Chromosome Banding Analysis in CLL Panagiotis Baliakas, MD-PhD

Chromosome Banding Analysis in CLL Panagiotis Baliakas, MD-PhD Dept of Immunology, Genetics and Pathology Science for Life Laboratory, Uppsala University Medical Genetics, University Hospital, Uppsala

Cytogenetic analysis is clinically relevant in hematology Döhner H et al. Blood 2017

Cytogenetic analysis is clinically relevant in hematology Greenberg PL et al. Blood 2012

Do we think genetically in CLL?

Döhner H et al. N Engl J Med 2000 Puente et al. Nature 2011/Wang et al. N Engl J Med. 2011 Jeronim et. Leukemia 2014/Baliakas et al. Leukemia 2015 Do we think genetically in CLL? 11q del Isolated del13q 13q del only 12q trisomy Is there still a place for chromosome banding analysis (CBA) 17p del (N = 325) Normal in CLL? 0 24 48 72 96 120 144 168 Time (months)

CBA in CLL travelling back in time......the frequency of chromosomal abnormalities in the disease appears to be much higher than has previously been thought... Blood 1980

Cytogenetic complexity in CLL: clinical considerations Juliusson G et al. NEJM 1990 Dierlamm J et al. Cancer Gent Cytogen 1997

Survival (%) Temporarily at the backstage Is FISH-analysis enough? 100 80 60 40 17p del (N = 325) 11q del Time (months) 13q del only Isolated del13q Is FISH-analysis informative of the 12q trisomy actual clonal cytogenetic background? Should we care about aberrations that 20 Normal are not detected by FISH? 0 0 24 48 72 96 120 144 168 Döhner H et al. N Engl J Med 2000

Missing the forest for the trees? Cases with normal FISH or isolated del(13q) may harbor complex karyotype without CK with CK Baliakas et al. AJH 2014

Cytogenetic complexity in CLL open issues What is the predictive significance? Which are the actual links to TP53 abnormalities? What is the significance of complex karyotype in the era of novel agents?

Cytogenetic complexity inferior outcome after FCR...patients without presence of chromosome 17 or complex cytogenetic abnormalities demonstrated better response duration and survival after therapy. Badoux XC et al. Blood 2011

Cytogenetic complexity inferior outcomes in CLL11 Herling CD et al. Blood 2016

Cytogenetic complexity predicts for inferior outcome to ibrutinib in R/R CLL Thompson PA. Cancer 2015

Cytogenetic complexity predicts for inferior outcome to ibrutinib in R/R CLL CK was associated with inferior OS (25 months) independently of del(17p) Concerns Low number of cases No data on TP53 mutations Different treatment regimens Thompson PA. Cancer 2015

Idelalisib may overcome the adverse impact of cytogenetic complexity in R/R CLL Kreuzer KA. ASH 2016

Idelalisib may overcome the adverse impact of cytogenetic complexity in R/R CLL Kreuzer KA. ASH 2016

Idelalisib may overcome the adverse impact of complex karyotype in R/R CLL No impact of CK or TP53abs on PFS or OS for CLL patients treated with Idelalisib-R Concerns Very low success rate regarding CBA Short follow up Kreuzer KA. ASH 2016

Cytogenetic complexity predicts for inferior outcome to venetoclax in R/R CLL Anderson MA et al. Blood 2017

Cytogenetic complexity predicts for inferior outcome to venetoclax in R/R CLL Concerns Low number of patients Heterogeneous prior treatment regimens No prior exposure to BcR inhibitors No multivariate analysis

Cytogenetic complexity in CLL - open issues What is the clinically relevant definition of complex karyotype in CLL? Is the number or the type of aberrations that explain the unfavorable clinical outcome? What are the actual links with TP53 abnormalities?

ERIC: joining forces 5479 pts from 17 European Institutions 5290 pts included 10 metaphases 96.5% success n=5290 n, % Male Female Median age diagnosis <55 >70 MBL Binet A Binet B Binet C 3302, 62% 1988, 38% 64.6 years 1157/5231, 22% 1633/5231, 31% 383/4454, 9% 3030/4454, 68% 753/4454, 17% 288/4454, 6% U-CLL 1514/3453, 44% TP53abs 657/4968, 13% del(11q) 601/4834, 12% Trisomy 12 825/4719, 17% del(13q) 2541/4750, 53% Treated (median FU: 5.9 years) 2314/4875, 48% Baliakas et al. In preparation

Time of the analysis 6m from diagnosis 12m from diagnosis 18m from diagnosis Before treatment/ Untreated pts 3540/5179, 68% 3784/5179, 73% 3968/5179, 77% 4447/4868, 91% Methodology CPG/IL2 TPA TPA-CPG/IL2 939, 18% 2630, 50% 1720, 32% Baliakas et al. In preparation

Overview of chromosomal aberrations 3abs n=355 (46%) All patients n=5479 Patients with 10 metaphases n=5290 (97%) Stimulation Protocol Comlex Karyotype (CK) n=794 (15%) CK ( 3abs) Non-CK n=4496 (85%) CK ( 5abs) CPG/IL2 253/934, 27% 92/934, 10% TPA 259/2518, 10% 80/2518, 4% 4 abs n=168 (22%) 5abs n=251 (32%) Normal/del(13q) n=2659 (59%) 1 abn (non-del(13q)) n=1122, 25% 2abs n=715, 16% Baliakas et al. In preparation

Overview of chromosomal aberrations Normal/del(13q) FISH in 551 CK (3 abs) cases with available FISH data: n=156, 28% Cases with CK ( 3abs) and normal/del(13q) FISH 3abs 4abs 5abs 86/289, 30% 28/124, 23% 39/189, 21% Baliakas et al. In preparation

Impact of CK ( 3 aberrations) on clinical outcome 100% nonck, n=4360 CK, n=735 75% % Alive 50% 25% p<0.0001 0% 0 5 10 15 20 Time (years from CBA) OS is measured from date of the chromosomal analysis until death or last follow-up Baliakas et al. In preparation

Impact of CK ( 3 aberrations) on clinical outcome N=2376 HR 95% CI p-value Male 1.123 0.946-1.338 0.18 CK 1.578 1.267-1.966 <0.0001 Trisomy 12 1.139 0.926-1.401 0.21 del(11q) 1.109 0.883-1.393 0.37 TP53abs 2.183 1.761-2.707 <0.0001 U-CLL 2.371 1.973-2.850 <0.0001 Binet A 0.631 0.526-0.754 <0.0001 Baliakas et al. In preparation

Is cytogenetic complexity always bad?

The +12,+19 story +12,+19,+other trisomy (n=43) +12,+19,+structural (n=38) P-value Age, (median) 64.6 56.6 0.7 Male 33/43 30/38 0.81 Binet B/C 8/39 6/24 0.68 M-CLL 19/21 32/34 0.61 del(13q) 39/43 30/35 0.49 del(11q) 0/39 1/36 0.29 TP53abs 2/41 1/37 0.61 Baliakas et al. In preparation

The +12,+19 story 100% 75% % Alive 50% +12,+19,+other trisomy, n=40 +12,+19,+structural abnormality, n=36 25% p=0.58 0% 0 5 10 15 20 Time (years from CBA)

The +12,+19 story 100% % Alive 75% 50% +12,+19,+other, n=76 nonck, n=4292 CK, n=658 25% p<0.0001 0% 0 5 10 15 20 25 Time (years from CBA)

Number of aberrations 3abs 4abs 5abs U-CLL 130/240, 54% 69/111, 62% 109/143, 76% del(11q) 86/320, 27% 47/148, 31% 48/223, 21% TP53abs 89/341, 26% 62/160, 38% 157/243, 65% * * Baliakas et al. In preparation

3abs vs 4abs vs 5abs Baliakas et al. In preparation

3abs vs 4abs vs 5abs vs other Baliakas et al. In preparation

3abs vs 4abs vs 5abs vs other non TP53abs Baliakas et al. In preparation

3abs vs 4abs vs 5abs vs other within TP53abs 100% 75% TP53abs/non CK, n=320 TP53abs/3abs, n=83 TP53abs/4abs, n=57 TP53abs/>4abs, n=147 % Alive 50% 25% p<0.05 0 2 4 6 8 10 12 Time (years from CBA) Baliakas et al. In preparation

Only high-complexity is independently associated with a worse clinical outcome N=2376 HR 95% CI p-value Male 1.160 0.975-1.380 0.09 5abs 1.844 1.230-2.763 0.003 3-4abs 1.206 0.909-1.598 0.19 Trisomy 12 1.207 0.979-1.488 0.08 del(11q) 1.153 0.915-1.453 0.22 TP53abs 1.960 1.558-2.466 <0.0001 U-CLL 2.321 1.927-2.794 <0.0001 Binet B/C 1.574 1.313-1.887 <0.0001

Conclusions Cytogenetic complexity is an independent prognostic marker in CLL Not all complex karyotypes are equivalent Low and intermediate complexity (3 or 4 abs) impact on outcome only if accompanied by TP53abs High complexity ( 5abs) is associated homogeneously with the worst clinical outcome independently of TP53abs and IGHV SHM status There is a place for CBA in CLL

G. Papanicolaou Hospital, Thessaloniki, GR Niki Stavroyianni Giwrgos Papaiwannou Michalis Iskas Achilles Anagnostopoulos Anastasia Athanasiadou MLL Munich Leukemia Laboratory, Germany Sabine Jeromin Claudia Haferlach Spanish Cytogenetic Group Anna Puiggros Julio Delgado Pau Abrisqueta Rosa Collado M Jose Calasanz Neus Ruiz-Xiville Carolina Moreno Blanca Espinet Laboratoire d hématologie, Hopital Avicenne, France Fanny Baran Marszak Virginie Eclache Florence Cymbalista Hematology Department and University Pierre et Marie Curie, Hopital Pitie-Salpetriere, Paris, France Florence Nguyen Khac Fred Davi Hematology Section, University of Ferrara, Italy Rigolin Gian Matteo Antonio Cuneo CERTH, Thessaloniki, GR Evangelia Stalica Aliki Xochelli Kostas Stamatopoulos Academic Medical Center Amsterdam, Netherlands Alexander C. Leeksma Arnon Katter Division of Hematology, Department of Medicine, University of Padua Andrea Visentin Livio Trentin CEITEC, Masaryk University, Brno, Czech Republic Karla Plevova Jana Kotaskova Kristina Durechova Michael Doubek Sarka Pospisilova Department of Haematology, Royal Bournemouth Hospital, UK Zadie Davis David Oscier First Department of Propaedeutic Medicine, University of Athens, Greece Theodoros Iliakis Panayotis Panayotidis Department of Hematology, Ljubljana University,Slovenia Helena Podgornik ERIC, The European Research Initiative on CLL Paolo Ghia

Thank you for your attention panagiotis.baliakas@igp.uu.se