Course Of Chronic Lymphocytic Leukemia Research Articles

Association of Genetic Variants at the CDKN1B and CCND2 Loci Encoding p27Kip1 and Cyclin D2 Cell Cycle Regulators with Susceptibility and Clinical Course of Chronic Lymphocytic Leukemia.

Beyond the essential role of p27Kip1 and cyclin D2 in cell cycle progression, they are also shown to confer an anti-apoptotic function in peripheral blood (PB) lymphocytes. Although the aberrant longevity and expression of p27Kip1 and cyclin D2 in leukemic cells is well documented, the exact mechanisms responsible for this phenomenon have yet to be elucidated. This study was undertaken to determine the associations between polymorphisms in the CDKN1B and CCND2 genes (encoding p27Kip1 and cyclin D2, respectively) and susceptibility to chronic lymphocytic leukemia (CLL), as well as their influence on the expression of both cell cycle regulators in PB leukemic B cells and non-malignant T cells from untreated CLL patients divided according to the genetic determinants studied. Three CDKN1B single-nucleotide polymorphisms (SNPs), rs36228499, rs34330, and rs2066827, and three CCND2 SNPs, rs3217933, rs3217901, and rs3217810, were genotyped using a real-time PCR system. The expression of p27Kip1 and cyclin D2 proteins in both leukemic B cells and non-malignant T cells was determined using flow cytometry. We found that the rs36228499A and rs34330T alleles in CDKN1B and the rs3217810T allele in the CCND2 gene were more frequent in patients and were associated with increased CLL risk. Moreover, we observed that patients possessing the CCND2rs3217901G allele had lower susceptibility to CLL (most pronounced in the AG genotype). We also noticed that the presence of the CDKN1Brs36228499CC, CDKN1Brs34330CC, CDKN1Brs2066827TT, and CCND2rs3217901AG genotypes shortened the time to CLL progression. Statistically significant functional relationships were limited to T cells and assigned to CDKN1B polymorphic variants; carriers of the polymorphisms rs34330CC and rs36228499CC (determining the aggressive course of CLL) expressed a decrease in p27Kip1 and cyclin D2 levels, respectively. We indicate for the first time that genetic variants at the CDKN1B and CCND2 loci may be considered as a potentially low-penetrating risk factor for CLL and determining the clinical outcome.

Monocytosis Developing in the Course of Chronic Lymphocytic Leukemia: Case Report

Monocytosis Developing in the Course of Chronic Lymphocytic Leukemia: Case Report

CLL-256 Monocytosis Developing in the Course of Chronic Lymphocytic Leukemia: Case Report

CLL-256 Monocytosis Developing in the Course of Chronic Lymphocytic Leukemia: Case Report

The role of P53 gene and p53 protein in non-Hodgkin malignant lymphoma.

TPS177 Background: Background and study aim P53 gene mutations are the most common genetic abnormalities of cancer. They have been extensively studied in various mature B-cell malignancies, including chronic lymphocytic leukemia (CLL). In recent years, more attention has been paid to the importance of the p53-expressed protein in CLL, and a combination with low survival and non-response to classical conventional chemotherapy, due to mutations in the p53 gene, with progression to Richter Syndrome. Identifying different p53 gene mutations is very important because these mutations have an impact on the patient's clinical course in CLL. Methods: The frequency of p-53 protein expression in 85 patients diagnosed with CLL was analyzed by the Enzyme-Linked Immune-Absorbent Assay (ELISA) technique to investigate the relationship of this protein to the stage of the disease, as well as the impact on response to treatment and survival. Cell extracts 10³×10³/L in 100 μl lysis buffer were applied to ELISA plates coated with PAb 240 capture antibody. Clinical trial information: ISRCTN12539707 .

The diversity of the microbiome impacts chronic lymphocytic leukemia development in mice and humans.

The gut microbiota plays a critical role in maintaining a healthy human body and its dysregulation is associated with various diseases. In this study, we investigated the influence of gut microbiome diversity on the development of chronic lymphocytic leukemia (CLL). Analysis of stool samples from 59 CLL patients revealed individual and heterogeneous microbiome compositions, but allowed for grouping of patients according to their microbiome diversity. Interestingly, CLL patients with lower microbiome diversity and an enrichment of bacteria linked to poor health suffered from a more advanced or aggressive form of CLL. In the Eµ-TCL1 mouse model of CLL, we observed a faster course of disease when mice were housed in high hygiene conditions. Shotgun DNA sequencing of fecal samples showed that this was associated with a lower microbiome diversity which was dominated by Mucispirillum and Parabacteroides genera in comparison to mice kept under lower hygiene conditions. In conclusion, we applied taxonomic microbiome analyses to demonstrate a link between gut microbiome diversity and the clinical course of CLL in humans, as well as the development of CLL in mice. Our novel data serve as a basis for further investigations to decipher the pathological and mechanistic role of intestinal microbiota in CLL development.

Integrative NGS testing reveals clonal dynamics of adverse genomic defects contributing to a natural progression in treatment-naïve CLL patients.

Large-scale next-generation sequencing (NGS) studies revealed extensive genetic heterogeneity, driving a highly variable clinical course of chronic lymphocytic leukaemia (CLL). The evolution of subclonal populations contributes to diverse therapy responses and disease refractoriness. Besides, the dynamics and impact of subpopulations before therapy initiation are not well understood. We examined changes in genomic defects in serial samples of 100 untreated CLL patients, spanning from indolent to aggressive disease. A comprehensive NGS panel LYNX, which provides targeted mutational analysis and genome-wide chromosomal defect assessment, was employed. We observed dynamic changes in the composition and/or proportion of genomic aberrations in most patients (62%). Clonal evolution of gene variants prevailed over the chromosomal alterations. Unsupervised clustering based on aberration dynamics revealed four groups of patients with different clinical behaviour. An adverse cluster was associated with fast progression and early therapy need, characterized by the expansion of TP53 defects, ATM mutations, and 18p- alongside dynamic SF3B1 mutations. Our results show that clonal evolution is active even without therapy pressure and that repeated genetic testing can be clinically relevant during long-term patient monitoring. Moreover, integrative NGS testing contributes to the consolidated evaluation of results and accurate assessment of individual patient prognosis.

Predicting Stage Progression in Binet Stage a Chronic Lymphocytic Leukemia.

The variable clinical course of chronic lymphocytic leukemia (CLL) and the lack of consensus on follow-up and treatment strategies have necessitated a prognostic model for identifying high-risk patients at the time of diagnosis. We involved a retrospective analysis of demographic and clinical characteristics of 212 patients diagnosed with Binet stage A CLL and thus eligible for risk stratification by both the International Prognostic Score for Early-stage CLL (IPS-E) and the alternative IPS-E (AIPS-E). We evaluated the applicability of these prognostic indices in our young, Middle Eastern cohort (median age 59 at diagnosis). During the study period with a median follow-up of 3.5 years, 67 patients (32 %) experienced progression to first treatment and cumulative incidence of treatment was 13 % at 1 year and 28 % at 3 years after diagnosis. Sixty-nine (51 % of the 136 with a known value) patients harbored an unmutated immunoglobulin heavy chain gene (IGHV) and 21 (10 %) an 11q or 17p deletion with 11 % lacking FISH results. For each early-stage CLL prognostic index, more patients were identified as high-risk for disease progression (51 % of 124 patients evaluable for IPS-E; 42 % of 109 patients evaluable for AIPS-E) than intermediate-risk and low-risk. Multivariable models involving the IPS-E and AIPS-E components revealed that unmutated IGHV and elevated absolute lymphocyte count were significant predictors of earlier treatment requirement. Both prognostic scores were discriminative of time to first treatment (log-rank p < 0.001; c-statistics of 0.74 for IPS-E and 0.69 for AIPS-E). Although clarity on clinical behavior with regard to initiation of treatment remains elusive, IPS-E and AIPS-E are valuable tools for identifying high-risk patients.

New Prognostic Indicators in CLL: Relation to Disease Burden

Abstract Background Identifying prognostic markers is important for the clinical and pathological course of chronic lymphocytic leukemia (CLL). Cluster of differentiation CD49d expression and percentage of smudge cells in CLL patients have recently been reported as newer prognostic factor. Aim of the Study To estimate CD49d expression as an independent prognostic marker in CLL patients and to investigate its relation to the known prognostic factors Methods Thirty adults with CLL were enrolled. Smudge cells percentage was calculated by microscopic evaluation of blood smears. Testing of cluster of differentiation CD49d expression was done by flowcytometry and detection of ataxia telangiectasia mutated (ATM) gene, protein 53(P53) gene deletions and trisomy 12 were performed using fluorescent in situ hybridization (FISH). Results CD49d expression was associated with lymphadenopathy, splenomegaly, advanced staging, high total leucocytic count, immunophenotyping scoring, CD38 positivity, short LDT, low smear cell percentage, and presence of p53 deletion. Low percentage of Smear cell (&amp;lt;30%) showed a significantly higher incidence of lymphadenopathy and organomegaly. Additionally, it was associated with a high total leucocytic count, low platelet count, high atypical lymphocytic count and typical IPT scoring, shorter LDT, positive CD38 expression and CD49d expression and ATM and P53 deletions. Conclusion CD49d expression and low smudge cell percent were consistently associated with poor prognostic indicators, suggesting that they could be considered as adverse predictors and they should be merged together to improve the power of the prognostic panels of CLL in the clinical setting.

NOTCH1 mutation in chronic lymphocytic leukaemia is associated with an enhanced cell cycle G1/S transition and specific cyclin overexpression: Preclinical ground for targeted inhibition.

Studies prior to next-generation sequencing (NGS) showed that the frequent indolent course of chronic lymphocytic leukaemia (CLL) is related to most cells remaining quiescent in the G0 -G1 cell cycle phase, due to the expression of dysregulated cyclin genes. Of note, the activating nature of the NOTCH1 mutation in T lymphoblastic leukaemia also drives the dysregulation of cell cycle genes. Our goal was to comprehensively revisit the cell cycle in NOTCH1-mutated CLL (NOTCH1MUT ) to test for potential therapeutic targets. Among 378 NGS-annotated CLL cases, NOTCH1MUT cells displayed a unique transcriptome profile of G0 -G1 cell cycle components, with an overexpression of early-phase effectors, reaching a 38-, 27- and ninefold change increase for the complex elements CCND3, CDK4 and CDK6, respectively. This NOTCH1MUT cells' profile was related to more cells traversing through the cell cycle. In-vitro targeted inhibition of NOTCH1 gamma-secretase and CDK4/6 reversed the distribution of cells through the cycle phases and enhanced the killing of NOTCH1MUT CLL cells, suggesting new therapeutic approaches.

FISH Analysis of CDKN2A/B Deletion in Chronic Lymphocytic Leukemia

Introduction: The course of chronic lymphocytic leukemia (CLL) ranges from indolent to rapid disease progression, including transformation to an aggressive lymphoma (Richter transformation, RT). A subset of CLL pts have been shown to acquire deletions of the tumor suppressor CDKN2A/B. RT has been associated with deletion of CDKN2A/B, however, prior studies’ sample populations were limited or not primarily focused on those with this deletion. Due to the rarity of this genetic abnormality in CLL and severity of RT, additional studies concerning this subgroup should be investigated. Here, we examine a larger cohort of CLL pts with CDKN2A/B deletion by fluorescence in situ hybridization (FISH) to provide further clarity on this genetic lesion. Methods: We conducted a retrospective case study for all pts for whom cytogenetic clinical samples were submitted for extended CLL FISH panel analysis over a 3.5 year (yrs) period, between 2015 and 2018 at The Ohio State University. Pts were screened for CDKN2A/B deletion with a new or follow up diagnosis of CLL or small lymphocytic lymphoma (SLL). Cytogenetic testing was performed on cells stimulated with pokeweed mitogen, phorbol myristate acetate (PMA), and CpG oligonucleotides. FISH for D13S319, D12Z3, ATM, TP53, BCL6, MYC, REL, SEC63, MYB, and CDKN2A/B was performed via manufacturer's recommendations. IGHV mutational status was determined using PCR. A 50-gene hematologic sequencing panel was performed via Ion Torrent. Overall survival (OS) from first detection of abnormal CDKN2A/B results were examined. Cox regression model was used to evaluate OS post CDKN2A/B deletion. The Fine and Gray Model was used to examine correlation of variables with regard to RT, treating death without RT as a competing risk. Results: 636 pts had sample(s) submitted for extended CLL FISH panel analysis. Of these, 43 (6.8%) pts with confirmed CLL or SLL were found to have loss of CDKN2A/B by FISH, including 6 pts within one year of diagnosis. Median age at diagnosis was 54.9 yrs (range 41.9-77.7). Loss of CDKN2A/B was detected at a median of 7.8 yrs (range diagnosis-26.1) from diagnosis. Of those with known IGHV status (n=33), 91% were unmutated. A complex karyotype (>3 clonal chromosomal abnormalities) was found in 90% percent of pts. In regard to CDKN2A/B deletion, 77%, 16%, and 7% of pts had heterozygous, homozygous, or subclonal populations of heterozygous as well as homozygous loss, respectively. Additional FISH testing showed 23% had gain of REL, 16% had BCL6 gain/rearrangement, 16% had deletion 6q, 37% had gain/rearrangement of MYC, 16% had loss of ATM, 14% had trisomy 12, and 58% had deletion 13q. Deletion of TP53 was seen in 63%. Sequencing data was available for 15 pts (35%), of note, 10 pts had mutations in TP53, with 4 also having mutations in SF3B1. In terms of OS, there were 30 deaths in the cohort, with median OS of 10.8 yrs from diagnosis (95% CI 8.0-14.4). With a median follow-up of 4.9 yrs among survivors, the median OS from time of detection of CDKN2A/B deletion was 1.7 yrs (95% CI 0.3-4.7). Multivariable analysis of OS post CDKN2A/B detection was significant for increasing beta-2-microglobulin measured at first visit at our institution (p=0.0044, hazard ratio (HR) 1.32 (95% CI 1.09-1.60)) and CDKN2A/B subclonal heterozygous and homozygous loss (p=0.0024, HR 9.81 (95% CI 2.25-42.73)). Of the 43 pts with loss of CDKN2A/B, 21 (49%) progressed via RT (n=20) or prolymphocytic leukemia (PLL) (n=1). The Cumulative Incidence Rate of RT development 12-months post CDKN2A/B deletion was 23.5% (95% CI 10.9-38.9), at 24-months, it was 29.4% (15.1-45.3). Deletion of TP53 was seen in 85.7%. Albeit there was limited pts with detection of CDKN2A/B deletion prior to RT, the multivariable model for RT found loss of TP53 (p=0.02, HR 4.53 (95% CI 1.33-15.43)) and homozygous and heterozygous loss of CDKN2A/B (p=0.0008, HR 6.08 (95% CI 2.13-17.39)) were independently significant. Conclusion: Here we show that deletion of CDKN2A/B in CLL is a very rare occurrence and was seen predominantly in pts with highly aggressive disease characteristics. Close to half of our cohort progressed with RT or PLL. Additional investigation of serial samples is needed to establish when CDKN2A/B deletion occurs relative to RT. Our results indicate that prospective FISH analysis for CDKN2A/B deletion, in conjunction with other high-risk genetic alterations, to establish RT prognostication in high-risk CLL is warranted.

ASSOCIATION OF THE FREQUENCY OF SF3B1 GENE MUTATIONS IN CHRONIC LYMPHOCYTIC LEUKEMIA PATIENTS WITH THE STRUCTURE OF THE B-CELL RECEPTOR

Introduction. The course of chronic lymphocytic leukemia (CLL) varied from indolent to rapidly progressive. Stratification of CLL patients into risk groups is based on the stage of disease, the mutational status of immunoglobulin variable region genes (IGHV genes), and mutations of ТР53, NOTCH1, and SF3B1 genes. The frequency of SF3B1 gene mutations increases significantly in the progression of CLL. Aim: to determine the group of CLL patients with increased risk of developing SF3B1 mutations. Material and methods. Analysis was performed on the group of 261 CLL patients. The SF3B1 mutations and IGHV gene mutational status were studied by polymerase chain reaction (PCR) followed by direct sequencing. Results. SF3B1 mutations were identified in 30 patients (11.5%). The frequency of mutations did not differ among primary patients (8.6%) and patients examined before the start of the first line of therapy (9.9%) but increased in relapsed patients (23.8%), p = 0,01. In cases with the expression of IGHV3-21, IGHV3-30, IGHV4-59, and IGHV4-61 genes, regardless of their mutational status, the risk of developing SF3B1 mutations increased 4.97 times (95% CI = 2.21–11.19; p = 0.000047). In addition, stereotypy of the B-cell receptor (cluster #2), the risk of SF3B1 gene mutations increased in 8.65 times (95% CI = 1.66–45.05; p = 0.0027). Conclusion. The expression of individual IGHV genes and the configuration of the B-cell receptor are significant measure the probability of occurrence of SF3B1 gene mutations. Key words: chronic lymphocytic leukemia, SF3B1 gene mutations, IGHV genes, B-cell receptor stereotype

Features of the course of chronic lymphocytic leukemia in the presence of a genetic mutation of leukemia cells: 17p13 deletion and its impact on disease prognosis.

e19515 Background: In order to identify the features of the course of the disease in patients with chronic lymphocytic leukemia (CLL) when prescribing standard polychemotherapy (PCT) according to the RFC scheme (rituximab, fludarabine, cyclophosphamide) we investigated chromosomal aberrations in leukemia cells. Methods: We observed 190 patients (aged 57.4±23.7 years, 87 men, 103 women). Cytogenetic studies were conducted. Clinical and hematological remission was evaluated. Results: 52% of patients had single chromosomal aberrations, 25% - double, 23% - complex. A deletion of 17p13 (del (17p13)) with a level on leukemia cells from 2 to 98% in the period from the moment of CLL diagnosis of 11.8±7.2 months was found in 85 people (44.7%), with a level of more than 15% - in 24 (12.6%), of which with a level of 21% - 98% - in 12 (6.3%). During standard PCT according to the RFC scheme, among 44 patients with a level of cells with del (17р13) less than 15%, when controlled after 12 months, 12 (37.5%) showed an increase in the number of these cells to an average of 22.5%, which correlated (p &lt; 0.1) with early relapses of the disease and the formation of secondary resistance to cytostatic treatment; in 20, there was no correlation between an increase in the number of cells and progression (partial remission (PR) was achieved); in 12 patients, cells with del (17p13) were not detected, and patients were characterized by the achievement of complete clinical and hematological remission (CR), which indicates the effectiveness of the FCR scheme in most patients. In 12 patients with the level of cells with del (17p13) 21% - 98%, no statistically significant increase in them was detected after 12±3 months (p &gt; 0.15), however, remission was not achieved. They were treated with ibrutinib. Among the 8 patients with a recurrent course while taking ibrutinib at a dose of 420 mg per day for 2 to 4 years, severe infections were observed in the first months of therapy; in 4 patients the number of infectious episodes reduced later. 4 achieved PR (50%), 3 - PR (37.5%), 1 - stabilization. Conclusions: Thus, the level of blood cells with del (17p13) less than 15% in patients with CLL does not determine the severity of the disease and sensitivity to cytostatic treatment. These patients in the first line of chemotherapy are indicated for R, which, as a rule, does not cause irreversible elimination of cells with del (17p13), but slows down the growth of the tumor clone. This may determine the achievement of longer CR and PR and lead to a significant improvement in the long-term prognosis of the disease, and therefore the widely used RFC chemotherapy for B-CLL remains effective in most primary and pretreated patients. The detection of forms with a 17p13 deletion in an amount of more than 15% among tumor leukemia cells makes it possible to select a group of patients for prescribing ibrutinib, the overall response rate in which was 87.5%.

Structure and prognostic signifi cance of 13q14 deletion in chronic lymphocytic leukemia

Introduction. 13q14 deletion is the most common chromosomal abnormality in chronic lymphocytic leukemia (CLL), and as the sole abnormality determines the most favorable prognosis of the disease. Using molecular genetic methods two subtypes of 13q14 deletion were identifi ed based on the size of the lost chromosomal material: small (type I) with the involvement of the D13S319 segment containing MIR15A/MIR16-1 and DLEU1 genes and large (type II) containing centromeric region of 13q14 involving RB1 gene. Data on the impact of type I and II deletions on the course of CLL are controversial.Aim — to evaluate the prognostic signifi cance of different variants of 13q14 deletion in CLL.Patients and methods. The study enrolled two cohorts of CLL patients. Cohort 1: 256 patients who were studied by FISH with DNA probes for detection of 13q14/D13S319, 11q23/ATM, 17p13/TP53 deletions, and trisomy 12 before immunochemotherapy. 101 patients with identifi ed 13q14/D13S319 deletion were analyzed with a DNA probe for RB1 locus for determination of deletion size (type I or type II). Cohort 2: 28 patients at different stages of the disease with deletion 13q14 detected by FISH were studied by using combination of standard and molecular cytogenetic methods (mFISH, mBAND, arrayCGH) to clarify the structure of 13q abnormalities.Results. In Cohort 1 chromosomal aberrations were detected in 75 % of patients: 13q deletion — 52 % (isolated — 36 % of all cases and 48 % of cases with deletion), 11q deletion — 19 %, +12 — 13 %, 17p deletion — 6 %. 13q14 deletion type I was detected in 56 %, type II — in 44 % of patients. Type II deletion correlated with the presence of 11q deletion (p = 0.05). Isolated deletions of type I and II were found in 61 and 39 %, respectively. Biallelic deletion was identifi ed in 12.7 % of patients with 13q deletion. Statistically signifi cant differences in OS were obtained in type I and II groups of patients with isolated 13q14 deletions: median OS was not reached and made 67.5 months, respectively, p = 0.05. In Cohort 2 structural abnormalities of chromosome 13 by conventional cytogenetic analysis (CCA) were identifi ed in 50 % of cases: 13q deletion — 11 cases; translocations involving 13q14 — 6 cases. In 5 cases with biallelic deletion identifi ed by FISH, 13q14 deletion by CCA was detected in two patients, and only in one allele.Conclusion. In general, 13q14 deletion is a cytogenetic factor of favorable prognosis for CLL but its structure is heterogeneous. Loss of tumor suppressor RB1 (type II deletion) negatively affects OS in patients treated with immunochemotherapy

CD34+ cell of origin for immunoglobulin heavy chain variable region unmutated, but not mutated, chronic lymphocytic leukemia

The clinical course of chronic lymphocytic leukemia (CLL) is highly variable. Immunoglobulin heavy chain variable region (IgHV) mutation status is among the most important prognostic factors, with unmutated IgHV associated with inferior outcomes. CLL presumably arises from mature B cells. However, we hypothesized that IgHV unmutated CLL could arise early in B cell differentiation. We prospectively studied 29 patients with mutated and 88 with unmutated IgHV CLL for the presence of CD34+CD19+ cells harboring CLL chromosomal abnormalities. CD34+CD19+ cells were never detected in mutated CLL. In contrast, a small but distinct population of CD34+CD19+ cells harboring the CLL chromosomal abnormality was present in 86/88 patients with unmutated IgHV across all cytogenetic subtypes. Moreover, the CD34+CD19+ cells generated a 3.8 ± 0.7 fold CLL cell expansion over 3–4 weeks in cultures containing IL-3 and IL-2. Unmutated IgHV CLL appears to arise in CD34+ B cells, which perhaps contributes to its poorer prognosis.

Dynamic Bayesian networks for prediction of health status and treatment effect in patients with chronic lymphocytic leukemia

Chronic lymphocytic leukemia (CLL) is the most common blood cancer in adults. The course of CLL and patients' response to treatment are varied. This variability makes it difficult to select the most appropriate treatment regimen and predict the progression of the disease. This work was aimed at developing and validating dynamic Bayesian networks (DBNs) to predict changes of the health status of patients with CLL and progression of the disease over time. Two DBNs were developed and implemented i.e. Health Status Network (HSN) and Treatment Effect Network (TEN). Based on the literature data and expert knowledge we identified relationships linking the most important factors influencing the health status and treatment effects in patients with CLL. The developed networks, and in particular TEN, were able to predict probability of survival in patients with CLL, which was in line with the survival data collected in large medical registries. The networks can be used to personalize the predictions, taking into account a priori knowledge concerning a particular patient with CLL. The proposed approach can serve as a basis for the development of artificial intelligence systems that facilitate the choice of treatment that maximizes the chances of survival in patients with CLL.

Expression of CTLA-4 and CD86 Antigens and Epstein-Barr Virus Reactivation in Chronic Lymphocytic Leukemia-Any Link with Known Prognostic Factors?

Simple SummaryChronic lymphocytic leukemia (CLL) accounts for one-third of all leukemias. The Epstein-Barr virus (EBV) has the ability to transform B-cells into cancer cells. A history of EBV infection increases the chances of acquiring CLL and it worsens the prognosis in CLL. We tried to assess whether EBV affects the course of CLL by deregulating the CTLA-4/CD86 pathway. The expression of CTLA-4 and CD86 on immune cells in patients with CLL has been evaluated and linked to indicators of EBV infection and clinical outcomes. Our studies have shown that anergy, which is expressed by inhibition through the interaction of CTLA-4 and CD86, is an important mechanism leading to the inhibition of the antitumor response and CLL progression.Infection with Epstein-Barr virus (EBV) worsens the prognosis in chronic lymphocytic leukemia (CLL), but the underlying mechanisms are not yet established. We intended to assess whether EBV affects the course of CLL by the deregulation of the CTLA-4/CD86 signaling pathway. We used polymerase chain reaction to measure the load of EBV DNA in the blood of 110 newly diagnosed patients with CLL. The expression of CTLA-4 and CD86 antigen on lymphocytes was assessed with flow cytometry. Additionally, CTLA-4 and CD86 serum concentrations were measured through enzyme-linked immunosorbent assays. Fifty-four percent of the patients had detectable EBV DNA [EBV(+)]. In EBV(+) patients the CTLA-4 and CD86 serum concentrations and their expressions on investigated cell populations were significantly higher than in EBV(−) patients. EBV load correlated positively with unfavorable prognostic markers of CLL and the expression of CTLA-4 on CD3+ lymphocytes (r = 0.5339; p = 0.027) and CD86 on CD19+ cells (r = 0.6950; p < 0.001). During a median follow-up period of 32 months EBV(+) patients were more likely to require treatment or have lymphocyte doubling (p < 0.001). Among EBV(+) but not EBV(−) patients, increased expressions of CTLA-4 lymphocytes were associated with elevated risks of progression. We propose that EBV coinfection may worsen prognosis in CLL patients, partly due to EBV-induced up-regulation of CTLA-4 expression.

Treatment Approaches to Chronic Lymphocytic Leukemia With High-Risk Molecular Features.

The clinical course of chronic lymphocytic leukemia (CLL) is highly variable. Over the past decades, several cytogenetic, immunogenetic and molecular features have emerged that identify patients suffering from CLL with high-risk molecular features. These biomarkers can clearly aid prognostication, but may also be capable of predicting the efficacy of various treatment strategies in subgroups of patients. In this narrative review, we discuss treatment approaches to CLL with high-risk molecular features. Specifically, we review and provide a comprehensive overview of clinical trials evaluating the efficacy of chemotherapy, chemoimmunotherapy and novel agent-based treatments in CLL patients with TP53 aberrations, deletion of the long arm of chromosome 11, complex karyotype, unmutated IGHV, B cell receptor stereotypy, and mutations in NOTCH1 or BIRC3. Furthermore, we discuss future pharmaceutical and immunotherapeutic perspectives for CLL with high-risk molecular features, focusing on agents currently under investigation in clinical trials.

Routine Follow-up Visits for Chronic Lymphocytic Leukemia Managed Initially By Watch and Wait Rarely Lead to Interventions: A North Denmark Population-Based Study

The clinical course of chronic lymphocytic leukemia (CLL) is highly variable. Most patients are diagnosed at an early, asymptomatic disease stage without immediate need of treatment, and therefore initially managed by “watch and wait” (WAW). The aim of this study was to investigate the value of routine follow-up visits for CLL patients managed by WAW.A total of 305 patients with newly diagnosed CLL were identified during the surveyed time period (2007-2014). Thirty-one patients were excluded due to treatment-initiation within 90 days of diagnosis, which left a total of 274 (90%) patients, initially managed by WAW, for further analyses (Table 1). Each patient underwent allocation into a low- or high-risk CLL group. The low-risk group (Binet stage A, mutated IgVH, and normal cytogenetics/13q-) constituted 59% of patients, while the high-risk group (Binet stage B/C, and/or unmutated IgVH, and/or trisomy 12/11q-/17p) included the remaining 41% of patients.The total number of follow-up visits conducted during the study period was 2,335 and detailed information from each was collected, including clinical and laboratory findings (CLL-symptoms, physical examination findings, and blood values: hemoglobin, LDH, thrombocyte- and leukocyte count) and interventions . Interventions occurred at 388 (17%) follow-up visits and were defined as follows (including overall frequency): biopsy (lymph node or bone marrow, (1%)), image diagnostics (X-ray (0.4%), ultrasound (1%), or CT-scan (2%)), additional blood tests (3%), CLL-related therapy (2%), increased frequency of blood tests (5%) and increased frequency of follow-up visits (9%).Interventions were prompted by the following clinical and laboratory findings (including proportions and overall frequency): symptoms (31 (8%)), physical findings (15 (4%)), abnormal blood values (87 (22%), symptoms & physical findings (8 (2%)), symptoms & abnormal blood values (101 (26%)), physical findings & abnormal blood values (59 (15%)), symptoms, physical findings, & abnormal blood values (51 (13%)), and no obvious reported symptoms, physical findings, & abnormal blood values present (36 (9%)).The median follow-up time was 3.1 years. The mean interval between outpatient routine follow-up visits was 123 days (~3.9 months), with observed difference between high-risk (109 days (~3.3 months)) and low-risk patients (134 days (~4.3 months), P= 0.039). We analyzed the time from diagnosis to first intervention, and found a 38% risk of having first intervention during the initial year after diagnosis, 16% during the second year, 8% during the third year, and 15% between 4 and 6 years after diagnosis. Within the study period, 76 (28%) patients initiated CLL-directed treatment, with high-risk patients having a significantly higher risk of receiving treatment (P < 0.001), whereas 63 (23%) patients died (27 deaths occurred before CLL treatment).The risk of undergoing at least one intervention within 2 years of diagnosis was 54% (95% CI: 47-60), while the risk of receiving treatment within 2 years was 21% (95% CI: 16-27). Given that patients did not undergo an intervention nor receive treatment within the first year after diagnosis, the risk of receiving an intervention within the following 2 years dropped to 42% (95% CI: 33-51, Figure 1), while the risk of receiving treatment in that time frame was 14% (95% CI: 7-20). The corresponding risk of treatment within the following 2 years, for patients undergoing one or more interventions during the first year, was 31% (95% CI: 20-43, P= 0.001 for comparison with no intervention, Figure 2). After adjustment for risk group, using a stratified version of Gray's test, the risk of receiving treatment remained higher in the group that had one or more intervention within the first year after diagnosis (P= 0.048).In summary, this study demonstrates that routine follow-up visits in CLL rarely lead to clinical interventions. Only 17% of 2,335 visits led to an intervention with as little as 3% of routine visits resulting in CLL-directed treatment. Furthermore, patients that did not undergo interventions in the first year after CLL-diagnosis were less likely to receive CLL treatment in near future, suggesting that less intensive disease surveillance strategies can be pursued for this group. [Display omitted] DisclosuresEl-Galaly:Roche: Other: Travel funding; Takeda: Other: Travel funding.

Chronic Lymphocytic Leukemia Patient Reported Outcomes and Quality of Life: Findings from the Cancer Experience Registry

Background: Approximately 20,000 new cases of chronic lymphocytic leukemia (CLL) are expected in the US in 2017 (ACS 2017), yet understanding of the psychosocial consequences of CLL is inadequate. Many people with CLL undergo an active surveillance (“watch and wait”) treatment plan, which can pose unique challenges. The purpose of this exploratory study was to compare how CLL patients describe their quality of life compared to other US population groups and describe the extent to which CLL affects daily life, finances, and professional and family relationships.Methods: 134 individuals with CLL enrolled in the Cancer Support Community's online Cancer Experience Registry, provided sociodemographic information and clinical history, and completed surveys including the Patient-Reported Outcomes Measurement Information System (PROMIS-29v2.0), which assesses seven health-related quality of life domains. We used multiple linear regression analysis to examine the association between course of CLL (undergoing observation, currently receiving first treatment, currently receiving second or subsequent treatment, in remission or maintenance therapy) and PROMIS subscale T-scores adjusting for sociodemographic variables (age, gender, education, income).Results: The sample was 47% female, 96% White; mean age was 61 (SD=9) years; mean time since CLL diagnosis was 7 (SD=5) years. More than one-third (37%) were undergoing observation (“watch and wait”) before initiating any treatment, 6% were receiving their first treatment, 12% were in active second or subsequent therapy, and 29% in remission. 38% of CLL respondents described their overall health as very good or excellent, and 45% as good; 17% indicated fair or poor health. When considering individual responses, considerable proportions of CLL patients reported substantially worse quality of life (>1 SD) than U.S. population national averages for anxiety (21% of respondents), fatigue (21%), physical functioning (15%), social functioning (12%), depression (11%), sleep disturbance (9%) and pain interference (5%). Additionally, many respondents indicated that CLL “somewhat to very much” affected their views on life expectancy (62%), quality of life (41%), finances (40%), ability to work (34%), and relationships with friends and family (26%). All regression models predicting PROMIS subscales were significant (R2 = .13 to .20, ps < .05). With respect to CLL course, worse anxiety was significantly associated with active treatment, whether first line of therapy (B=8.0, p <.05) or subsequent therapy (B=6.2, p <.05). Currently receiving second or subsequent therapy was significantly associated with worse physical (B=−5.2, p <.05) and social functioning (B=−6.4, p <.05), and greater levels of fatigue (B=7.6, p <.01) and depression (B=5.1, p <.05). There was also a significant relationship between sleep disturbance and currently receiving second or subsequent treatment (B=5.7, p <.01). No significant associations were found between observation (“wait and wait”) status or disease remission and quality of life outcomes.Conclusion: Over one-fifth (21%) of CLL survivors are experiencing substantial levels of anxiety and fatigue, compared to the general U.S. population. Poorer health-related quality of life was associated with active treatment but not active surveillance (“watch and wait”) or when disease was in remission. It remains unclear the extent to which advancing disease versus treatment contributes to worse quality of life. Next steps include further examination of factors that put CLL patients at greater risk for poorer outcomes and the evaluation of interventions designed to address emotional distress and quality of life concerns, especially among people with progressing disease. DisclosuresBuzaglo:Takeda Oncology: Research Funding; Pharmacyclics, Inc: Research Funding; Pfizer Oncology: Research Funding; Novartis: Research Funding; Janssen Biotech, Inc: Research Funding; Genentech, Inc: Research Funding; Eli Lilly and Company: Research Funding; Celgene Corporation: Research Funding; Bristol-Myers Squibb: Research Funding; Boehringer Ingelheim: Research Funding; AbbVie: Research Funding; Amgen Corporation: Research Funding; Bayer: Research Funding. Flowers:Burroughs Welcome Fund: Research Funding; Janssen Pharmaceutical: Research Funding; Infinity: Research Funding; TG Therapeutics: Research Funding; V Foundation: Research Funding; Celgene: Consultancy, Research Funding; OptumRx: Consultancy; Educational Concepts: Research Funding; Prime Oncology: Research Funding; Millennium/Takeda: Research Funding; Genentech/Roche: Consultancy, Research Funding; Onyx: Research Funding; Research to Practice: Research Funding; Pharmacyclics LLC, an AbbVie Company: Research Funding; Bayer: Consultancy; National Institutes Of Health: Research Funding; Seattle Genetics: Consultancy; Gilead: Consultancy; Abbvie: Consultancy, Research Funding; Acerta: Research Funding; Eastern Cooperative Oncology Group: Research Funding; Clinical Care Options: Research Funding; National Cancer Institute: Research Funding; Spectrum: Consultancy.

A Retrospective Analysis of 450 TP53 Mutations in a Real Life Cohort of CLL from the French Innovative Leukemia Organization (FILO) Group

A Retrospective Analysis of 450 TP53 Mutations in a Real Life Cohort of CLL from the French Innovative Leukemia Organization (FILO) Group