported. Data on 4,979 cases and 4,752 controls from nine American/European studies from the InterLymph consortium (1988-2008) were pooled. For diffuse large B-cell lymphoma (DLBCL), follicular lymphoma (FL), and chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL), joint associations of body mass index (from self-reported height and weight) and 12 polymorphisms in cytokines IL1A (rs1800587), IL1B (rs16944, rs1143627), IL1RN (rs454078), IL2 (rs2069762), IL6 (rs1800795, rs1800797), IL10 (rs1800890, rs1800896), TNF (rs1800629), LTA (rs909253), and CARD15 (rs2066847) were investigated using unconditional logistic regression. BMI-polymorphism interaction effects were estimated using the relative excess risk due to interaction (RERI). Obesity (BMI ≥ 30 kg/m(2)) was associated with DLBCL risk [OR = 1.33; 95% confidence interval (CI), 1.02-1.73], as was TNF-308GA+AA (OR = 1.24; 95% CI, 1.07-1.44). Together, being obese and TNF-308GA+AA increased DLBCL risk almost 2-fold relative to those of normal weight and TNF-308GG (OR = 1.93; 95% CI, 1.27-2.94), with a RERI of 0.41 (95% CI, -0.05-0.84; Pinteraction = 0.13). For FL and CLL/SLL, no associations with obesity or TNF-308GA+AA, either singly or jointly, were observed. No evidence of interactions between obesity and the other polymorphisms were detected. Our results suggest that cytokine polymorphisms do not generally interact with BMI to increase lymphoma risk but obesity and TNF-308GA+AA may interact to increase DLBCL risk. Studies using better measures of adiposity are needed to further investigate the interactions between obesity and TNF-308G>A in the pathogenesis of lymphoma.

Ibrutinib combined with bendamustine and rituximab (BR) in previously treated chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL): First results from a randomized, double-blind, placebo-controlled, phase III study.

LBA7005 Background: The phase III HELIOS study evaluated the first-in-class, oral covalent BTK inhibitor ibrutinib in combination with BR (BR+ibr) vs BR plus placebo (BR+plb) in patients (pts) with previously treated CLL/SLL. The preplanned interim analysis reported here showed that the primary end point was met, upon which the IDMC recommended unblinding the study. Methods: Pts received BR ( ≤ 6 cycles) and were randomized 1:1 to ibr (420 mg daily) or plb. Purine analog refractoriness was a stratification factor. Pts with del17p ( > 20% of cells) were excluded. Primary end point was independent review committee (IRC)-assessed progression-free survival (PFS). Secondary end points included overall survival (OS) and overall response rate (ORR) per IRC. Results: 578 pts were randomized (289 per arm); median age 64 yrs; 38% Rai Stage III/IV; median 2 prior therapies. 6 cycles of BR were completed in 83% and 78% of pts in the ibr and plb arms, respectively. At a median follow-up of 17.2 months, IRC-assessed PFS was significantly longer with BR+ibr vs BR+plb (median not reached vs 13.3 months; HR: 0.203, 95% CI: 0.150-0.276, P< 0.0001); PFS results were consistent across high-risk subgroups. ORR and CR/CRi rates were 82.7% vs 67.8% (P< 0.0001) and 10.4% vs 2.8%. Median OS was not reached. 90 pts (31%) in the BR+plb arm with confirmed PD crossed over to receive ibr, as permitted per the protocol. Incidence of most AEs was similar between arms. The most common all-grade AEs with BR+ibr and BR+plb were neutropenia (58.2% vs 54.7%) and nausea (36.9% vs 35.2%); most common grade 3/4 AEs were neutropenia (53.7% vs 50.5%) and thrombocytopenia (15.0% each arm). Rates of grade 3/4 atrial fibrillation were 2.8% and 0.7%, and major hemorrhage were 2.1% and 1.7%. Fatigue (FACIT-Fatigue) was improved with BR+ibr vs BR+plb. Conclusions: The addition of ibr to BR reduced the risk of progression or death by 80% compared with BR+plb. ORR was also significantly improved. Safety of BR+ibr was consistent with the known profiles for BR and ibr. The data further support ibr as an important treatment option for pts with previously treated CLL/SLL. Clinical trial information: EudraCT No. 2012-000600-15; UTN No. U1111-1135-3745.

Ibrutinib Versus Ofatumumab in Previously Treated Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma (CLL/SLL): Results From the Randomized Phase III RESONATE™ (PCYC-1112) Trial

304 Ibrutinib Versus Ofatumumab in Previously Treated Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma (CLL/SLL): Results From the Randomized Phase III RESONATETM (PCYC-1112) Trial J Jennifer R. Brown, MD, PhD1, John C. Byrd, MD2, Susan O’Brien, MD3, Jacqueline C. Barrientos, MD4, Neil E. Kay, MD5, Nishitha M. Reddy, MBBS, MD6, Steven Coutre, MD7, Constantine S. Tam, MBBS, MD8, Stephen Mulligan, MBBS, PhD, FRACP, FRCPA9, Ulrich Jaeger, MD10, Stephen Devereux, PhD, FRCP, FRCPath11, Paul M. Barr, MD12, Richard Furman, MD13, Thomas Kipps, MD, PhD14, Florence Cymbalista, MD, PhD15, Maria Fardis, PhD, MBA16, Jesse McGreivy, MD16, Fong Clow, DSc16, Danelle F. James, MD, MAS16, Peter Hillmen, MD, PhD, FRCP, FRCPath17 1Dana-Farber Cancer Institute, Boston, MA, USA; 2The Ohio State University Medical Center, Columbus, OH, USA; 3University of Texas MD Anderson Cancer Center, Houston, TX, USA; 4North Shore Long Island Jewish Health System, Manhasset, NY, USA; 5Mayo Clinic, Rochester, MN, USA; 6Vanderbilt-Ingram Cancer Center, Nashville, TN, USA; 7Stanford University School of Medicine, Stanford, CA, USA; 8Peter MacCallum Cancer Centre and St. Vincent’s Hospital, Melbourne, Australia; 9Royal North Shore Hospital, Sydney, Australia; 10Medical University of Vienna, Vienna, Austria; 11Kings College Hospital, NHS Foundation Trust Denmark Hill, London, UK; 12University of Rochester Cancer Center, Rochester, NY, USA; 13Weill Cornell Medical College/New York Presbyterian Hospital, New York, NY, USA; 14Moores UCSD Cancer Center, San Diego, CA, USA; 15Hopital Avicenne, Paris, France; 16Pharmacyclics, Inc., Sunnyvale, CA, USA; 17The Leeds Teaching Hospitals, St. James Institute of Oncology, Leeds, UK Context: Ibrutinib, a first-in-class, once-daily oral, covalent inhibitor of Bruton’s tyrosine kinase, demonstrated single-agent activity and an acceptable safety profile in a phase II relapsed/refractory (R/R) CLL/SLL study (Byrd et al. NEJM 2013). Ibrutinib is FDA approved for CLL patients who have received ≥1 prior therapy, and for patients with del(17p) CLL. Objective: Interim safety and efficacy results from an international, multicenter, open-label, randomized phase III study of single-agent ibrutinib vs ofatumumab in R/R CLL/SLL Patients: Patients with R/R CLL/SLL who received ≥1 previous therapy considered inappropriate for purine analogs Main Outcome Measures: Independent Review Committee-assessed PFS (primary); overall survival (OS), ORR, safety (secondary) Intervention: 420 mg oral ibrutinib daily or IV ofatumumab 300/2000 mg (12 doses) Results: 391 patients (median age 67 years, 40% ≥70 years, 30% del17p); 195 randomized to ibrutinib, 196 to ofatumumab. Ibrutinib patients had median 3 prior therapies vs 2 for ofatumumab. Ibrutinib significantly improved PFS (median not reached vs 8.1 months; HR 0.215, 95% CI 0.146-0.317, P<0.0001; 78.5% risk reduction), and OS (median not reached; HR 0.434, 95% CI 0.238-0.789, P=0.0049; 57% risk reduction) vs ofatumumab. Ofatumumab patients (n=57) with confirmed progressive disease crossed over to the ibrutinib arm. ORR by IRC, including partial response with lymphocytosis: 62.6% for ibrutinib vs 4.1% for ofatumumab. Similar effects were seen in del(17p) and purine analog-refractory subsets. Most frequent adverse events (AEs) for ibrutinib vs ofatumumab: diarrhea (47.7% vs 17.8%), fatigue (27.7% vs 29.8%), and nausea (26.2% vs 18.3%). Any-grade atrial fibrillation was observed more frequently with ibrutinib (5.1% vs 0.5%). Major hemorrhage rates: 1% for ibrutinib vs 1.6% for ofatumumab. Drug discontinuation due to AEs: 4.1% for ibrutinib vs 3.6% for ofatumumab. At median time on study of 9.6 months, 86% of ibrutinib patients were continuing treatment. Conclusions: Single-agent ibrutinib significantly improved PFS, OS, and ORR in patients with previously treated CLL/SLL compared with ofatumumab. The effect of ibrutinib on PFS was observed irrespective of baseline features, including del(17p) or purine analog-refractory disease. The safety profile was comparable with that reported previously. These results support ibrutinib as an effective therapy for patients with previously treated CLL.

Activity and Tolerability of Ibrutinib in Combination With Ofatumumab in Patients With Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma (CLL/SLL)

S206 (21%) and 17pdel in 8 (12.9%) cases. The median time to first treatment was 22.8 months. We analyzed OS using 20 months as an arbitrary set point to stratify patients based on our calculated median time to treatment. The median OS for patients requiring treatment before 20 months vs. patients treated after 20 months were 7.8 and 12.1 years, respectively (p1⁄40.014). Chi square analysis revealed that NOTCH1 and trisomy 12 were associated with patients requiring treatment before 20 months (p1⁄40.028 and p1⁄40.015, respectively). There was no correlation among TP53 mutation (p1⁄40.52) and 17p deletion (p1⁄40.522) with requiring early treatment. Median OS of patients with mutated NOTCH1 vs. wild type NOTCH1 was 11 years and 15.7 years, respectively (p1⁄40.334). Conclusion: In our study, we showed the association of NOTCH1 mutations with earlier need for treatment (<20 months) and that time to first treatment did correlate with a statistically significant 35.5% reduction in OS. Independent of time to treatment, patients with mutated NOTCH1 had a shorter median OS; however this was not statistically significant. Prospective studies will be important to determine the impact of NOTCH1 in patients with high-risk CLL.

Chronic lymphocytic leukemia/small lymphocytic lymphoma: another neoplasm related to the B-cell follicle?

Although there has been increased attention paid to the critical nature of nodal involvement in chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL), the B-cell compartment it is most closely related to and its relationship to the follicle remain uncertain. A clinicopathologic investigation of 60 extramedullary biopsies of LEF1+ CLL/SLL, including 29 cases with perifollicular/follicular (PF/F) growth, was therefore performed. A subset of PF/F cases demonstrated inner mantle zone preservation or intra-mantle zone growth. All PF/F and 16/31 other cases contained CD21+ follicular dendritic cells. No cytogenetic, IGHV mutational or gene usage differences were seen between PF/F and diffuse cases. PF/F cases were more often kappa positive (p < 0.03) and had fewer involved nodal sites (p = 0.0004). These findings suggest that at least a subset of bona fide CLL/SLL is related to the follicle, most likely the outer mantle zone, and that at least a subset of the diffuse cases may represent “later” disease.

Ibrutinib combined with bendamustine and rituximab (BR) in previously treated chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL): First results from a randomized, double-blind, placebo-controlled, phase III study.

Ibrutinib combined with bendamustine and rituximab (BR) in previously treated chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL): First results from a randomized, double-blind, placebo-controlled, phase III study.

Management of chronic lymphocytic leukemia.

Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL) is usually diagnosed in asymptomatic patients with early-stage disease. The standard management approach is careful observation, irrespective of risk factors unless patients meet the International Workshop on CLL (IWCLL) criteria for "active disease," which requires treatment. The initial standard therapy for most patients combines an anti-CD20 antibody (such as rituximab, ofatumumab, or obinutuzumab) with chemotherapy (fludarabine/cyclophosphamide [FC], bendamustine, or chlorambucil) depending on multiple factors including the physical fitness of the patient. However, patients with very high-risk CLL because of a 17p13 deletion (17p-) with or without mutation of TP53 (17p-/TP53mut) have poor responses to chemoimmunotherapy and require alternative treatment regimens containing B-cell receptor (BCR) signaling pathway inhibitors. The BCR signaling pathway inhibitors (ibrutinib targeting Bruton's tyrosine kinase [BTK] and idelalisib targeting phosphatidyl-inositol 3-kinase delta [PI3K-delta], respectively) are currently approved for the treatment of relapsed/refractory CLL and all patients with 17p- (ibrutinib), and in combination with rituximab for relapsed/refractory patients (idelalisib). These agents offer great efficacy, even in chemotherapy refractory CLL, with increased tolerability, safety, and survival. Ongoing studies aim to determine the best therapy combinations with the goal of achieving long-term disease control and the possibility of developing a curative regimen for some patients. CLL is associated with a wide range of infectious, autoimmune, and malignant complications. These complications result in considerable morbidity and mortality that can be minimized by early detection and aggressive management. This active monitoring requires ongoing patient education, provider vigilance, and a team approach to patient care.

Lack of association between using aspirin and development of non-Hodgkins lymphoma: a meta-analysis.

Non-Hodgkins lymphoma (NHL) is a heterogeneous group of malignancies, originating in the lymphatic organs, whose incidence is increasing in developed as well as developing countries. Epidemiological evidence suggests that aspirin may reduce the incidence and mortality of several cancers. The main objective of this study was to evaluate the potential relationship between using aspirin and development of NHL with a meta-analysis. A total of 7 studies were included. Outcome was calculated and reported as odds ratios (ORs). Heterogeneity was assessed with Cochrane Q and I2 statistics. Dissemination bias was evaluated by funnel plot visualization and trim-and-fill analysis. Our analysis showed OR of developing NHL overall of 1(95% CI: 0.87-1.16, p=0.9), and in females this was 0.81 (95%CI: 0.72-.92, p=0.001) and in males 1.01 (95%CI: 0.82-1.26, p=0.86). The odds ratio (OR) of chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) was 0.85 (95%CI: 0.75-0.97, p=0.02), The ORs of follicular lymphoma (FL) and large B-cell lymphoma (DLBCL) in individuals exposed to aspirin were 1.12 (95%CI: 0.86-1.45, p=0.37) and 1.03 (95%CI: 0.9-1.19, p=0.6) respectively. In conclusion, individuals taking aspirin do not demonstrate any change in risk of Non-Hodgkins lymphoma.

Flow cytometric analysis of lymphoid enhancer-binding factor 1 in diagnosis of chronic lymphocytic leukemia/small lymphocytic lymphoma.

Nuclear overexpression of lymphoid enhancer-binding factor 1 (LEF1) assessed by immunohistochemistry has been shown to be highly associated with chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) among small B-cell lymphomas. The purpose of this study was to evaluate the utility of flow cytometric analysis of LEF1 in the diagnosis of CLL/SLL. Normal peripheral blood was used to validate the test. Flow cytometric analysis of LEF1 was performed in 64 patient samples qualitatively and quantitatively by comparing the staining intensity and the ratios of the median fluorescence intensities (MFIs) of LEF1 in B cells of interest to the internal reference cell populations. The results were correlated with the pathologic diagnosis. Proper sample processing ensured sufficient separation of positive LEF1 staining in T cells from negative staining in normal B and natural killer (NK) cells. Qualitative analysis of patient samples showed that all 25 cases of CLL/SLL but none of the other small B-cell lymphomas were positive for LEF1. Using a B/NK MFI ratio of 1.5 and B/T MFI ratio of 0.45 separated CLL/SLL cases from non-CLL lymphomas. Flow cytometric analysis of LEF1 is sufficient to differentiate CLL/SLL from other small B-cell lymphomas and may serve as a useful tool in the diagnosis of CLL/SLL.

Racial differences in three major NHL subtypes: Descriptive epidemiology

BackgroundNHL (non-Hodgkin lymphoma) consists of over 60 subtypes, ranging from slow-growing to very aggressive. The three largest subtypes are DLBCL (diffuse large B-cell lymphoma), FL (follicular lymphoma), and CLL/SLL (chronic lymphocytic leukemia/small lymphocytic lymphoma). For each subtype, different racial groups have different presentations, etiologies, and prognosis patterns. MethodsSEER (Surveillance, Epidemiology, and End Results) data on DLBCL, FL, and CLL/SLL patients diagnosed between 1992 and 2010 were analyzed. Racial groups studied included NHW (non-Hispanic whites), HW (Hispanic whites), blacks, and API (Asians and Pacific Islanders). Patient characteristics, age-adjusted incidence rate, and survival were compared across races. Stratification and multivariate analysis were conducted. ResultsThere are significant racial differences for patients’ characteristics, including gender, age at diagnosis, stage, lymph site, and age, and the patterns vary across subtypes. NHWs have the highest incidence rates for all three subtypes, followed by HWs (DLBCL and FL) and blacks (CLL/SLL). The dependence of the incidence rate on age and gender varies across subtypes. For all three subtypes, NHWs have the highest five-year relative survival rates, followed by HWs. When stratified by stage, racial difference is significant in multiple multivariate Cox regression analyses. ConclusionsRacial differences exist among DLBCL, FL, and CLL/SLL patients in the U.S. in terms of characteristics, incidence, and survival. The patterns vary across subtypes. More data collection and analysis are needed to more comprehensively describe and interpret the across-race and subtype differences.

Mitochondrial DNA copy number and chronic lymphocytic leukemia/small lymphocytic lymphoma risk in two prospective studies.

Mitochondrial DNA copy number (mtDNA CN) may be modified by mitochondria in response to oxidative stress. Previously, mtDNA CN was associated with non-Hodgkin lymphoma (NHL) risk, particularly chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL). We conducted a replication study in the Prostate, Lung, Colorectal, and Ovarian (PLCO) study and pooled with published ATBC (Alpha-Tocopherol, Beta-Carotene) data. In PLCO, 292 NHL cases (95 CLL/SLL cases) and 301 controls were pooled with 142 NHL cases (47 CLL/SLL cases) and 142 controls from ATBC. Subjects answered a questionnaire and provided blood. DNA was extracted from prediagnostic peripheral white blood, and mtDNA CN assayed by quantitative polymerase chain reaction. Unconditional logistic regression estimated mtDNA CN and NHL risk by odds ratios (OR) and 95% confidence intervals (95% CI). Greater mtDNA CN was associated with increased risk of CLL/SLL among males in PLCO (3rd vs. 1st tertile: OR, 2.21; 95% CI, 1.03-4.72; Ptrend: 0.049) and pooled (T3 vs. T1: OR, 3.12; 95% CI, 1.72-5.68; Ptrend: 0.0002). Association was stronger among male smokers (Ptrend: <0.0001) and essentially identical for cases diagnosed <6, >6-8, and >8 years from blood draw (pooled: Pinteraction: 0.65). mtDNA CN and risk of other NHL subtypes and multiple myeloma showed no association. Mitochondrial DNA CN was associated with risk of CLL/SLL in males/male smokers. The risk was observed among cases diagnosed as long as 8 years after blood draw. These results suggest that higher mtDNA CN may reflect a process involved in CLL/SLL development.