The Chronic Lymphocytic
Leukemia
(CLL)
The Chronic Lymphocytic Leukemias (1)
• The group of clonal diseases characterized by proliferation and
accumulation of small, mature lymphocytes in blood, bone
marrow and lymphoid tissues (lymph nodes, spleen)
• Neoplastic lymphocytes belong most often to B-cell lines and they
have the special for B-cell antigenes on their surface;
exceptionally neoplastic lymphocytes belong to T-cell lines or NKcell
• According to REAL (Revised European-American Lymphoma)/ /WHO classification
CLLs belong to the group of:
– lymphoproliferative diseases
– lymphomas
Lymphoproliferative diseases
• Primary lymphatic system
(central)
– bone marrow
– thymus
• Secondary lymphatic system
(peripheral )
– spleen
– lymph nodes
– MALT (The mucosaassociated lymphoid tissue =
also called mucosaassociated lymphatic tissue)
Clinical stages of lymphomas according
to Ann Arbor’s classification
I
II
III
IV
A: no general symptoms
B: general symptoms such as fever, night sweats, weight
loss
Lister T, et al. J Clin Oncol 1989; 7:1630
• Ann Arbor’s classification is specific for all lymphomas
• CLL is classified according to
Rai and Binet classification
WHO classification
B-Cell neoplasms
- Precursor B-cell neoplasm:
B-lymphoblastic leukemia/lymphoma
- Mature (peripheral) B-cell neoplasms:
B-cell chronic lymphocytic leukemia/small
lymphocytic lymphoma
B-cell prolymphocytic leukemia
Lympfioplasmacytic lymphoma
Splenic marginal zone B-cell lymphoma
(+ /- villous lymphocytes)
Hairy cell leukemia
Plasma cell myeloma/plasmacytoma
Extranodal marginal zone B-cell lymphoma
of MALT type
Nodal marginal zone B-cell lymphoma
(+/— monocytoid B cells)
Follicular lymphoma
Mantle-cell lymphoma
Diffuse large B-cell lymphoma
Mediastinal large B-cell lymphoma
Primary effusion lymphoma
Burkitts lymphoma/Burkitt cell leukemia
T-cell and NK-cell neoplasms
- Precursor T-cell neoplasm:
T-lymphoblastic lymphoma/leukemia
- Mature (peripheral) T-cell neoplasms:
T-cell prolymphocytic leukemia
T-cell granular lymphocytic leukemia
Aggressive NK-cell leukemia
Adult T-cell lymphoma/leukemia (HTLV1 +)
Extranodal NK/T-cell lymphoma, nasal type
Enteropathy-type T-cell lymphoma
Hepatosplenic gamma-delta T-cell lymphoma
Subcutaneous panniculitis-like T-cell
lymphoma
Mycosis fungoides/Sezary syndrome
Anaplastic large-cell lymphoma, T/null cell,
primary cutaneous type
Peripheral T-cell lymphoma, not otherwise
characterized
Angioimmunoblastic T-cell lymphoma
Anaplastic large-cell lymphoma, T/null cell,
primary systemic type
The Chronic Lymphocytic Leukemia (1)
• Chronic lymphocytic leukemias are derived from:
• B-cell line
– B-cell chronic lymphocytic leukemia
– B-cell chronic prolymphocytic leukemia
– Hairy cell leukemia
– Splenic marginal zone B-cell lymphoma ( + /- villous
lymphocytes)
• T-cell line
– T-cell chronic lymphocytic leukemia
– T-cell chronic prolymphocytic leukemia
– T-cell granular lymphocytic leukemia
• Chronic lymphocytic leukemias differ form each other in biology,
morphology, antigen structure of the cell and in clinical course
The B-CLL - definition
• B-CLL is a neoplastic disease characterized by proliferation and
accumulation of small, mature, long-living lymphocytes in blood,
marrow and lymphoid tissues (lymph nodes, spleen)
• This lymphocytosis leads to specific clinical and laboratory symptoms
of B-CLL
• The neoplastic lymphocytes have on their surface the special for Bcell line antigens – CD19, CD20 and also CD5, CD23, and a very
weak expression of surface immunoglobulin
B-CLL epidemiology
• Most common adult leukemia in Europe and North America (in USA
incidence of about 3/100.000 population)
• predominantly, CLL is a disease of elderly (50-55 years)
• 40% of leukemias in patients over 60 years old
• Morbidity:
– Men 2,2-3,69 / 100 000 / year
– Women 0,9-1,59 / 100 000 / year
/men affect twice as often as women; 2:1 ratio of male to female /
• CLL morbidity rapidly increases with age (especially between 50 and 60
years of age)
• in 98% of patients the leukemic cells are a monoclonal population of
mature B lymphocytes with low-density surface immunoglobulin
• death from infections, BM failure, high-grade transformation (Richter's
syndrome), kachexia
B-CLL etiology & pathogenesis (1)
• the cause of CLL is unknown
• there is increased incidence in farmers, rubber manufacturing
workers and tire repair workers
• genetics factors have been postulated to play a role in high
incidence of CLL in some families
B-CLL etiology & pathogenesis (2)
• Cytogenetics - clonal chromosomal abnormalities are detected in
approximately 50% of CLL patients
• Immunoglobulin genes - monoclonal surface immunoglobulin is
expressed by over 90% of patients (60% kappa and 40% lambda light
chains)
– nearly half of all cases have leukemia cells that express mutated
immunoglobulin variable region genes (Ig VH genes) - associated
with more indolent disease
• Immunologic abnormalities
– autoimmune disease (hemolytic anemia and thrombocytopenia, pure
red cell aplasia)
– hypogammaglobulinemia
– cellular immune defects
B-CLL clinical symptoms (1)
• often none! - 25% of patients are asymptomatic and the diagnosis is
typically accidental
• unspecific: night sweats, fever, weakness (many patients have
fatigue, reduced exercises tolerance or malaise, weight loss)
• recurrent infections (bacterial, viral – Herpes Zoster, fungal) – they
are the most common cause of death
• bleeding and symptoms of anemia and thrombocytopenia
• Lymphadenopathy (lymph node enlargement)
– at diagnosis - nontender in 80% of patients
– later - may become very large
• splenomegaly - mild to moderate in 50% of patients
• hepatomegaly
• some organs infiltration (lungs, pleura, skin and soft tissue)
Blood lymphocytosis does not cause symptoms!
B-CLL clinical symptoms (2)
Cervical and
axillary
limfadenopathy in
60-years old
patient with B-CLL
B-CLL clinical symptoms (2)
Cervical and
axillary
limfadenopathy in
70-years old
patient with B-CLL
B-CLL clinical symptoms (3)
Cervical
limfadenopathy in
patient with B-CLL
B-CLL clinical symptoms (3)
The CLL patient
can have
splenomegaly
B-CLL clinical symptoms (3)
The CLL patient has
splenomegaly, which is
visble
B-CLL laboratory features (1)
• Morphology:
– Leucocytosis with monoclonal lymphocytosis of greater than 5.000/ul.
– anemia
• Because of „displacement ”
• and/or autoimmunohemolic (10-20% of patients have a positive
direct antiglobulin test; AIHA is commonly connected with the
presence of warm auto- antibodies IgG class – rapidly increasing
fatigue, skin getting yellow, anemia with enlarged reticulocytosis,
higher level of bilirubin)
• pure red cell aplasia is very rare (selective aplasia of red cell line
in bone marrow)
– thrombocytopenia
• Because of „displacement ”
• and/or immunologic (about 5% of B-CLL patients have antyplatelet antibodies)
• protein electrophoresis – Hipogammaglobulinemia, monoclonal protein
in 5% of patients
B-CLL laboratory features (2)
• Peripheral blood smear:
– Lymphocytosis
• small, mature, morphologically
normal
– Smudge cells
– Neutropenia
• Because of „displacement ”
• and/or autoimmunologic
B-CLL laboratory features (3)
• Bone Marrow smear (cytological examination)
– extensive replacement of marrow element by mature
lymphocytes (more than 30%)
B-CLL laboratory features (4)
• Bone Marrow Biopsy (histological examination):
Lymphocyte infiltration
– nodular infiltration,
– interstitial infiltration,
– difussed infiltration
– mixed infiltration
Difussed infiltration
(unfavourable
prognostic factor)
B-CLL laboratory features (5)
• Bone Marrow Biopsy
Interstitial
infiltration
B-CLL laboratory features (6)
• lymph node finding (histopathological examination)
- diffuse infiltration of small lymphocytes identical to low-grade, small
lymphocytic lymphoma
B-CLL laboratory features (7)
• Immunophenotype:
– CD5+/CD19+/CD23+/CD20+,
– sometimes also CD38+,
– low expression of CD22;
– lack expression of CD 10-, CD 103-,
– 90% of the patient have a very weak expression of surface
immunoglobulin (kappa or lambda light chain, IgM, IgD)
B-CLL features (8)
• Radiological examinations (X-ray, ultrasonography, CT, ...)
• Serological examinations (direct and indirect antiglobulin tests)
• Biochemical examinations (lactate dehydrogenase, 2-microglobulin)
B-CLL laboratory features (9)
• Cytogenetic examinations - clonal chromosomal abnormalities are
detected in approximately 50% of CLL patients
– deletion 13 (13q14.3)
– trisomy 12
– structural abnormalities of chromosomes 11 (11q-), 14, 17
Genomic aberrations found in approximately 50% of CLL
Diagnosis of B-CLL
Blood test
lymphocytosis ≥ 5G/l (6 weeks)
Morphology
monoclonal population of small mature lymphocyte
B-cell CLL phenotype
clonal CD5+/CD19+ population of lymphocyte
Markers of clonality
κ/λ light chain restriction; cytogenetical abnormalities
Bone marrow infiltration
> 30% of nucleated cells on aspirate
Lymph node
diffuse infiltrate of small lymphocytes
RAI’s CLINICAL STAGING SYSTEM
Stage
Clinical Features at Diagnosis
Median
Survival
(years)
0
Low risk
Blood lymphocytosis>5G/l,
Bone marrow lymphocytosis>30%
>12,5
I
Intermediate risk
Blood lymphocytosis>5G/l,
Bone marrow lymphocytosis>30%
and enlarged lymph nodes
8
II
Intermediate risk
Blood lymphocytosis>5G/l,
Bone marrow lymphocytosis>30%
and enlarged spleen and/or liver
6
III
High risk
Blood lymphocytosis>5G/l,
Bone marrow lymphocytosis>30%
and anemia (Hb < 11g/dl)
1,5-2
IV
High risk
Blood lymphocytosis>5G/l,
Bone marrow lymphocytosis>30%
and thrombocytopenia(< 100 000 /ul)
1,5-2
CLL – Rai stages
BINET’s CLINICAL STAGING SYSTEM
Stage
Clinical Features at Diagnosis
A
Blood lymphocytosis>5G/l,
Bone marrow lymphocytosis>30%
and less than 3 areas of palpable lymphoid-tissue enlargement
Without anemia (Hb >= 6,21 mmol/l, 10 g/dl) and thrombocytopenia
> 120
month
B
Blood lymphocytosis>5G/l,
Bone marrow lymphocytosis>30%
and 3 and more areas of palpable lymphoid-tissue enlargement
Without anemia (Hb >= 6,21 mmol/l, 10 g/dl) and thrombocytopenia
60 month
C
Blood lymphocytosis>5G/l,
Bone marrow lymphocytosis>30%
with anemia (Hgb <10g/dL) or thrombocytopenia (Plt <100.000/uL)
24 month
An area: cervical, axillary left, axillary right,
inquinofemoral left, inquinofemoral right lymph nodes, spleen, liver
Median
Survival
(month)
CLL – Binet’s stages
New prognostic indicators in B-CLL (1)
Prognostic factor
Good prognosis
Bad prognosis
Clinical stage according to
Binet
Rai
A
0
B, C
I, II, III, IV
Non-Difussed infiltration
<=80% lymphocytes
<= 50 x 109/l
<= 10%
Difussed infiltration
> 80% lymphocytes
> 50 x 109/l
>10%
> 12 months
<= 12 months
Bone marrow infiltration in
- bone marrow biopsy
- cytological examination
Leucocytosis
Prolymphocytes in
peripheral blood
Leukemia cell doubling time
New prognostic indicators in B-CLL (2)
Prognostic factor
Good prognosis Bad prognosis
Serum markers:
- lactate dehydrogenase activity
(LDH)
- ß2-mikroglobulin activity
- lymphocyte’s thymidine kinase
activity
- CD23 expression
Normal range
Clonal chromosomal abnormalities
Normal karyotype Del (11q)
isolated del (13q) Del (17p)
CD 38 expression
<= 30 %
Elevated
> 30%
New prognostic indicators in B-CLL (3)
Prognostic factor
Good prognosis Bad prognosis
The mutational status of
mutated
immunoglobulin variable region of
heavy chain genes (IgvH)
unmutated
ZAP–70 expression
low (< 20%)
high ( > 20 %)
Survivin
absence
presence
New prognostic indicators in B-CLL (4)
- summary
•
•
•
•
•
•
•
•
•
clinical stage
bone marrow histology (diffuse replacement carries worst prognosis)
leukemia cell doubling time (less than 1 year - worse prognosis)
percentage of prolymphocyte
high cell-surface expression of CD38
ZAP-70 expression
serum level of: B2-microglobulin; thymidine kinaze, LDH, sCD23
IgVH mutational status
genetic features - FISH cytogenetic
– low-risk: normal kariotype; isolated del(13q)
– high-risk: del(17p0, del(11q), trisomy 12
CLL : ZAP-70
ZAP70 is an intracellular protein which is strongly correlated with the
VH status in CLL
CLL – treatment (1)
• We have to remember:
– B-CLL – indolent lymphoma, but incurable
– Elderly patients – risk of additional diseases
– Course of the disease can be very long, indolent for many years,
patient can die because of another reason which is not connected to BCLL.
• Decision about treatment depends on clinical stage, prognostic factors and
patient’s condition
• Indications to treatment:
• III/IV stage according to Rai’s classification
• Progressive disease (rapidly increasing lymphadenopathy,
infections, general symptoms)
• leukemia cell doubling time <6 (12) months
• rapidly increasing organomegaly
• Secondary anemia, neutropenia, thrombocytopenia because of
bone marrow infiltration
• Richter’s syndrome
CLL – treatment (2)
• Watch and wait
• Monotherapy
– Glucocorticoids (autoimmunological complications)
– alkylating agents (Chlorambucil, Cyclophosphamide)
– purine analogues (Fludarabine, Cladribine, Pentostatin)
• Combination chemotherapy
– Chlorambucil/Cyclophosphamide + Prednisone
– purine analog (Fludarabine) + Cyclophosphamide +/- Mitoxantrone
– CVP, CHOP (Cyclophosphamide, Doxorubicin, Vincristin,
Prednisone)
• Monoclonal antibodies (monotherapy and in combination)
– Alemtuzumab (anti-CD52) = CAMPATH
– Rituximab (anti-CD20) = Mabthera
– antiCD23 etc.
– monoclonal antibodies conjugated with radionuclides = Ibritumomab
tiuxetan = Zevalin
• Splenectomy (hypersplenism)
• Radiotherapy (massive lymphadenopathy)
CLL – treatment (3)
• Hematopoietic stem cell transplantation
– autologous - still no cure with auto-SCT
– allogenic with reduced intensity conditioning
• Even RIC-SCT is still a risky procedure - indicated only in highrisk disease
• Can allo-SCT cure CLL? - YES
• New and novel agents
– Oblimersen – bcl2-directed antisense oligonucleotide
– Lenalidomide
– Flavopiridol
– Anti-CD23
– Anti-CD40
• Vaccine strategies
• Supportive therapy (allopurinol, G-CSF, blood and platelet transfusion,
immunoglobulins, antibiotics)
Response criteria
(NCI working group 1996)
• Complete response (for at least 2 months)
– clinical features – normal
– morphology – normal (Hb>11 g/dl; Pt>100 000 /ul, lymphocytes
<4000 G/l; neutrofiles >1500 G/l))
– bone marrow - lymphocytosis less than 30%
• Partial response
• Stable Disease
• Progressive Disease
Richter’s Syndrome
• is always the transformation of CLL into an aggressive Lymphoma –
diffuse large cell lymphoma (DLCL) or Hodgkin‘s lymphoma
• usually evolves after a long indolent course • can occur as 1st manifestation of CLL: Primary Richter‘s - but still
CLL
• has a poor prognosis