Global warming in the leukaemia microenvironment: Chronic Lymphocytic Leukaemia (CLL) Nina Porakishvili

Transcription

1 Global warming in the leukaemia microenvironment: Chronic Lymphocytic Leukaemia (CLL) Nina Porakishvili

2 Working plan Case study; Epidemiology; Diagnosis; Immunobiology; Prognostication; Stratification and treatment; Our own research

3 Case study The patient is a 73 year old man who was found to have mild splenomegaly on a routine physical examination. White count was normal but there was a slight relative lymphocytosis, and a platelet count of 100,000. A peripheral blood specimen was sent for flow cytometry.

4 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 not tender in 80% of patients later - may become very large splenomegaly - mild to moderate in 50% of patients hepatomegaly Clinical symptoms

5 Lymphadenopathy in 60-years old patient with B-CLL

6 CLL epidemiology and aetiology The most common adult leukemia in Europe and North America (in USA incidence of about 3/ population) Predominantly, CLL is a disease of elderly; Male to female ratio 1.7:1; Morbidity: Men: 2,2-3,69 / / year Women: 0,9-1,59 / / year Morbidity rapidly increases with age.

7 Age-related incidence of CLL Redaelli et al., 2004

8 Age and gender-related incidence of CLL

9 Epidemiology Race Higher in Caucasians; Lower in African Americans; Asian and Pacific Islanders; 90% lower in China and Japan; Japanese in Hawaii incidence = Japan (Points to genetic rather than environmental factors);

10 Epidemiology Environmental Risks None known; No increase in atomic bomb survivors; Possibly: Rubber manufacturers Farmers Benzene/solvents Multiple pneumonias

11 Epidemiology Family Studies Family members of CLL patients have greater risks of: Lymphoid malignancies; Hematologic malignancies; Solid malignancies.

12 Diagnosis of CLL Blood test lymphocytosis greater than 5.000/μl (6 weeks) Morphology B-cell CLL phenotype monoclonal population of small mature lymphocytes clonal CD5+/CD19+ population of lymphocytes Markers of clonality κ/λ light chain restriction; cytogenetic abnormalities Bone marrow infiltration > 30% of nucleated cells on aspirate Lymph node diffuse infiltrate of small lymphocytes

13 Peripheral blood smear: CLL laboratory features 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). Neutropenia Smudge cells

14 Bone Marrow smear (cytological examination) extensive replacement of marrow elements by mature lymphocytes (more than 30%) CLL laboratory features

15 Differential flow cytometry diagnosis of CD19 lymphocytosis Dighiero and Hamblin, 2008 Plus with bacterial and viral infections

16 Flow cytometry diagnosis

17 CLL Binet staging system Stage Blood Counts Involved Areas Median survival (years) A B C Hb >100 g/l and platelets > /L Hb >100 g/l and platelets > /L Hb <100 g/l or platelets < /L, or both <3 >10 >3 7 Any number 5

18 Binet staging and survival

19 CLL Rai staging system Stage Modified Stage Description Median survival (years) 0 Low-risk Lymphocytosis a > 10 I Intermediaterisk Lymphocytosis+ lymphadenopathy 7-9 II Intermediaterisk Lymphocytosis+ splenomegaly± lymphadenopathy 7-9 III High-risk Lymphocytosis + anemia a ± lymphadenopathy or splenomegaly IV High-risk Lymphocytosis + thrombocytopenia a ± anemia ± splenomegaly ± lymphadenophaty

20 Rai staging and survival

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24 Tumour Dormancy A clinical phenomenon in which tumour cells are present but the population does not increase for long periods of time; Tumour cells can re-grow many years or even decades later; Represents an important clinical problem.

25 Mechanisms of Tumour Dormancy Angiogenic Dormancy: Balance between angiogenic stimulators and inhibitors Cellular Dormancy: Cell cycle arrest: Suppressive effects of the immune system.

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27 The most used prognostic factors in CLL Unmutated Immunoglobulin Heavy Variable (IGVH) genes are associated with poor prognosis; Expression of CD38 in associated with poor prognosis; High expression of ZAP-70 tyrosine kinase is associated with poor prognosis; CLL cells with these characteristics are resistant to chemotherapy; Lymphocyte doubling time.

28 Unfavourable prognosis: high lymphocyte doubling time Probability of survival Survival time according to LDT (all stages) Months Doubling time 12 months Doubling time >12 months Montserrat E, et al. Br J Haematol. 1986;62: )

29 The most used prognostic factors in CLL Unmutated Immunoglobulin Heavy Variable (IGVH) genes are associated with poor prognosis; Expression of CD38 in associated with poor prognosis; High expression of ZAP-70 tyrosine kinase is associated with poor prognosis; CLL cells with these characteristics are resistant to chemotherapy; Lymphocyte doubling time.

30 Chiorazzi et al., 2005

31 Chiorazzi et al., 2005

32 Prognosis: effect of IGVH gene mutations on survival

33 The most used prognostic factors in CLL Unmutated Immunoglobulin Heavy Variable (IGVH) genes are associated with poor prognosis; Expression of CD38 in associated with poor prognosis; High expression of ZAP-70 tyrosine kinase is associated with poor prognosis; CLL cells with these characteristics are resistant to chemotherapy; Lymphocyte doubling time.

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35 Percent surviving (%) Prognosis: effect of CD38 expression on survival Months CD38 30% Mean = months CD38 <30% Mean = 288 months N=162 P= Orchard JA, et al. Lancet. 2004;363:

36 The most used prognostic factors in CLL Unmutated Immunoglobulin Heavy Variable (IGVH) genes are associated with poor prognosis; Expression of CD38 in associated with poor prognosis; High expression of ZAP-70 tyrosine kinase is associated with poor prognosis; CLL cells with these characteristics are resistant to chemotherapy; Lymphocyte doubling time.

37 Probability of survival (%) ZAP-70 expression and survival of patients with Binet stage A CLL <20% ZAP-70-positive cells 20% ZAP-70-positive cells N=44 P= Years after diagnosis 1. Crespo M, et al. N Engl J Med. 2003;348:

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39 Proportion surviving Unfavourable prognosis: high levels of soluble 2- microglobulin in untreated CLL Effect of 2 -microglobulin on survival in untreated CLL Pts Died 2 M < > Years 1. Keating M. Unpublished data. 2. Hallek M, et al. Leuk Lymphoma. 1996;22: Sarfati M, et al. Blood. 1996;88: Fayad L, et al. Blood. 2001;97:

40 MHC Class I Domain Organisation

41 Probability Unfavourable prognosis: high levels of scd U/mL >574 U/mL Months Sarfati M, et al. Blood. 1996;88:

42 Genetic abnormality Genetic abnormalities in CLL Incidence (%) Median survival (months) Clinical correlation del 13q Typical morphology Mutated IGVH Stable disease Atypical morphology Progressive disease del 11q Bulky lymphadenopathy Unmutated IGVH genes Progressive disease Early relapse post autograft p53 loss/mutation in 17p Atypical morphology Unmutated V H genes Advanced disease Drug resistance

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44 Dighiero and Hamblin, 2008

45 Effect of genetic abnormalities on survival Döhner H, et al. N Engl J Med. 2000;343:

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47 P53 mutations in chronic lymphocytic leukemia

48 Major complications Immunodeficiency: Recurrent infections, hypogammaglobulinemia, increased risk of secondary malignancies. Autoimmunity haemolytic anaemia.

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50 When to Treat? Classic Paradigm Non-immune Anemia/ Thrombocytopenia Symptomatic splenomegaly Symptomatic Lymphadenompathy Proposed Paradigm Treat based on risk And symptoms wait and watch approach

51 Conventional treatment of CLL

52 Dighiero and Hamblin, 2008

53 Gribben, 2008 Treatment regimes

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55 MoAbs for CLL Antibody Alemtuzumab (Campath-1H) Rituximab (Rituxan, Mabthera) Epratuzumab (LymphoCide) Hu-1D10 (Apolizumab) IDEC-152 (Lumiliximab) IDEC-114 Bevacizumab (Avastin) BL-22 Antigen CD52 CD20 CD22 HLA-DR CD23 CD80 VEGF CD22( conjugate with Pseudomonas)

56 Alemtuzumab CAMPATH-1 Monoclonal Antibody CD52 antigen Expressed on approximately 5% of lymphocyte surface Exceptionally lytic with human complement Different isotypes and variants: Campath-1M Campath-1G Campath-1H rat IgM rat IgG2b human IgG1

57 Hallek, 2013

58 Byrd et al., 2014

59 Hallek, 2013

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64 Hallek, 2013

65 FAQ What is the mechanism of the resistance to apoptosis of UM, CD38+ or ZAP70+ B-CLL cells? Are there two different diseases: with the expansion of mutated or unmutated B-CLL clones? Why B-CLL cells removed from the blood quickly die from apoptosis in vitro?

66 Kostareli et al., 2012

67 CD180 Protein 661 aa. extracellular domain has leucine rich motif; maps to 5q ; Anti-CD180 primes B cell for IgM-mediated apoptosis. Orphan receptor; 74% identity with murine RP105 (radiation protection: protects from radiation-induced apoptosis); Found on blood B lymphocytes, tonsilar mantle zone B cell, but weak/absent in germinal centres, also expressed by monocytes, dendritic cells. Associates with MD-1 - required for activation. Antibodies to CD180 result in proliferation of normal B cells.

68 CD180/MD1 and TLR4/MD2

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72 Porakishvili et al., Br J Haematol, 2005, 2011 CD180 is preferentially expressed by B-CLL clones using mutated (M) IgVh genes compared to those with unmutated IgVh genes (UM)

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78 Pre-ligation of CD180 re-directs sigm-induced PI3K/BTK/AKT signalling pathways towardsp38mapk activation hardly happens Porakishvili et al., 2015

79 Porakishvili et al., 2011, 2015 IgM IgD AKT

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82 Acknowledgements Dr Ketki Vispute UoW/UCL Dr Tamar Tsertsvadze, TSU Dr Nina Kulikova, TSU Nadeeka Rajakaruna UoW Uzma Syed UoW Kristina Zaitseva - UoW Dr Andrew Steele UCL/SOTON Professor Amit Nathwani - UCL Professor Edward Clark University of Seattle Professor Nicholas Chiorazzi NY, Feinstein institute Dr Sergey Krysov, QM, London Professor Peter Lydyard, UCL/UoW