Post on 26-Mar-2015
PARALLELISMO TRA PROFILO PARALLELISMO TRA PROFILO GENETICO-MOLECOLARE ED GENETICO-MOLECOLARE ED
ETEROGENEITA’ FENOTIPICA, CLINICA ETEROGENEITA’ FENOTIPICA, CLINICA E PROGNOSTICA DELLA LLCE PROGNOSTICA DELLA LLC
Robin FoàRobin FoàEmatologiaEmatologia
Università “Università “La SapienzaLa Sapienza”, Roma”, Roma
Rieti, 27 Ottobre 2006Rieti, 27 Ottobre 2006
CHRONIC LYMPHOCYTIC LEUKEMIA
• Most frequent leukemia in Western countries (30% of all leukemias vs 2-5% in Asian countries).
• Median age at diagnosis: c65 yrs • M/F ratio 1.5:1• Familial cases (4-5% first-degree relatives?)• Diagnosis usually made in asymptomatic individuals• Lymphadenopathy, splenomegaly, infections• Immune disturbances hypogammaglobulinemia
(20 - 40%), AIHA (10 - 20%), T and NK cell defects
CLL: WHY RELATIVE INTERESTCLL: WHY RELATIVE INTERESTIN THE PAST YEARS?IN THE PAST YEARS?
• A disease of the ‘elderly’; median age c65 yrs A disease of the ‘elderly’; median age c65 yrs
• A disease with a chronic, often indolent, A disease with a chronic, often indolent, clinical courseclinical course
• No grips on the heterogeneous clinical No grips on the heterogeneous clinical coursecourse
• Limited therapeutic options, namely Limited therapeutic options, namely chlorambucilchlorambucil
• A conservative, often A conservative, often ‘wait and watch’‘wait and watch’ management has been the treatment of choicemanagement has been the treatment of choice
CHANGE IN ATTITUDE TOWARDS CLLCHANGE IN ATTITUDE TOWARDS CLL Increased prevalence due to extended life expectancyIncreased prevalence due to extended life expectancy
Biologic age Biologic age who is old nowadays??who is old nowadays??
Increasingly diagnosed in younger individuals Increasingly diagnosed in younger individuals c20% of patients under 55 yrsc20% of patients under 55 yrs
Increased diagnosis due to broader use of routine blood tests
Identification of biologic features of prognostic relevanceIdentification of biologic features of prognostic relevance
New therapeutic options, including auto and New therapeutic options, including auto and allotransplantation procedures, MoAb and new drugsallotransplantation procedures, MoAb and new drugs
Concept of living (and working) with leukemiaConcept of living (and working) with leukemia quality of life and overall expectationsquality of life and overall expectations
CLL - EXTENDED BIOLOGIC CHARACTERIZATION
• For a better understanding of theFor a better understanding of the pathophysiology pathophysiology of the diseaseof the disease
• For a more accurate For a more accurate diagnostic definitiondiagnostic definition• For a biologically-based For a biologically-based prognosticprognostic stratificationstratification
of patientsof patients• For the dFor the definition of markers for MRD monitoring• For an optimal For an optimal therapeutictherapeutic (or non-therapeutic) (or non-therapeutic)
algorythmalgorythm• ? For the design of ? For the design of innovative therapeutic innovative therapeutic
strategiesstrategies
Approaches Utilized for a Modern Characterization of CLL
• Morphology dd, typical vs atypical CLL• Immunophenotype dd, typical vs atypical CLL,
CD38 expression, degree of antigen expression• Cytogenetics for prognostic stratification• Mutated or unmutated IgVH profile for
prognostic stratification• ZAP-70 expression for prognostic stratification• Further biologic properties of leukemic cells, cell-to-
cell interplay and cytokine network(s)• Host immune status T cells, NK cells, DC, etc• Gene profiling
CLLCLL PLL HCL SLVL MCL FL PLL HCL SLVL MCL FL
sssIIIggg +++++++++ ++++++ ++++++ ++++++ ++++++
CCCDDD555 +++ +++
CCCDDD222333 +++ ///+++ ///+++
FFFMMMCCC777 +++ +++ +++ +++ +++
CCCDDD222222 ///+++ +++ +++ +++ +++ +++
CCCDDD111000 (((+++))) +++
CCCDDD777999bbb +++ ///+++ +++ +++ +++
PHENOTYPE OF B-CELL CHRONIC PHENOTYPE OF B-CELL CHRONIC LYMPHOPROLIFERATIVE DISORDERSLYMPHOPROLIFERATIVE DISORDERS
(TdT-/CD19/20+)(TdT-/CD19/20+)
CLLCLL
SIgSIg++
CD5+CD5+
CD22-/+CD22-/+CD20CD20++
CD23++CD23++
FMC-7-/+FMC-7-/+
CD19+
SIg++SIg++
CD5+CD5+
FMC7+FMC7+
CD22++CD22++
CD20++CD20++
CD23-/+ CD23-/+ MCLMCL
"ATYPICAL" CLL"ATYPICAL" CLL• On morphological grounds: On morphological grounds: cases with a cases with a
typical immunophenotypic profile, but with typical immunophenotypic profile, but with more than 10% of large lymphocytes and/or more than 10% of large lymphocytes and/or prolymphocytes and/or cells with nuclear cleftsprolymphocytes and/or cells with nuclear clefts
• On immunophenotypic grounds: On immunophenotypic grounds: cases with cases with a typical morphology, but with the expression a typical morphology, but with the expression of FMC7 and/or of bright sIgof FMC7 and/or of bright sIg
‘‘Atypical’ CLL account for c20% of Atypical’ CLL account for c20% of cases, have a more advanced disease and a cases, have a more advanced disease and a
worse prognosisworse prognosis
FREQUENCY OF CHROMOSOME LESIONS IN CLLFREQUENCY OF CHROMOSOME LESIONS IN CLL(comparison of CCA and FISH)(comparison of CCA and FISH)
Aberration Cytogenetics (*) FISH (**)
Clonal 30-50% 82%
Normal 50-70% 18%
del 13q14 single 7-11% 36-45%
12q trisomy 13-19% 11-14%
del 11q22-23/ATM 6-13% 8-25%
del 17p/p53 1-5% 3-7%
del 6q21 1% 2%
(*) % total abnormal(**) Dohner et al, 2001 EHA
Survival and specific chromosome aberrations Survival and specific chromosome aberrations Dohner et al, NEJM (2000)Dohner et al, NEJM (2000)
SURVIVAL BASED on IgV MUTATION STATUS and SURVIVAL BASED on IgV MUTATION STATUS and CD38 EXPRESSION among B-CLL of RAI CD38 EXPRESSION among B-CLL of RAI
INTERMEDIATE RISKINTERMEDIATE RISK
Damle et al. Blood 1999;94:1840
B-CLL UTILIZING VB-CLL UTILIZING VHH3-21 REPRESENT 3-21 REPRESENT
an UNFAVORABLE PROGNOSTIC SUBSET an UNFAVORABLE PROGNOSTIC SUBSET
of B-CLL with MUTATED IgVof B-CLL with MUTATED IgVHH GENES GENES
Blood 99:2262, 2002
““SUPERSTABLE” CLL PATIENTSSUPERSTABLE” CLL PATIENTS
Guarini et al, Blood 102, 1035, 2003
IgVH, CD38, p53 & CD4/CD8 IN ‘IgVH, CD38, p53 & CD4/CD8 IN ‘SUPERSTABLESUPERSTABLE’ CLL’ CLLCaseCase % Mutated IgV% Mutated IgV % CD38% CD38 p53 CD4/CD8 ratiop53 CD4/CD8 ratio 11 4.7 4.7 1 1 wt wt n.d.n.d. 22 7.6 7.6 3 3 wt wt 2 2 33 3.3 3.3 48 48 wt wt 1.2 1.2 44 5.0 5.0 1 1 wt wt 2.182.18 55 3.6 3.6 2 2 wt wt 1 1 66 7.0 7.0 1 1 wt wt 4 4 77 11.4 11.4 1 1 wt wt 2.5 2.5 88 6.0 6.0 1 1 wt wt 3 3 99 6.1 6.1 1 1 wt wt 2 2 1010 3.6 3.6 1 1 wt wt 1.661.66 1111 12.7 12.7 1 1 wt wt 2.282.28 1212 7.5 7.5 1 1 wt wt 2.2 2.2 1313 8.4 8.4 1 1 wt wt 2 2 1414 1.3 1.3 1 1 wt wt 2 2 1515 10.7 10.7 1 1 wt wt 1 1 1616 7.5 7.5 9 9 wt wt 2.6 2.6 1717 3.8 3.8 4 4 wt wt 1 1 1818 4.0 4.0 6 6 wt wt 2.5 2.5 1919 4.7 4.7 2 2 wt wt 4.5 4.5 2020 10.8 10.8 1 1 wt wt 3.663.66
Guarini et al, Blood 2003
Plasma cells
Germinal Center and Lymphomagenesis
Naive B-cell
GC cells
Memory B-cells
BCL-6
Syndecan
CLL MCL FL BL
Apoptosis
IgV mutationsDLCL MM
- ++
IgV hypermutationIg isotype switch
CLL
-
MZ
Schroeder & Dighiero. Immunol Today, 1994Hamle et al. Blood, 2000Hamblin et al. Blood, 2000
OTHER DLBCL CLL
NON MUTATED
MUTATED HIGH & LOW
Rosenwald et al (J Exp Med 2001)
NON MUTATED
MUTATED HIGH & LOW
Klein et al (J Exp Med 2001)
CLL is a unique disease with two different features:
Rosenwald et al (J Exp Med 2001)
<20% ZAP70
20% ZAP70
Crespo et al., NEJM 2003
Survival probability according to ZAP70 expression (A stage)
ZAP70 expression and IgVH mutational status
Diagnosis• CLL is a heterogeneous disease, not only
from the clinical standpoint– Morphology– Immunophenotype– IgV mutated vs IgV unmutated– Zap-70+ vs Zap-70-– Cytogenetic/genetic -clinical correlates– Gene profile
How many diseases?
CHRONIC LYMPHOCYTIC LEUKEMIACHRONIC LYMPHOCYTIC LEUKEMIA PASTPAST
WAIT & SEEWAIT & SEE
CHLORAMBUCIL CHLORAMBUCIL
CONSERVATIVE CONSERVATIVE APPROACHAPPROACH
PRESENTPRESENT
* Fludurabine CR
* Combined chemotherapy (eg Fluda+Cyclo)
* MoAb (Rituximab, Campath)
* Chemo + MoAb (FCR, FluCam)
* Other purine analogs (2-CdA, DcF)
* Transplantation programs (auto, allo, ric allo)
* Allografting/minitransplant ± DLI
* New drugs and compounds
HEMATOPOIETIC TOXICITY ASSOCIATED WITH IMMUNE DEPRESSION (DEFICIT T, NK, DC)
A Few Concepts to be Considered for the Optimal Management of CLL Patients
• Age-dependent treatment (taking into account biologic age)
• Early and aggressive treatment may be curative
• Change in definition of remission
• High remission rate after first-line therapy associated with longer PFS
• Choice of first-line treatment is very important
MODERN APPROACH TO THE MODERN APPROACH TO THE MANAGEMENT OF CLLMANAGEMENT OF CLL
• An integrated biologic An integrated biologic work-up at diagnosiswork-up at diagnosis
• A biologically-based A biologically-based prognostic stratificationprognostic stratification and and possible design of a new possible design of a new scoring systemscoring system
• A biologically-based A biologically-based therapeutic (and non-therapeutic (and non-therapeutic) algorythmtherapeutic) algorythm
• Change in “therapeutic” approach for “younger” Change in “therapeutic” approach for “younger” patients with poor prognostic factors?patients with poor prognostic factors?
• Early and aggressive treatment?Early and aggressive treatment?
• Aim at Aim at disease eradication disease eradication (MRD monitoring) ??(MRD monitoring) ??
CD38 EXPRESSION FREQUENCY IN B-CD38 EXPRESSION FREQUENCY IN B-
CELL CHRONIC LYMPHOPROLIFERATIVE CELL CHRONIC LYMPHOPROLIFERATIVE
DISORDERS DISORDERS AT DIAGNOSISAT DIAGNOSIS
PATIENTSPATIENTS CD38+>10%CD38+>10% CD38+ >20%CD38+ >20%
CLL (N° 110)CLL (N° 110) 19 (17.2%)19 (17.2%) 15 (13.6%)15 (13.6%)
CD5+ NHL (N° 46)CD5+ NHL (N° 46) 25 (54%)25 (54%) 19 (41.3%)19 (41.3%)
NHL (CD5-) (N° 51)NHL (CD5-) (N° 51) 8 (15.6%) 8 (15.6%) 6 (11.7%) 6 (11.7%)
Treatment-Free Survival CD38+ pts: cut-off=20%
p<.0001
CD38 neg
CD38 pos
Gentile et al, BJH 2005
p<.0001
Treatment-Free Survival in Rai Stage 0 Patients According to CD38 Positivity (cut-off=20%)
CD38 neg
CD38 pos
Gentile et al, BJH 2005
Change over Time of Remission Criteria
– Moving away from palliative treatmentclearance of blood major marker
– Moving towards a curative approach
clearance of bone marrow– No longer on a morphologic definition of
remission, but the use of immunophenotypic and genetic monitoring of minimal residual disease
High risk17p13 deletions or p53 mutations, 11q22-q23
deletions and unmutated IgVH
unmutated IgVH ± 12q trisomy ± ZAP-70 ± CD38+
Standard risk
BIOLOGICAL WORK-UP FOR ‘YOUNGER’ CLL
Correct diagnostic definition & dd(ndr, should always take place!)
Phase II pilot study to evaluate a therapeutic strategy diversified accoring
to the biologic profile of patients with CLL with advanced stage and/or
progressive disease aged <60 years
LLC0405 GIMEMA Protocol
“YOUNG” CLL PATIENTS WITH PROGRESSIVE DISEASE
Fludarabine + Campath-1H
NR
agedonor
Auto, AlloTransplantation orFurther Campath
MCR
PBSC
W & W
CR PR
HIGH RISK
OffStudy
agedonor
“YOUNG” CLL PATIENTS WITH PROGRESSIVE DISEASE
Fludarabine + Cyclophosphamide x 4
Standard risk
Campath
CR-CIR
W & W
PBSC
W & W
NR MCR
NR CR CIR PR
W & W
PR
Off study
FC x 2
PROBLEMATICHE
• Ottimale inquadramento diagnostico e diagnosi differenziale
• Stratificazione prognostica alla diagnosi su base biologica almeno fino a 65 anni
problema di numerosità, di tecnologie e competenze, di riproducibilità, di costi
• Possibilità di monitorizzare la MRM (immunologica e molecolare)
clinicalclinicalimmunedeficiencyimmunedeficiency
cellular and humoralcellular and humoralimmune impairmentimmune impairment
Inhibition of Inhibition of CD40L expressionCD40L expression
Stimulation ofStimulation ofIg productionIg production
T B
CLL
CLL
ImpairedImpairedinteractionsinteractions
with B and APCwith B and APC
Immune defects
Tumor cell activation,Tumor cell activation,proliferation and inhibitionproliferation and inhibition
of apoptosisof apoptosis
B-CLL cell accumulation
InappropriateInappropriateproduction ofproduction of
autoreactive antibodiesautoreactive antibodies
Autoimmune phenomena
IL-4IL-4
IL-4IL-4
IL-4IL-4
IL-4IL-4
IgIg
CD40CD40
CD40LCD40L
membrane and soluble membrane and soluble mediator interactionsmediator interactions
genomicgenomiccharacterization, characterization,
new drugsnew drugs
Changes in approach to CLL – From patients to genes
Last decades’ evolution in the understanding of CLL
BNKT
1970s 1970s →→ 80s 80s 1980s 1980s →→ 90s 90s
2000 2000 →→
1995 00s1995 00s NEW THERAPIES
BIOLOGICALLY-BASED PROGNOSTIC STRATIFICATION
AcknowledgmentsAcknowledgments::
A. Guarini, S. De Propris, S. Chiaretti, I. Dalla Starza, A. Guarini, S. De Propris, S. Chiaretti, I. Dalla Starza,
E. Ghia, F. Mancini, R. Maggio, M. Mancini, I. Del E. Ghia, F. Mancini, R. Maggio, M. Mancini, I. Del
Giudice, F.R. Mauro – Giudice, F.R. Mauro – RomeRome
G. Castoldi, A. Cuneo – G. Castoldi, A. Cuneo – FerraraFerrara
G. Gaidano, D. Capello – G. Gaidano, D. Capello – NovaraNovara
J. Ritz – J. Ritz – BostonBoston
GIMEMA networkGIMEMA network