Small Lymphocytic Lymphoma Patients Research Articles

Are small lymphocytic lymphoma and chronic lymphocytic leukemia the same disease? The unsolved dilemma

The management of small lymphocytic lymphoma (SLL) as chronic lymphocytic leukemia (CLL) or an indolent non-Hodgkin lymphoma is highly debated. In this single-center, real-life study, 38 SLL patients managed between 2008 and 2022 were evaluated. Overall, 26/38 cases (68.4%) needed treatment and all but one received CLL concordant therapy, including BR (9/38 cases), fludarabine, cyclophosphamide, rituximab (5/38 cases), rituximab and chlorambucil (4/38 cases), BTK inhibitors (7/38 cases) and steroid (1 case with immune thrombocytopenia). Patients treated between 2008 and 2018 were more likely to receive chemoimmunotherapy compared to patients treated in 2019-2022, that were more likely to receive BTK inhibitors. The median PFS was 54 months and 3-y PFS was 58%, while the median OS was not reached, with a 3-y OS of 84%. We confirm a wide heterogeneity in SLL management and we suggest prospective studies are needed to improve the knowledge of its biology and harmonize its treatment.

Outcomes of Patients with Small Lymphocytic Lymphoma (SLL) Receiving First Line Treatment

INTRODUCTION Chronic lymphocytic leukemia (CLL) and SLL represent a single entity in current classifications per the WHO-HAEM5 and ICC. Both are characterized by malignant B cells with an identical immunophenotype, but they are distinguished by the predominant site of disease burden, such as peripheral blood for CLL and nodal compartments for SLL. Most clinical trials and retrospective studies involving CLL/SLL do not separate out SLL patients. In this study, we report reasons for treatment initiation and outcomes in a cohort of SLL patients seen at our institution. METHODS Using the Mayo Clinic CLL Database, we retrospectively identified patients with SLL who received first line therapy between 12/1995 and 2/2023. Patients were classified as having SLL if they met at least one of the following criteria for diagnosis: 1) presence of lymphadenopathy or splenomegaly (either by exam or scans) and an absolute clonal B cell count of < 5 x 109/L; or 2) presence of lymphadenopathy or splenomegaly (either by exam or scans) and an absolute lymphocyte count of < 11 x 109/L (if absolute clonal B cell count was not available). Although the presence of anemia (hemoglobin < 11 g/dL) and thrombocytopenia (platelets < 100 x 109/L) are considered as exclusion criteria for a diagnosis of SLL, patients were included if these cytopenia were due to autoimmune hemolytic anemia (AIHA) or immune thrombocytopenia (ITP) with < 50% bone marrow involvement by SLL (bone marrow biopsy confirmed). Patients treated for SLL with extranodal involvement were also included. Indications for SLL treatment were abstracted by chart review and included one of the following: 1) symptomatic or progressive lymphadenopathy and/or splenomegaly, 2) autoimmune cytopenias, 3) extranodal/direct organ infiltration; and 4) other (e.g., cryoglobulinemia, paraneoplastic, non-infiltrative renal disease such as minimal change disease). Overall survival (OS) was defined as the time from treatment start until date of death or last known to be alive. Treatment-free survival (TFS) was defined as the time from treatment start until the earliest of date of next treatment, or death. Kaplan-Meier method was used to display OS and TFS. Cox proportional hazards regression models were used to estimate associations of factors with time-to-event outcomes. RESULTS We identified 182 patients with SLL who received first line treatment. The median age at treatment start was 66 years, and 132 (73%) were male. Unmutated IGHV was identified in 60/82 (73%) patients and peripheral blood fluorescent in situ hybridization (FISH) assessed pre-treatment start showed del13q in 10%, trisomy 12 in 43%, del11q in 7%, del17p in 8%, and no abnormalities in 33%. TP53 disruption (del17p and/or TP53 mutation) was present in 7/89 (8%) patients prior to first therapy. The median follow-up after diagnosis was 6.9 years. The indications for treatment were grouped as follows: symptomatic or progressive lymphadenopathy/splenomegaly (n=130), extranodal/direct organ infiltration (n=30), AIHA/ITP (n=10), and other (n=12). For the entire cohort, the median TFS was 2.9 years and the median OS was 12.3 years. The median TFS by the treatment indication groups were 3.3, 5.1, 1.6, and 5.3 years, respectively (Figure 1). The median OS by treatment indication groups were 11.1, 10.5, 8.8, and 19.9 years, respectively. Among the 160 patients with symptomatic or progressive lymphadenopathy/splenomegaly or extranodal disease, the treatments administered include: mAb alone (n=35), chemotherapy alone (n=33), chemoimmunotherapy (n=57), targeted agent (n=33; Bruton tyrosine kinase inhibitor [BTKi] based n=28; venetoclax-based n=3, BTKi + venetoclax n=2), and other (n=2). The median TFS by treatment groups were 2.4, 2.0, 3.8, and 6.0 years (Figure 2), respectively (excluding the small “other” subgroup of 2 patients). The median OS for these groups were 9.5, 9.7, 15.0, and not evaluable, respectively. Only older age at treatment start predicted for shorter TFS (HR 1.02; 95%CI 1.002-1.038; p=0.03) and shorter OS (HR 1.05; 95%CI 1.03-1.07; p<0.01). CONCLUSIONS In this study of patients with SLL who received therapy, the most frequent indications for treatment included symptomatic lymphadenopathy and/or splenomegaly, followed by extranodal disease. Trisomy 12 was the most frequently detected abnormality on peripheral blood FISH testing. Treatment with novel agents achieved durable TFS and OS.

Cerdulatinib Pharmacodynamics and Relationships to Tumor Response Following Oral Dosing in Patients with Relapsed/Refractory B Cell Malignancies: Results from a Phase I Dose Escalation Study

Preclinical studies suggest that the spleen tyrosine kinase (SYK) and Janus kinase (JAK) family members can contribute to both tumor intrinsic and microenvironment-derived survival signals. A dual inhibitor of these kinases (cerdulatinib) was therefore developed, and a phase I dose-escalation study was completed to understand tolerability and efficacy, and their relationship to pharmacokinetics (PK) and pharmacodynamics (PD). Here, we report on PK/PD relationships and associations with tumor response in patients from the phase I dose-escalation portion of the clinical trial (NCT01994382).Repeat CT scans were obtained from 6 patients with chronic lymphocytic leukemia (CLL) or small lymphocytic lymphoma (SLL), 12 patients with follicular lymphoma (FL), 12 patients with diffuse large B cell lymphoma, and 6 patients with mantle cell lymphoma. Meaningful clinical responses were observed in patients with CLL/SLL and FL, as previously reported (Hamlin et al, 2016); hence, the correlation between tumor response and PD markers was examined in these patient populations.Complete inhibition of SYK and JAK signaling pathways was achieved in whole blood of dosed patients at tolerated exposures. The level of target inhibition in blood correlated with serum cerdulatinib concentration, and the concentrations at which 50% inhibition was acheived (IC50) against B cell antigen receptor (BCR), interleukin (IL)-2, IL-4, and IL-6 signaling pathways ranged from 0.22-1.08 μM, depending on the phosphorylation event measured. Significant correlations were observed between inhibition of both SYK and JAK signaling pathways and tumor response, most notably the BCR and IL-4 signaling pathways. Serum markers of inflammation were also reduced following cerdulatinib administration, several of which significantly correlated with tumor response, including β-2 microglobulin, C-reactive protein, interferon γ-induced protein 10 (IP10), and macrophage inflammatory protein 3β (MIP3β). Of note, lymphocytosis was observed in CLL, SLL, and FL patients. Evidence of diminished tumor cell surface expression of CD69 and CD86, diminished CD5 expression (a negative regulator of BCR signaling), and enhanced C-X-C chemokine receptor type 4 (CXCR4) expression were observed in 2 patients with CLL, consistent with suppression of BCR and IL-4 signaling.Fresh tumor samples were obtained from the peripheral blood of 6 CLL patients treated with cerdulatinib, as well as archival tumor biopsies obtained from 4 FL patients and 1 MCL patient, which were submitted for next-generation sequencing. Clinical activity was observed in CLL patients bearing mutations to NOTCH1, ATM, p53, and KRAS, which are among the most frequently observed mutations in this disease. One of the responding patients bore a 17p deletion. Importantly, 2 patients with ibrutinib-relapsed CLL who progressed within the first cycle of therapy with cerdulatinib had 3 mutations in common: p53, EP300, and BTK (C481S). Genetic correlates in FL were more limited, with data on 4 patients, 3 of whom had evidence of tumor reduction and 1 which progressed. The 2 best responding patients with whom we have genetic information bore mutations to ZMYM3, KMT2D, FAT4, BCL2, BCL6, CD79B, and STAT6 . Lastly, strong clinical activity was observed in a transformed FL patient who presented with increased MYC, BCL2, and BCL6 expression by immunohistochemistry (“triple-hit” lymphoma).These data demonstrate the ability of cerdulatinib to potently and selectively inhibit SYK and JAK signaling at tolerated exposures in patients with relapsed/refractory B cell malignancies. Moreover, the extent of target inhibition, as well as suppression of inflammation, correlated with tumor response. Cerdulatinib is currently under investigation as part of a phase IIa study to further evaluate efficacy and tolerability in this population. DisclosuresCoffey:Portola Pharmaceuticals, Inc.: Employment, Equity Ownership. Feng:Portola Pharmaceuticals, Inc.: Employment, Equity Ownership. Betz:Portola Pharmaceuticals, Inc: Employment, Equity Ownership. Pandey:Portola Pharmaceuticals, Inc.: Employment, Equity Ownership. Birrell:Portola Pharmaceuticals, Inc.: Employment, Equity Ownership. Leeds:Portola Pharmaceuticals, Inc.: Employment, Equity Ownership. Der:Portola Pharmaceuticals, Inc.: Employment, Equity Ownership. Kadri:Portola Pharmacueticals, Inc.: Research Funding. Lu:Portola Pharmacueticals, Inc.: Research Funding. Segal:Portola Pharmacueticals, Inc.: Research Funding. Wang:Karyopharm: Research Funding; Portola: Research Funding. Michelson:Portola Pharmacueticals, Inc.: Employment. Curnutte:Portola Pharmaceuticals, Inc.: Employment, Equity Ownership. Conley:Portola Pharmaceuticals, Inc.: Employment, Equity Ownership, Patents & Royalties.

Pattern of Immunocompetent Peripheral Blood Cell Subpopulations in B-Cell Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma

Background. In the WHO classification small lymphocytic lymphoma (SLL) and B-cell chronic lymphocytic leukemia (В-CLL) are combined into one nosological entity of lymphoid tumors due to their similar tumor cell immunophenotype. Up to now, there is no consensus on either their similarities or the differences between them. Distinction between В-CLL and SLL is drawn with respect to clinical and hematological manifestations of tumors. The reason for the differences that determine tumor spreading in a patient may lie in specific states of some immune system components. Comparison of immune system parameters within the CLL/SLL model provides a unique opportunity to trace the behavior of immunity indicators in local und disseminated pathogenetically similar neoplastic processes and to identify possible prognostic factors. Aim. To compare quantitative representations of peripheral blood lymphocyte subpopulations in SLL and В-CLL. Materials & Methods. Immunocompetent cells (relative and absolute Т- and NK-cell counts), immunophenotype, and tumor clone volume were assessed using multicolor flow cytometry based on the expression of СD3, CD4, CD8, CD16, CD19, CD20, CD23, CD5, CD79b, FMC7, CD22, CD43, CD38 antigens, and immunoglobulins light chain IgK and IgA. Before chemotherapy onset, the data of 17 SLL and 81 CLL patients (22 of them with B-lymphocyte count of 35-79 % and 59 with 80-99 %) were compared. As a control, peripheral blood lymphocyte subpopulations in 50 relatively healthy individuals (blood donors) were analyzed. Results. The analysis of NK-cells and Т-lymphocyte subpopulations in SLL showed the preserved number of killer/cytotoxic cells of innate and adaptive immunity (CD16+, CD8+), the reduction of CD4+ Т-cell count, and CD4/CD8 ratio. In CLL a considerable increase of main subpopulations of residual normal lymphocytes was detected. However, the extent of their increase proved to be considerably lower than increase in the volume of tumor B-cell clone, which signifies a rising exhaustion of immune system effector components. Conclusion. The present study yielded characteristic features of residual normal lymphocyte subpopulations in SLL and CLL with different leukocytosis grades. SLL patients demonstrated the reduction of relative and absolute Т-cell counts with Т-helper (CD3+, СD4+) phenotype, and the increase of cytotoxic CD8+ Т-cells and NK-cells. Lymphocytosis (35-79 %) in the CLL-I group was due not only to tumor В-cells but also to Т-killer (CD16+, CD8+) and Т-helper (CD4+) absolute counts, which were 1.7-2.5 times higher than in SLL and the control group. Residual lymphocyte subpopulation pattern (80-99 %) in the CLL-II group compared with the control group was characterized by a significantly higher absolute count of CD8+ T-cells and CD16+ NK-cells, as well as higher Т-regulatory index compared with SLL and CLL-I groups. These data point to the necessity for further and more detailed study of residual lymphocyte subpopulation pattern within the CLL/SLL model in order to identify additional predisposing factors.

Expression of the Fractalkine Receptor (CX3CR1) Is Significantly Increased in Immune Cells of Chronic Lymphocytic Leukemia and Small Lymphocytic Lymphoma patients with Active Disease

Fractalkine (CX3CL1) is a chemokine constitutively expressed in many hematopoietic and non-hematopoietic tissues (Bazan J.F. et al., Nature, 1997). It mediates different biological activities by binding to its receptor CX3CR1, expressed on different cell types such as natural killer (NK) cells, monocytes, cytotoxic effector T cells and B cells. The CX3CL1/CX3CR1 axis is involved in the pathogenesis of several cancers including various B-cell malignancies (Ferretti E. et al.,Mediators Inflamm, 2014). CX3CR1 was found both at the mRNA and protein levels in several subtypes of lymphoma (Andreasson, U. et al.,Cancer Lett, 2008). In this study, we analysed the expression of the fractalkine receptor (CX3CR1) in peripheral blood mononuclear cells (PBMC) of chronic lymphocytic leukemia (CLL) and small lymphocytic lymphoma (SLL) patients (pts) with active disease (n=22), pts with newly diagnosed diffuse large B-cell lymphoma (DLBCL) (n=21) as well as classical Hodgkin lymphoma (cHL) (n=19) and compared with healthy donors (n=14). PBMC populations were assessed by flow-cytometry including T cells, NK cells and monocytes. Statistical comparisons between groups were done using the non-parametric Mann-Whitney U test. CLL/SLL pts had a median age of 75 years with equal sex distribution. Thirteen pts had high-risk and 9 intermediate-risk disease according to the modified Rai staging system; 1/21 had 17p deletion. Median lymphocyte count was 103 x 109/L (range 1.5-312). Of the 19 cHL pts, 12 had limited (stage 1-2A) and 7 had advanced (stage 2B-4) disease. Of the 21 DLBCL pts, 10 had stage 1, 4 had stage 2, 2 had stage 3 and 5 had stage 4 disease. CLL/SLL pts had significantly higher absolute number of CD4+and CD8+ T cells compared to controls, DLBCL and cHL patients (p=0.02, p=0.0001 and p<0.0001 for CD4+ T cells and p=0.0007, p<0.0001 and p=0.0002 for CD8+ T cells, respectively). DLBCL and cHL pts had lower CD4+ numbers compared to controls (p<0.005), while no difference was observed for CD8+ cells (Fig. 1A). The absolute numbers of CD4+ and CD8+ cells expressing the CX3CR1 were also significantly higher in CLL pts compared to controls and the other patient groups (p≤0.0001 for all comparisons). No significant difference was observed between either DLBCL or cHL pts and controls (Fig. 1B). Both the CD56bright and the CD56dim NK cell populations were also studied. CLL pts were found to have a significantly higher numbers of NK cells (p=0.001) and CD56dim NK cells (p=0.0027) compared to controls, while no difference was found for the other patient groups. No difference was observed between CLL pts and controls with regard to the CD56bright NK cells, which, however, were lower in both DLBCL and cHL pts than in controls (p<0.05) (Fig. 2A). The absolute numbers of NK cells expressing CX3CR1 was also significantly higher in CLL compared to controls (p=0.002). This was observed in both the CD56dim (p=0.004) and the CD56bright (p=0.04) subpopulations. In the other patient subgroups, no significant difference was observed with the exception of CX3CR1+CD56bright NK cells, which were lower in both DLBCL and cHL pts compared to controls (Fig. 2B). The median monocyte count was not significantly different among the patient groups or controls. Monocyte sub-populations were then defined by flow-cytometry: classical (CD14highCD16low), intermediate (CD14highCD16high) and non-classical (CD14lowCD16high). The median percentage of monocytes expressing CX3CR1 was >95% in all the patient groups and did not significantly differ from controls. No significant difference was observed for the monocyte subpopulations either. In conclusion, CLL/SLL pts with active disease have significantly higher numbers of T and NK cells expressing the fractalkine receptor (CX3CR1) compared to both controls and pts with DLBCL and cHL. No difference was observed for the monocytes. CX3CR1 might be a therapeutic target in CLL/SLL. Small molecule inhibitors of this axis are in clinical development. Disclosures Palma: Takeda: Research Funding. Olin:Kancera AB: Employment, Equity Ownership. Schultz:Kancera AB: Employment, Equity Ownership. Mellstedt:Kancera AB: Consultancy, Equity Ownership, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding. Österborg:Kancera AB: Research Funding; Abbvie: Research Funding; Janssen: Research Funding; BeiGene: Research Funding; Gilead: Research Funding.

The Role of Imaging in Predicting Time to First Treatment and Overall Survival in Individuals with CLL-like High Count Monoclonal B-Cell Lymphocytosis

Background: The 2008 International Working Group for CLL (IWCLL) criteria define MBL as a clonal B-cell disorder with a peripheral blood B-cell count of <5 x 109/L, in the absence of cytopenias(s), lymphadenopathy and/or organomegaly on physical examination, and no other concomitant lymphoproliferative disorder. In the presence of palpable lymphadenopathy and/or organomegaly, and a B-cell count of < 5 x 109/L, a diagnosis of small lymphocytic lymphoma (SLL) is established. A study by Gentile et al (Am J Hematol. 2013) reported that 29 out of 62 individuals with clinically identified MBL (42%) had lymphadenopathy identified on CT imaging. Notably, however, after a median follow-up of 35 months, the rate of progression among cases of MBL with lymphadenopathy identified on CT imaging was only 6.9% (2/29 patients), which was no different than in cases of MBL without lymphadenopathy on CT imaging (rate of progression, 9%; 3/33 patients). Our study sought to 1) determine if lymphadenopathy and/or organomegaly detected by imaging studies performed for unrelated reasons in individuals with MBL can identify a subset with shorter time to first CLL therapy (TFT) and overall survival (OS); and 2) compare outcomes of individuals with MBL who have incidentally detected lymphadenopathy/splenomegaly and SLL patients. Methods: We used the Mayo Clinic CLL Database to identify individuals with high-count MBL (absolute B-cell count: 0.5 - 4.9 x 109/L) and divided them into the following three cohorts: a) Cohort A: no imaging studies available at MBL diagnosis; b) Cohort B: imaging studies done within one year of MBL with no evidence of lymphadenopathy and/or organomegaly; and c) Cohort C: imaging studies done within one year of MBL with lymphadenopathy and/or organomegaly, attributable to MBL. All individuals with MBL were first seen at Mayo Clinic after 1/1/2002; those with a concomitant lymphoproliferative disorder within 3 months of diagnosis were excluded. Patients with SLL seen during the same time interval were identified as a comparison cohort. We compared the baseline characteristics (Kruskal Wallis for continuous and Chi-square for categorical variables) and TFT and OS across the three MBL cohorts, and patients with SLL. Cumulative incidence of TFT was adjusted for the competing risk of death. Age- and sex-adjusted OS was analyzed using inverse weights methods. Results: 657 individuals with high-count MBL with a median follow-up of 6.7 years were identified: 415 (63%) individuals were in Cohort A, 142 (22%) in Cohort B, and 100 in (15%) Cohort C. Compared to Cohort B, individuals in Cohort C were more likely to have unmutated IGHV, high expression of CD38, and higher beta-2 microglobulin level (Table 1). SLL patients were younger, had higher rate of unmutated IGHV, and had high expression of CD49d compared to MBL individuals in Cohort C (Table 1). There was suggestive evidence of a difference in TFT between Cohorts B and C (estimated 10-year treatment rate 28.3% vs. 41.6%; p=0.16; HR 1.62 95% CI 0.84-3.15). TFT was significantly shorter in SLL patients compared to those with Cohort C (estimated 10-year treatment rate 71% vs. 41.6%, respectively, P<0.001; Figure 1A). There was a trend toward shorter OS in Cohort C compared to Cohort B (estimated 10-year OS rate 53.7% vs. 64.2%, respectively, P=0.09; Figure 1B). In contrast, there was no difference in OS among MBL individuals in Cohort C compared to those with SLL (estimated 10-year OS rate 56.9% vs. 62.6%, P=0.72). Summary/Conclusion: Our findings demonstrate that individuals with MBL who have incidentally identified lymphadenopathy/splenomegaly at diagnosis are more likely to have an unfavorable risk profile, shorter TFT and OS compared to patients who did not have lymphadenopathy/splenomegaly at MBL diagnosis. Additionally, these individuals have a longer TFT but similar OS compared to SLL patients seen during the same time interval. If externally validated, these findings have significant implications for individuals with newly diagnosed MBL. Disclosures Ding: Merck: Research Funding; DTRM Biopharma: Research Funding. Kenderian:Novartis: Patents & Royalties, Research Funding; Tolero: Research Funding; Humanigen: Other: Scientific advisory board , Patents & Royalties, Research Funding; Lentigen: Research Funding; Morphosys: Research Funding; Kite/Gilead: Research Funding. Kay:MorphoSys: Other: Data Safety Monitoring Board; Infinity Pharmaceuticals: Other: DSMB; Celgene: Other: Data Safety Monitoring Board; Agios: Other: DSMB. Parikh:AstraZeneca: Honoraria, Research Funding; Janssen: Research Funding; AbbVie: Honoraria, Research Funding; Acerta Pharma: Research Funding; Ascentage Pharma: Research Funding; Genentech: Honoraria; Pharmacyclics: Honoraria, Research Funding; MorphoSys: Research Funding.

Small Lymphocytic Lymphoma: Analysis of Two Cohorts Including Patients in Clinical Trials of the German Chronic Lymphocytic Leukemia Study Group (GCLLSG) or in "Real-Life" Outside of Clinical Trials.

Only few studies have focused exclusively on patients with small lymphocytic lymphoma (SLL). In the present report, 103 SLL patients were analyzed from both, clinical trials of the German Chronic Lymphocytic Leukemia Study Group and Greek centers, and emphasis was placed on the therapeutic strategy. The impact of lymph node characteristics, such as the presence of proliferation centers (PCs) on response and survival was also assessed. SLL patients included in clinical trials were treated mostly with fludarabine-based regimens while those in "real-life" were staged and treated mostly as patients with low-grade lymphomas. Our analysis showed a trend for better survival for patients with SLL without detectable PCs. Patients with SLL outside of clinical trials are usually treated as cases of lymphoma. In addition, this analysis supports published data regarding the adverse prognostic value of the presence of PCs in lymphoid nodes in SLL.

Richter syndrome: A rare complication of chronic lymphocytic leukemia or small lymphocytic lymphoma.

Richter's syndrome (RS) is a rare complication with an unfavorable prognosis, in which chronic lymphocytic leukemia (CLL) or small lymphocytic lymphoma (SLL) transform into a more aggressive type of lymphoma, most commonly into diffuse large B cell lymphoma (DLBCL) or less often into Hodgkin's lymphoma (HL). The objective of this research paper was to present a retrospective analysis of patients with CLL/SLL whose disease transformed into RS. The study included 217 patients (100 women and 107 men) with CLL/SLL diagnosed in the years 2006-2015 at the Department of Hematooncology and Bone Marrow Transplantation of the Medical University of Lublin, which transformed into RS. We analyzed clinical, laboratory, immunophenotypic (ZAP-70 and CD38 expression), histopathological, and genetic data (del(17p), del(11q)), which was collected at the time of CLL/SLL diagnosis, and some which was collected at the time of transformation. Richter's syndrome was diagnosed in 4.6% of all CLL and SLL patients. The group of patients with RS consisted of 9 patients with primary CLL and 1 patient with a diagnosis of SLL (8 patients with transformation into DLBCL and 2 patients with transformation into HL). Leukemic lymphocytes showed evidence of peripheral blood lymphocyte membrane expression of ZAP70+/CD38+ (1 patient), of ZAP-70+/CD38- (3 patients), of ZAP-70-/CD38- (1 patient), and of ZAP-70-/CD38+ (5 patients). The deletion of 11q (del(11q)) was documented in 2 patients. In 4 cases, the location of RS was extremely rare (the thyroid gland, liver, skin, bladder, and central nervous system). Richter's syndrome is a rare, but probable complication of CLL/SLL with an unfavorable prognosis, and it should be taken into account at every stage of the disease, particularly when the course of the disease is aggressive.

Differences between chronic lymphocytic leukaemia and small lymphocytic lymphoma cells by proteomic profiling and SNP microarray analysis

The majority of malignant cells in chronic lymphocytic leukaemia (CLL) circulate in the peripheral blood whereas small lymphocytic lymphoma (SLL) cells reside in tissues. The aim of this study was to detect differences in chemokine receptor expression, DNA single nucleotide polymorphism (SNP) microarray analysis and proteomic profiling to help elucidate why the cells remain in their respective environments. We identified by flow cytometric studies of chemokine receptors and DNA SNP microarray analysis significant differences between cells from CLL and SLL patients. Proteomic analysis revealed two potential markers (m/z 3091 and 8707) to distinguish the two disorders. There was a significantly greater expression of leucocyte trafficking receptor CXCR3 (CD183) and migration and homing receptor CXCR4 (CD184), and significantly lower expression of cell adhesion molecule integrin α4 chain (CD49d), on CLL cells, compared with SLL cells. Conversely, SNP microarrays revealed greater numbers of copy-neutral loss of heterozygosity chromosomal aberrations, as well as gross chromosomal aberrations, in the SLL group, compared with the CLL group. These findings revealed that there was a significantly greater expression of trafficking, migration and homing receptors and significantly lower expression of adhesion molecules on CLL cells than on SLL cells, and that SLL may be a more progressive disease than CLL, with a more complex genotype.

NK cell dysfunction in chronic lymphocytic leukemia is associated with loss of the mature cells expressing inhibitory killer cell Ig-like receptors

ABSTRACTA prospective analysis of natural killer (NK) cell phenotype and function was performed on fresh peripheral blood samples from untreated patients with B-cell chronic lymphocytic leukemia (CLL) or small lymphocytic lymphoma (SLL). Compared to healthy controls, CD56dim NK cells in CLL patients displayed reduced expression of the NKG2D activating receptor and increased CD27 expression, which indicates declines in mature cells. In addition, NK cells from CLL patients showed reduced degranulation responses toward transformed B cells alone or with rituximab and were more sensitive to activation-induced cell death. We further noted a striking reduction in the frequency and viability of NK cells expressing the inhibitory killer cell Ig-like receptors (KIR)2DL1 and/or KIR3DL1, which progressed over time in most patients. Comparisons between a CLL patient and healthy monozygotic twin were consistent with our results in the larger cohorts. Functional and biomarker alterations were less pronounced on NK cells from SLL patients, which have lower tumor burden in peripheral blood than CLL, but significant reduction in degranulation under ADCC conditions and lower frequency and viability of KIR-expressing NK cells were still evident in SLL. We conclude that mature KIR-expressing NK cells respond to the high circulating B cell tumor burden in CLL, but undergo activation-induced apoptosis. Consequently, CLL patients may benefit from therapies that augment NK cell survival and function.

Phase 2 Trial of Entospletinib (GS-9973), a Selective Syk Inhibitor, in Chronic Lymphocytic Leukemia (CLL) and Small Lymphocytic Lymphoma (SLL)

Abstract Background: Spleen tyrosine kinase (Syk) is a mediator of B-cell receptor signaling in normal and transformed B-cells. GS-9973 is an orally bioavailable, selective inhibitor of Syk. Methods: This Phase 2 trial enrolled 41 patients with CLL and 15 patients with SLL treated with GS-9973 800 mg BID. Tumor imaging occurred at weeks 8, 16, 24 and then every 12. Response was independently evaluated according to Hallek 2008 as modified by Cheson 2012 for patients with CLL and Cheson 2007 for patients with SLL. Primary endpoint for the study was PFS at 24 weeks. Results: The median ages of CLL and SLL patients were 73 (range 51-89) and 70 (range 57-84), respectively. 68% of CLL subjects and 60% of SLL subjects were male. Ten patients had 17p deletions/TP53 mutations and 17 had SF3B1 or NOTCH1 mutation, or 11q22.3 deletion. The median number of prior regimens for CLL was 2 (range 1-8) and for SLL was 2 (range 1-10). Prior therapies included anti-CD20 antibodies (98%), alkylating agents (86%, [bendamustine 63%]) and fludarabine (66%). 12 CLL and 6 SLL patients are still on treatment; the median duration of treatment for all CLL and SLL patients was 36 weeks The most common treatment emergent AEs (any Grade/≥Gr 3, independent of causality) were fatigue (70%/7%), nausea (54%/2%), diarrhea(48%/0%), cough(34%/0%), dizziness (32%/2%), headache (29%/0%), pyrexia (29%/0%), decreased appetite (27%/2%), upper respiratory tract infection(27%/0%), constipation (23%/0%). Common laboratory abnormalities were increased AST (30%/5%), increased ALT (43%/4%), increased total bilirubin (41%/16%), anemia (50%/7%) and neutropenia (54%/29%). Forty-nine patients were treated for at least 8 weeks and 54 patients had ≥ 1 efficacy assessment, two patients discontinued prior to the first response assessment, one due to AE and one withdrew consent. Per investigator assessment, 51 out of 52 (98%) patients evaluable for SPD experienced reduced tumor bulk; 38 (73%) achieved a decrease of ≥ 50%. The ORR was 62.5% (95% CI: 48.6%, 75.1%), with 35 patients achieving a PR and no subject achieving a CR. Thirteen patients (23.2%) had stable disease. The primary end point of 24 weeks PFS was 72.3% (95% CI: 57.1%, 83.0%). Median PFS was 20.5 months (95% CI: 7.7 months, not reached). There were 24 patients (42.9%) with events, 22 (39%) with disease progression and two deaths (4%) attributed to septic pneumonia and pseudomonal infection which was unrelated to entospletinib by investigator assessment. Among the 35 responding patients, median DOR was 21.3 months (95% CI: 13.2 months, not reached). Results of an independent response assessment are pending and will be presented. Entospletinib was well tolerated and demonstrated substantial activity in patients with CLL, and SLL including those with poor prognostic features. Entospletinib activity seems comparable to that reported by other approved BCR pathway inhibitors with the median PFS reported for Idela of 15.8 months (Blood. 2014;123(22):3390-3397) and Ibrutinib reported 42.6% overall response rate and a PFS of 70-80% @ 12 months (ibrutinib PI) Current studies plans include studying Entospletinib in combination therapy. Figure 1. Figure 1. Figure 2. Figure 2. Figure 3. Figure 3. Disclosures Sharman: Gilead: Consultancy, Honoraria, Research Funding, Speakers Bureau; Roche: Research Funding; Calistoga: Honoraria; Pharmacyclics: Consultancy, Honoraria, Research Funding; Celgene Corporation: Consultancy, Research Funding; TG Therapeutics, Inc.: Research Funding; Janssen: Research Funding. Kolibaba:Janssen: Research Funding; Genentech: Research Funding; Pharmacyclics: Research Funding; TG Therapeutics: Research Funding; GSK: Research Funding; Celgene: Research Funding; Acerta: Research Funding; Seattle Genetics, Inc.: Research Funding; Takeda Pharmaceuticals International Co.: Research Funding; Gilead: Consultancy, Research Funding. Abella:Gilead: Employment. Di Paolo:Gilead Sciences: Employment, Equity Ownership. Eng:Gilead: Employment. Hu:gilead: Employment. He:Gilead Sciences: Employment. Reddy:gilead: Employment. Yasenchak:Seattle Genetics, Inc.: Research Funding.

Natural Killer Cell Dysfunction in Chronic Lymphocytic Leukemia Is Associated with Loss of the Mature KIR3DL1+ Subset

Background: B-cell chronic lymphocytic leukemia (CLL) is a common blood cancer characterized by high prevalence of malignant B cells in peripheral blood. Small lymphocytic lymphoma (SLL) is considered to be a different presentation of the same disease, with the malignant B cells primarily localized in lymph nodes. Natural killer (NK) cells are innate immune effectors that can spontaneously identify and kill malignant cells, especially hematopoietic cancers. In peripheral blood of CLL patients, NK cells are chronically exposed to significant tumor burden, which is predicted to influence their phenotype and function. Effective NK cell function may be particularly beneficial in CLL patients, since commonly-used monoclonal antibody therapies (e.g. rituximab, alemtuzumab) rely at least partially on ADCC-mediated by NK cells.Methods: We performed a prospective analysis of biomarkers on fresh peripheral blood lymphocytes from 25 untreated CLL patients, 10 untreated SLL and 17 age-matched healthy controls by 10-color flow cytometry. All subjects signed IRB approved informed consent forms. Our study analyzed 180 distinct biomarker parameters, with a particular focus on NK and T cells. Differences in biomarker expression between patients with SLL, CLL, and healthy controls were compared by Wilcoxon rank-sum test.Results: Absolute numbers of NK and T cells per µl of blood were significantly higher in CLL patients, and this correlated with increased B cell numbers. As indicators of immune suppression, the frequency of regulatory T cells was significantly increased in CLL samples, as were levels of PD-1 expression on T cells and CD56dim NK cells. NK cells in CLL expressed higher levels of CD27, which is characteristic of a less mature phenotype, and CD56dim cells expressed lower levels of NKG2D. Compared to healthy controls, CLL samples displayed a marked reduction in degranulation by CD56dim NK cells in response to transformed 721.221 B cells, either with or without rituximab. CD56dim NK cells from CLL patients were also less viable under resting conditions or when challenged with target cells, especially in ADCC responses. We further observed a striking reduction in the frequency and viability of KIR3DL1+ NK cells, which progressed over time in most CLL patients. Surprisingly, CLL patients with the highest levels of PD-1 expression on NK cells possessed genes for both KIR3DL1 and its ligand, HLA-Bw4. Our findings were also clearly evident in a CLL patient compared to her healthy monozygotic twin, thereby providing compelling support for the results in the full patient cohort. The altered expression levels of nearly all of the NK cell biomarkers and degranulation were less pronounced in blood samples from SLL patients, presumably due to low tumor burden in peripheral blood.Conclusions: CLL patients have increased numbers of NK cells in peripheral blood, but these NK cells are less mature, are significantly depleted of the KIR3DL1+ subset, and have deficits in degranulation response, reduced expression of NKG2D activating receptor, increased expression of inhibitory PD-1, and enhanced susceptibility to activation-induced death when challenged with tumor targets and rituxumab. Our findings support the hypothesis that immune dysfunction in CLL may be due in part to a selective loss of mature KIR3DL1+ NK cells, possibly upon encountering overwhelming tumor burden in peripheral blood, and CLL patients may benefit from therapeutic strategies that augment NK cell function. DisclosuresNo relevant conflicts of interest to declare.

Possible role of CD22, CD79b and CD20 expression in distinguishing small lymphocytic lymphoma from chronic lymphocytic leukemia.

Aim of the studyFlow cytometry has an important role in diagnosis and classification of B-cell lymphoproliferative disorders (BCLPDs). However, in distinguishing chronic lymphocytic leukemia (CLL) from small lymphocytic lymphoma (SLL) only clinical criteria are available so far. Aim of the study was to determine differences in the expression of common B cell markers (CD22, CD79b and CD20) on the malignant lymphocytes in the peripheral blood samples of CLL and SLL patients.Material and methodsPeripheral blood samples of 56 CLL and 11 SLL patients were analyzed by 5-color flow cytometry on the CD45/CD19/CD5 gate for CD22, CD79b and CD20.ResultsIn the samples collected from the CLL patients, CD22 expression was detected in only 20% of patients in the low pattern, while in SLL patients the expression was medium and present in 90.9% of patients (p < 0.0001). For CD79b expression, statistical significance is reached both in the expression pattern, which was low/medium for CLL and high for SLL, and expression level (p = 0.006). The expression of CD20 was counted as the CD20/CD19 ratio. The average ratio was 0.512 in the CLL patients vs. 0.931 in the SLL patients (p = 0.0001).ConclusionsThe pattern of expression and expression level of CD22, CD79b and CD20 in peripheral blood could be used for distinguishing SLL from CLL patients.

NOTCH1 Mutations Are Associated With The 14q Deletion In Chronic Lymphocytic Leukemia (CLL) and Small Lymphocytic Lymphoma (SLL)

Deletions of the long arm of chromosome 14 are rare (<5%) but recurrently observed in mature B-cell neoplasms, particularly in CLL. The size of the deletions is variable, and the molecular consequences are unknown. The aim of our study is to characterize this abnormality in a large cohort of patients.The Groupe Francophone de Cytogenetique Hematologique (GFCH) collected data from 89 patients with CLL or Small Lymphocytic Lymphoma (SLL), harboring a del14q. Morphological review was performed for 65 of them and immunological review for 48. All karyotypes were reviewed by members of the GFCH. Fluorescence in situ hybridization (FISH) analysis was performed with CEP12, 13q14, TP53, ATM, 6q21, and IGH probes, and BACs RP11-35D12 and RP11-226F19 covering the ZFP36L1 gene on 14q24.1. SNP-array analysis (illumina omni1, omin2.5) was performed for 37 patients. The IGHV status was analyzed locally, or in our laboratory. The mutation hotspots of NOTCH1 (exon 34), SF3B1 (exons 14-16), XPO1 (exons 14-15), MYD88 (exon 5) and TP53 (exons 4-10) were analyzed by direct sequencing.Patients were classified as 49 CLL Matutes score 4-5, 5 atypical CLL score 3 (all CD5+, CD23+), and 27 SLL. Eight patients were excluded with a Matutes score<3 or not evaluable. The sex ratio M/F was 1.02, the median age at diagnosis was 64.5 years [29-87]. Regarding all CLL, there were 35 (66%) stages A, 10 (19%) stages B and 8 (15%) stages C. The median time between diagnosis and the first treatment (TTT) was 17 months [0-144], the overall survival (OS) at 5 years was 93.7%. For the 27 SLL patients, the median TTT was 1 month [0-85], and the OS at 5 years was 88.1%.The karyotype showed chromosomal translocation in 26/79 (33%) (10 balanced, 16 unbalanced) and was complex (> 3 abnormalities) in 26/79 (33%) cases. Using karyotype and FISH, we observed 28/79 (35%) trisomy 12, 12/79 (15%) 13q14 deletions, 11/80 (14%) TP53 deletions, 5/79 (6%) ATM deletions, 3/76 (4%) 6q21 deletions. The whole CLL cohort showed 15/53 (28%) tri 12, 11/53 (21%) del13q, 8/54 (15%) delTP53, 4/53 (7%) delATM, 2/50 (4%) del6q.IGHV status was not mutated in 41/53 (77%) patients, and the gene IGHV1-69 was rearranged in 21/52 (40%) cases. NOTCH1 gene was mutated in 14/45 (31%) patients, SF3B1 in 2/45 (4%), XPO1 in 2/45 (4%), MYD88 in 0/43, TP53 in 6/43 (14%) cases. A significant association was observed between TP53 disrupted and NOTCH1 mutations (p=.04). NOTCH1 mutation was not correlated with tri12.Regarding all the cytogenetic and molecular data, there was no significant difference between CLL score 4-5 and CLL score 3, and between CLL and SLL.Compared with common CLL in the literature, CLL with del14q dysplayed more tri12 (p<.03) and NOTCH1 mutations (p<.003), less del13q (p<.0006), more unmutated IGHV (p<.00001) and V1-69 repertoire (p<.00001). Compared with common SLL in the literature, SLL with del14q also exhibited more tri12, unmutated IGHV (p<.01) and V1-69 (p<.04).The 14q deletions appeared distributed along chromosome 14 from bands q11 to q32. The centromeric and telomeric breakpoints of the 14q deletion were investigated by FISH or SNP-array when material was available, and allowed us to identify a main group (Group 1) among 4 groups: Group 1: 37/77 (48%) patients, with IGH and ZFP36L1 loci rearranged; Group 2: 17/77 (22%), with ZFP36L1 deleted and IGH not deleted; Group 3: 7/77 (9%), with ZFP36L1 and IGH not deleted; Group 4, 16/77 (21%), all the other combinations. Group 1 showed a deletion del14q24.1-14q32.3 of about 38 megabases, which broke in or near ZFP36L1, and in the IGH gene. It included 26 (70%) CLL score 4-5 and 11 (30%) SLL. When compared to the other groups, Group 1 showed significantly more tri12 (p=.004), and NOTCH1 mutations (p=.02). IGHV status was unmutated in 22/24 (92%) patients in Group 1, 12/24 (50%) harboring the gene V1-69.In conclusion, the size of the 14q deletion is variable, with in about half of the cases a recurrent interstitial deletion 14q24.1-14q32.3. Both CLL and SLL with del14q, particularly with the 14q24.1-14q32.3 deletion, are associated with poor prognosis parameters, like short time to treatment, trisomy 12, NOTCH1 mutated, and unmutated IGHV status, with an overrepresentation of the V1-69 gene. Disclosures:No relevant conflicts of interest to declare.

High prevalence of adverse prognostic genetic aberrations and unmutated IGHV genes in small lymphocytic lymphoma as compared to chronic lymphocytic leukemia

According to the WHO classification, chronic lymphocytic leukemia (CLL) and small lymphocytic lymphoma (SLL) are considered the same entity. However, the clinical presentations are different. As yet, detailed molecular–genetic comparisons between CLL and SLL are scarce. In this study, we evaluated the presence of genetic abnormalities and (immunoglobulin heavy chain variable genes) IGHV use and mutation status in lymph node samples of patients presenting with lymphadenopathy alone and, therefore, classified as SLL (n = 21) or with persisting lymphadenopathy and absolute lymphocyte counts of ≥5 × 109/L and, therefore, classified as CLL/SLL (n = 17). In addition, blood samples of CLL patients were evaluated (n = 82). The majority of lymph node samples from SLL patients (66%) showed unmutated IGHV genes. This occurrence was significantly higher than in CLL (29%). Poor risk genetic aberrations (11q-, 17p-, and +12) were more prevalent in the SLL (45%) as compared to CLL (22%). Samples from CLL/SLL patients exhibited almost equal frequencies of poor risk genetic aberrations (53%), but lower frequencies of unmutated IGHV genes (35%), as compared to SLL. In summary, SLL not only differs clinically from CLL, but also genetically, with a higher propensity of adverse molecular parameters in SLL. CLL and SLL likely encompass a phenotypic spectrum within one disease entity.

Expression of the human concentrative nucleotide transporter 1 (hCNT1) gene correlates with clinical response in patients affected by Waldenström's Macroglobulinemia (WM) and small lymphocytic lymphoma (SLL) undergoing a combination treatment with 2-chloro-2′-deoxyadenosine (2-CdA) and Rituximab

Purpose Resistance to nucleoside analogues agents is likely to be multifactorial and could involve a number of mechanisms affecting drug penetration, metabolism and targeting. In vitro studies of resistant human cell lines have confirmed that human concentrative nucleoside transporter 1 (hCNT1)-deficient cells display resistance. Experimental design We applied real-time PCR method to assess the mRNA expression of equilibrative and concentrative nucleoside transporter (hENT1, hCNT1), deoxycytidine and deoxyguanosine kinase (dCK, dGK), 5′-nucleotidase (5′-NT), ribonucleotide reductase catalytic and regulatory (RR1, RR2) subunits in bone marrow cells from 32 patients with Waldenström's Macroglobulinemia (WM) and small lymphocytic lymphoma (SLL) who received 2CdA-based chemotherapy. Responses to chemotherapy, were then correlated to the expression of these markers. Results All 32 patients enrolled expressed lower levels of hCNT1 as compared to healthy donors. In univariate analysis, lower expression level of hCNT1 ( p = 0.0021) and RR2 ( p = 0.02) correlated with response to chemotherapy. In particular, patients with low levels of hCNT1 achieved inferior clinical response. No significant correlation between these genes expression and age, stage of disease was found. This study suggests that nucleotidase expression levels can be used to identify subgroups of WM and SLL patients who will likely respond differently to a 2CdA-based therapy.

Host Immunogenetic Single Nucleotide Polymorphisms (SNPs) Predict Overall Survival in Small Lymphocytic Lymphoma.

Small lymphocytic lymphoma (SLL) is an incurable indolent lymphoma, and there are relatively few prognostic biomarkers for this important NHL subtype. We evaluated the hypothesis that inherited variability in cytokine and immune-related genes was associated with overall survival in SLL. We genotyped 73 SNPs in 44 candidate genes in 140 SLL patients aged 20–70 years who participated in a population-based case-control study conducted from 1998–2000 through the Surveillance, Epidemiology, and End Results (SEER) cancer registries in Detroit, Seattle, Iowa, and Los Angeles. DNA was extracted from a venous blood sample or mouthwash buccal cell sample. All genotyping was conducted at the National Cancer Institute Core Genotyping Facility using the Taqman platform. Histology, stage, presence of B-symptoms, first course of therapy, date of last follow-up, and vital status were derived from linkage to registry databases at each study site in the spring of 2005. Cox proportional hazards analysis was used to estimate the hazard ratio (HR) and 95% confidence interval for the association between individual SNPs and overall survival, adjusted for age, demographic and clinical factors. Multiple simultaneous modeling strategies were used to identify the best summary multi-SNP risk score to predict survival. At last follow-up, there were 45 deaths in 140 patients (32%). The median follow-up of the 95 surviving patients was 58 months (range 24–75 months). In multivariate modeling, SNPs in IL13 (rs1800925; HRCC=2.36, 1.24–4.49), IL7R (rs1494555; HRGG =2.20, 0.84–5.76), and TNF-alpha (rs1800630; HRAC/AA=1.73, 0.95–3.17) were the strongest and most robust predictors of survival. Two or more deleterious genotypes from these three SNPs increased the risk of death (HR=2.2, 1.2–4.1) compared with one or fewer deleterious genotypes (p=0.009). Three groups (low, intermediate, and high risk) were defined by combining the SNP score and a clinical/demographic score. The 5-year Kaplan-Meier survival estimates for these groups were 85%, 65%, and 11%, respectively. Compared to patients with a low risk score, patients with intermediate (HR=2.5, 1.2–5.1) or high (HR=11, 4.3–27.7) risk scores had poorer overall survival (p=3.9 x 10−8). Our preliminary results suggest that SNPs in IL13, IL7R, and TNF-alpha alone and in combination predict overall survival in SLL, lending support to the hypothesis that host genetic background is a promising class of prognostic biomarkers in SLL.

Comparison of Small Lymphocytic Lymphoma with Chronic Lymphocytic Leukemia The M.D Anderson Cancer Center Experience.

Introduction: Small lymphocytic lymphoma (SLL) and chronic lymphocytic leukemia (CLL) are viewed as similar entities by the World Health Organization. Patients with SLL are usually treated on protocols for indolent lymphomas, although the biology of SLL differs from that of follicular lymphomas. The purpose of this study was to assess differences, if any, in presenting characteristics, cytogenetics, treatment outcomes, and factors predicting survival between patients with CLL and those with absolute lymphocyte counts <5,000 (SLL).Methods: An electronic database search of patients with CLL/SLL who presented at The University of Texas M.D. Anderson Cancer Center Department of Leukemia between 1985 and 2005 was performed.Results: Among 2,051 patients with untreated CLL/SLL, 199 patients had SLL and 1852 patients had CLL. Patients with SLL were referred for node enlargement (33%), coincidental abnormal white blood cell counts (27%), fatigue (11%), B-symptoms (10%), bruising/low platelets (8%), surgical specimens (8%), and other reasons (8%). In univariate analysis, patients with SLL had higher hemoglobin levels (p<0.001), lower IgA and IgM immunoglobulin levels (p=0.03 and p=0.01, respectively), and lower rates of bone marrow lymphocytic infiltration (p<0.001) than those with CLL. Age, sex, Binet stage, and β2-microglobulin levels were similar between the two groups. Fluorescence in situ hybridization (FISH) abnormalities were more frequent in tested patients with CLL compared with SLL patients (70% and 45%, respectively). Among 40 SLL patients with FISH abnormalities, 18% had 11q-, 25% had trisomy 12, 33% had 13q-, and 5% had 17p- abnormalities. Among 314 CLL patients with FISH abnormalities, 14% had 11q-, 16% had trisomy 12, 51% had 13q-, and 5% had 17p- abnormalities. Forty percent of patients with SLL and 49% of CLL patients required therapy after a median follow-up of 5.8 and 3.0 years, respectively (p<0.001). Among evaluable patients (SLL, 32; CLL, 710), the overall response rates to various therapies were 78% (CR, 41%) and 88% (CR, 48%), respectively. Responses were more frequent among SLL patients treated with fludarabine, mitoxantrone, and dexamethasone (FND), FND with rituximab (R-FND) or fludarabine, cyclophosphamide, and rituximab (FCR) and among patients with CLL treated with FCR. In multivariate analysis of all 2,051 SLL/CLL patients, factors predicting longer survival were younger age (p<0.0001), lower β2-microglobulin levels (p<0.0001), lower alkaline phosphatase levels (p<0.0001), higher hemoglobin levels (p<0.0001), smaller number of nodal sites (p<0.001), and lower lactate dehydrogenase levels (p=0.01); the absolute lymphocyte count was not a significant factor in survival (p=0.30).Conclusions: The presentation, cytogenetic abnormalities, and clinical outcome of SLL are similar but not identical to those of CLL. Our results suggest that SLL and CLL can be treated similarly. Regimens that include rituximab and a nucleoside analog, such as FCR or R-FND, are highly effective. Further characterization of SLL by genetic analysis is needed. Common response criteria should be standardized for both CLL and SLL, including the disappearance of radiologic and hematologic evidence of disease.

Motexafin gadolinium induces oxidative stress and apoptosis in hematologic malignancies

Redox mechanisms have been shown to be important in malignant cell survival and are a system that may be modified for the treatment of hematologic malignancies. Motexafin gadolinium (MGd) is a synthetic expanded porphyrin that selectively accumulates in tumor cells and oxidizes various intracellular metabolites, including ascorbate, nicotinamide adenine dinucleotide phosphate, glutathione, and protein thiols, to generate reactive oxygen species in a process known as futile redox cycling. The rationale for its use in hematologic malignancies is that, like naturally occurring porphyrins, it tends to concentrate selectively in cancer cells, and it has a novel mechanism of action of inducing redox stress and triggering apoptosis in a broad range of malignancies. MGd induces apoptosis in B-cell non-Hodgkin's lymphoma, chronic lymphocytic leukemia, and highly resistant myeloma cell lines. Furthermore, MGd is additive or synergistic with ionizing radiation, several chemotherapy agents, and rituximab in vitro and in vivo tumor models. Through gene expression profiling, various stress-related genes are upregulated in response to MGd, including genes encoding metallothioneins, heat shock proteins, and heme oxygenase. Preliminary results from clinical trials with MGd in hematopoietic malignancies have shown that it is well tolerated, with minimal hematologic side effects in both; it has single agent activity in very heavily pretreated chronic lymphocytic leukemia /small lymphocytic lymphoma patients, and it has induced prompt complete remissions in combination with 90Yttrium-ibritumomab (Y-90 Zevalin; Biogen Idec Inc., Cambridge, MA) for relapsed non-Hodgkin's lymphoma in the first two cohorts of patients enrolled. Various clinical trials studying MGd as a single agent and in combination with radiation and/or chemotherapy for the treatment of hematologic malignancies are ongoing.

Long-term follow-up of advanced-stage low-grade lymphoma patients treated upfront with high-dose sequential chemotherapy and autograft.

Long-term outcome, after first line intensified high-dose sequential (i-HDS) chemotherapy, was evaluated in 46 patients, aged < or =65 years, with advanced low-grade lymphoma. Seventeen patients had small lymphocytic lymphoma (SLL), 29 had follicular lymphoma (FL), 10 of them with histologic transformation. I-HDS included: (1) tumor debulking, by 2 APO+2 DHAP courses; (2) sequential administration of high-dose (hd) etoposide, methotrexate, and cyclophosphamide, followed by peripheral blood progenitor cell (PBPC) harvest; (3) hd-mitoxantrone + melphalan with PBPC autograft. Ten FL patients had their PBPC immunologically purged ex vivo. There were two treatment-related deaths; five FL patients had short-lasting response followed by disease progression, five SLL reached a stable PR; overall, 34 patients (74%) reached CR. At a median follow-up of 4.3 years, the estimated 9-year OS and EFS were 84% and 45%, respectively. No significant differences were observed in the OS among patients at low, intermediate or high IPI score, with an estimated OS projection of 95%, 78%, and 75%, respectively. FL had longer survival without evidence of residual disease (9-year EFS: 59%) as compared to SLL patients (8.8-year EFS: 17%); however, both groups had prolonged survival and no need of salvage treatment, as shown by the time to disease progression curve, projected to 66% and 62% for SLL and FL, respectively. The results indicate that hd-approach in low-grade lymphoma: (1) is associated with longer progression-free survival as compared to conventional therapies; (2) may imply higher tumor mass reduction in FL as compared to SLL patients; (3) offers long life expectancy, with potential survival benefits at least for patients at intermediate/high IPI score.