MED B Form CLL. Johannes Schetelig. London 09/April/

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1 MED B Form CLL Johannes Schetelig London 09/April/2013

2 Content Update on CLL (15 ) Experiment with mini MED B CLL Assessment of pre-treatment in CLL Cytogenetics in CLL What is the IGVH-Gene Mutations status? MED B CLL 2

3 Clinical presentation (CLL) Symptoms are mainly caused by cytopenia, lymphadenopathy, hepatosplenomegaly; B-Symptoms Fever Night sweats Weight loss Skin Pruritus Allergy

4 Diagnosis: CLL Differential blood count (microscopy): Lymphocytosis Smudge cells (Gumprecht) Confirmation of diagnose by immunophenotyping

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7 1 1. Head and neck 2 2. Axillae Hepatomegaly 4. Splenomegaly 5 5. Inguinal region

8 MED AB Manual Binet Stage Rai Stage 8

9 Percentage surviving patients Overall survival / Binet-Stage Overall survival / Rai-Stage 1.0 Binet-Stage A: median 14 years 1.0 Rai-Stage 0: median 17 years 0.8 Binet-Stage B: median 5 years Binet-Stage C: median 3 years 0.8 Rai -Stage I II: median 7 years Rai-Stage III IV: median 3 years N = N = Time (years) Time (years) Hospital Clinic Provincial (HCP) Barcelona.

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11 Watch & Wait for symptoms that require therapy Marrow failure (anemia, thrombocytopenia) Lymph nodes > 10 cm Lymphocyte doubling time < 6 months Refractory auto immune cytopenias Constitutional symptomes (B-symptoms or fatigue) Hallek M, et al. Blood 2008;111:

12 Chemotherapy Chlorambucil, Cyclophosphamide, Bendamustin, Fludarabine Antibodies Rituxan, Alemtuzumab, Ofatumumab Immune-Modulators Prednisolone, Dexamethasone, Revlimide Kinase Inhibitors Ibrutinib, Idelalisib

13 Shuffle Clb, R, R-Clb, R-Dexa, HDMP, R-HDMP, F, FR, FC, FCR, FCR-lite, FO, FCO, Flu-Cam, FCR, CFAR, BR, R-Benda, BO, BA, R 2, + lymphoma regimens CHOP, french-chop, DHAP, R-DHAP, radiation + Ibrutinib & Idelalisib &

14 Survival advantage? LRF CLL4 trial Catovsky, Lancet, 2007

15 Results of allogeneic HCT 36% (95%CI, 32%-41%) 47% (95%CI, 43%-51%) 15

16 mini MED B MED B CLL 16

17 Problem - Approach Minimal Essential Data were missing in order to interpret registry results on allogeneic HSCT in CLL: Pre-treatment? Cytogenetics? We carefully designed a comprehensive questionnaire (mini MED B) for patients who received their 1 st allo HSCT between 2000 and 2011 Data on 2897 patients were requested Data Quality Initiative 17

18 Data Quality Initiative 18

19 Data Quality Initiative 19

20 Thank you! Data Quality Initiative 20

21 Participating Countries DQI CLL Czech Republic 98 Denmark 55 Finland 28 France 39 Germany 351 Israel 6 Netherlands 33 Norway 11 Russia 5 Spain 52 Sweden 27 Switzerland 36 UK 30 Total 771 Data Quality Initiative - CLL 21

22 First results Comparison NMA vs. RIC (NA, denmark) New concepts on how to present GVHD (Leiden) Long-term outcome in CLL (LdW & MvG, NL) Descriptive analysis (CM, Spain) Risk factor analysis Data Quality Initiative - CLL 22

23 Assessment of pre-treatment MED B CLL 23

24 Purine-analogue refractory disease (fludara, cladribine, pentostatin), defined as nonresponse or progression within 6 months after CT Relapse within 24 months after PA-based combination chemotherapy CLL with del(17p)

25 Data Quality Initiative 25

26 Treatment report 26

27 Treatment report 27

28 Assessment of pre-treatment I Regimen Date start Date stop Response 28

29 Assessment of pre-treatment I Regimen Date start Date stop Response CLB NN.NN.2004 NN.NN.2008 UK Bendamustin NN NN PR Rituximab NN NN PR... 29

30 Assessment of pre-treatment II TOTAL NUMBER OF LINES BEFORE THIS HSCT: 30

31 Assessment of pre-treatment III CIBMTR current disease status options for NHL and Hodgkins o Disease untreated o PIF res - Primary induction failure resistant: NEVER in COMPLETE remission but with stable or progressive disease on treatment. o PIF sen / PR1 - Primary induction failure sensitive: NEVER in COMPLETE remission but with partial remission on treatment. o PIF unk - Primary induction failure sensitivity unknown o CR1-1 st complete remission: no bone marrow or extramedullary relapse prior to transplant o CR2-2 nd complete remission o CR rd or subsequent complete remission o REL1 unt - 1 st relapse untreated; includes either bone marrow or extramedullary relapse o REL1 res - 1 st relapse resistant: stable or progressive disease with treatment o REL1 sen - 1 st relapse sensitive: partial remission (if complete remission was achieved, classify as CR2) o REL1 unk - 1 st relapse sensitivity unknown o REL2 unt - 2 nd relapse untreated: includes either bone marrow or extramedullary relapse o REL2 res - 2 nd relapse resistant: stable or progressive disease with treatment o REL2 sen - 2 nd relapse sensitive: partial remission (if complete remission achieved, classify as CR3+) o REL2 unk - 2 nd relapse sensitivity unknown o REL3+ unt - 3rd or subsequent relapse untreated; includes wither bone marrow or extramedullary relapse o REL3+ res - 3 rd or subsequent relapse resistant: stable or progressive disease with treatment o REL3+ sen - 3 rd or subsequent relapse sensitive: partial remission (if complete remission achieved, classify as CR3+) o REL3+ unk - 3 rd relapse or greater sensitivity unknown 31

32 Assessment of pre-treatment IV Med-A June12 Status at HSCT: DISEASE HISTORY NUMBER OF PRIOR LINES OF TREATMENT unknown DISEASE STATUS: assessed at the time of HSCT TECHNIQUE used for the assessment: CT scan Cheson 1999: J Clin Oncol 17: sion (CR) Complete remission unconfirmed (CRU*) Number of this CR/CRu higher unknown *CRU complete response with persistent scan abnormalities of unknown significance, previously known as VGPR Partial response (PR) Number of this PR higher unknown Stable disease (SD) Chemorefractory progression Untreated relapse (from a previous CR)/progression (from a previous PR) Never treated Unknown TECHNIQUE used for the assessment: PET Cheson 2007: J Clin Oncol 25: Positive Negative Not done IF DISEASE STATUS IS NOT CR/CRU Did the patient ever achieve a CR/CRu before this HSCT? No Yes unknown Number of remissions (CR, CRu or PR) achieved by the patient prior to this HSCT Count all remissions including this one if applicable unknown 32

33 Assessment of pre-treatment IV Status at HSCT No. of lines of treatment? Status at HSCT? If status is not CR/CRu, has CR/CRu ever been achieved? Number of remissions (CR/CRu, PR) ever achieved prior to this HSCT? Options 1,2,3 or more, NK CR, PR. SD, PD, NK Yes/No/NK 1,2,3, Subtable if CR at HSCT no of this CR if PR at HSCT no of this PR Options 1 st, 2 nd, 3 rd or higher, NK 1 st, 2 nd, 3 rd or higher, NK 33

34 Which option do you think is best? Option 1: Collect raw data (regimen, start, stop, remission) Option 2: summarizing questions with underlying defs Option 3: combining information on status and no of previous remissions Option 4: counting lines of pre-treatment and number of remissions 34

35 Cytogenetic Report MED B CLL 35

36 Results from FISH screening in 325 patients with newly diagnosed CLL: 175 pts had a single abnormality, 67 had two and 26 > two abnormalities mir-15a/mir-16-1 located on 13q14.3 both downregulating Bcl2-expression Döhner, et al. NEJM 2000, 343,

37 Überleben (%) 100 Ausschließlich 13q-Deletion q-Deletion Trisomie 12q 20 17p-Deletion Normal Zeit (Monate) Döhner NEJM 2000

38 Cytogenetic Report 38

39 Karyotype Formula Karyotype (ISCN): 46, XY,?inv(12)(p11.2q13)[2]/46,XY [8].nuc ish 11q22.3(ATMx2) [200],(D12Z3x2) [200], 13q14(D13S319x2) [200], 13q34(SHGC ,PROZ,CUL4A,LAMP1,D13S1020[200], WI-9415)x2[200],14q32(IGHx2)[200],(D17Z1x2) [200],17p13(TP53x2)[200] 39

40 Karyotype Formula Karyotype (ISCN): 46, XY,?inv(12)(p11.2q13)[2]/46,XY [8].nuc ish 11q22.3(ATMx2) [200],(D12Z3x2) [200], 13q14(D13S319x2) [200], 13q34(SHGC ,PROZ,CUL4A,LAMP1,D13S1020[200], WI-9415)x2[200],14q32(IGHx2)[200],(D17Z1x2) [200],17p13(TP53x2)[200] Summary: questionable inversion 12 40

41 Conventional Banding Technique 41

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44 Karyotype Formula Karyotype (ISCN): 46, XY,?inv(12)(p11.2q13)[2]/46,XY [8].nuc ish 11q22.3(ATMx2) [200],(D12Z3x2) [200], 13q14(D13S319x2) [200], 13q34(SHGC ,PROZ,CUL4A,LAMP1,D13S1020[200], WI-9415)x2[200],14q32(IGHx2)[200],(D17Z1x2) [200],17p13(TP53x2)[200] Summary: questionable inversion 12 44

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46 Report on FISH analysis 46

47 Cytogenetic Report Distinguish between banding & FISH The banding analysis is comprehensive but less sensitive to specific lesions (microdeletions) FISH analysis is more sensitive, but you see only what you are looking for (which probes you use) 47

48 Cytogenetic Report in MED B 48

49 Summary Brief update on CLL Report on DQI in CLL How should pre-treatment information be collected? Cytogenetic reports IGVH mutations status 49

50 Thank you! MED B CLL 50

51 IGHV Mutationstatus MED B CLL 51

52 Chiorazzi, NEJM, 2005

53 Result IGVH sequencing 53

54 Report on IGVH mutation status 54

55 Report on IGVH mutation status 55

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57 Among healthy adults enrolled in the PLCO Cancer Screening Trial 45 subjects were identified in whom CLL was diagnosed later. Samples from these patients were re-analysed by FACS for MBL or by RT-PCR for IgV(h)-rearrangement 44 of 45 patients had a prediagnostic B-cell clone by either FACS or PCR and 41 patients by both methods. Time between collection of pre-diagnostic sample and diagnosis of CLL median 32 months (3 to 77 ) Landgren, NEJM, 2009, 360,

58 Rawstron, NEJM, 2008, 359,

59 Age group [years] Prevalence of MBL % % % % % > 89 75% Nieto, Blood, 2009, 114,

60 Minimal residual disease MED B CLL 60

61 Clearance of CLL-cells 5000 skin GVHD Days after allogeneic HCT

62 Report on MRD 62

63 Minimal Residual Disease FISH: Reported as being present: Yes / No Reported as percentage of lymphocytes with CLL immunophenotype or as absolute number PCR: Reported as being present: Yes / No Reported as percentage of lymphocytes with CLL immunophenotype or as absolute number 63

64 Remission Status MED B CLL 64

65 Reference Document: 65

66 Remission Criteria iwcll 66

67 Complete Remission CR Absence of clonal lymphocytes in the peripheral blood and absence of significant lymphadenopathy (e.g. LN >1,5 cm in diameter) and absence of hepatomegaly or splenomegaly and absence of constitutional symptoms. This definition of CR refers to clinical response. Not included are results obtained by immunophenotyping, cytogenetics and/or molecular biology. CR incomplete All CR criteria fulfilled except for anemia, thrombocytopenia and neutropenia. 67

68 Partial Remission To define a PR, at least two of the following parameters need to be documented for a minimal duration of 2 months: Decrease in blood lymphocytes 50% Decrease in lymph node size 50% (SPD or largest diameters) Decrease in size of the spleen/liver 50% Decrease of BM infiltration 50% The blood count should show one of the following results if abnormal prior to therapy: Neutrophils >1.500/μL or 50% improvement without G-CSF support Platelets > /μL or 50% improvement over baseline; Hemoglobin >11.0 g/dl or 50% improvement without transfusions or EPO support. 68

69 Stable Disease 69

70 Clinical Staging (CLL) Staging according to Binet (1981) Stage LK-Regions Hemoglobin Thrombocytes Survival A <3 6,5 mmol/l 100 Gpt/l > 10 years B 3 6,5 mmol/l 100 Gpt/l 5 years C any < 6,5 mmol/l < 100 Gpt/l 2 years LK-Regions: cervical, axillär, inguinal, liver, spleen (palpation) Alternative classification according to Rai: stage 0-IV