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

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

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.

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

Lymphadenopathy in 60-years old patient with B-CLL

CLL epidemiology and aetiology The 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; Male to female ratio 1.7:1; Morbidity: Men: 2,2-3,69 / 100 000 / year Women: 0,9-1,59 / 100 000 / year Morbidity rapidly increases with age.

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

Age and gender-related incidence of CLL

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);

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

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

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

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

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

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

Flow cytometry diagnosis

CLL Binet staging system Stage Blood Counts Involved Areas Median survival (years) A B C Hb >100 g/l and platelets >100 10 9 /L Hb >100 g/l and platelets >100 10 9 /L Hb <100 g/l or platelets <100 10 9 /L, or both <3 >10 >3 7 Any number 5

Binet staging and survival

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 1.5-5 1.5-5

Rai staging and survival

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.

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

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.

Unfavourable prognosis: high lymphocyte doubling time Probability of survival Survival time according to LDT (all stages) 1.0 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0.0 0 20 40 60 80 100 120 140 160 Months Doubling time 12 months Doubling time >12 months Montserrat E, et al. Br J Haematol. 1986;62:567-575)

Chiorazzi et al., 2005

Prognosis: effect of IGVH gene mutations on survival

Percent surviving (%) Prognosis: effect of CD38 expression on survival 100 90 80 70 60 50 40 30 20 10 0 Months CD38 30% Mean = 163.2 months CD38 <30% Mean = 288 months N=162 P=.008 0 100 200 300 400 500 Orchard JA, et al. Lancet. 2004;363:105-111.

Probability of survival (%) ZAP-70 expression and survival of patients with Binet stage A CLL 100 90 80 70 60 50 40 <20% ZAP-70-positive cells 20% ZAP-70-positive cells N=44 P=.01 30 20 10 0 0 4 8 12 16 20 24 28 32 36 Years after diagnosis 1. Crespo M, et al. N Engl J Med. 2003;348:1764-1775.

Proportion surviving Unfavourable prognosis: high levels of soluble 2- microglobulin in untreated CLL Effect of 2 -microglobulin on survival in untreated CLL 1.0 0.8 0.6 Pts Died 2 M 445 53 <2.1 429 95 2.1-3.0 183 53 3.1-4.0 175 67 >4.0 0.4 0.2 0.0 0 2 4 6 8 10 12 14 Years 1. Keating M. Unpublished data. 2. Hallek M, et al. Leuk Lymphoma. 1996;22:439-447. 3. Sarfati M, et al. Blood. 1996;88:4259-4264. 4. Fayad L, et al. Blood. 2001;97:256-263. 16 18

MHC Class I Domain Organisation

Probability Unfavourable prognosis: high levels of scd23 1.0 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0.0 574 U/mL >574 U/mL 0 20 40 60 80 100 120 Months Sarfati M, et al. Blood. 1996;88:4259-4264.

Genetic abnormality Genetic abnormalities in CLL Incidence (%) Median survival (months) Clinical correlation del 13q14 55-62 133-292 Typical morphology Mutated IGVH Stable disease + 12 16-30 114-122 Atypical morphology Progressive disease del 11q23 18 79-117 Bulky lymphadenopathy Unmutated IGVH genes Progressive disease Early relapse post autograft p53 loss/mutation in 17p 7 32-47 Atypical morphology Unmutated V H genes Advanced disease Drug resistance

Dighiero and Hamblin, 2008

Effect of genetic abnormalities on survival Döhner H, et al. N Engl J Med. 2000;343:1910-1916.

P53 mutations in chronic lymphocytic leukemia

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

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

Conventional treatment of CLL

Dighiero and Hamblin, 2008

Gribben, 2008 Treatment regimes

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)

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

Hallek, 2013

Byrd et al., 2014

Hallek, 2013

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?

Kostareli et al., 2012

CD180 Protein 661 aa. extracellular domain has leucine rich motif; maps to 5q12.-13.1; 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.

CD180/MD1 and TLR4/MD2

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)

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

Porakishvili et al., 2011, 2015 IgM IgD AKT

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