Risk factors for development of a second lymphoid malignancy in patients with chronic lymphocytic leukaemia

Predictive markers and driving factors behind Richter syndrome development

Transformation of chronic lymphocytic leukemia (CLL) to diffuse large B-cell lymphoma (DLBCL) is known as Richter syndrome (RS). In the entire CLL population, the cumulative prevalence of RS development steadily increases at a rate of 1% per year. Considering conventional predictors of CLL, patient subgroups at high risk of developing RS are characterized by the expression of CD38, absence of del13q14, and a lymph node size >3 cm. Novel risk factors for predicting RS development at CLL diagnosis have been recently identified and include: the host genotype of the CD38 locus and of other genes; telomere length of CLL cells; stereotyped B-cell receptor; and usage of specific immunoglobulin variable genes (IGHV4-39). Importantly, although some risk factors predict both CLL progression and transformation to RS, others (CD38 genotype, absence of del13q14, IGHV4-39 usage, stereotyped B-cell receptor) appear to specifically predict RS. The definition of RS encompasses at least two different conditions: DLBCLs that are clonally related to the pre-existing CLL (accounting for most cases), or DLBCL unrelated to the CLL clone. The transition from CLL to clonally related RS is accompanied by the acquisition of novel genetic alterations that may account for the chemorefractoriness of RS. Genome-wide studies that are currently ongoing are important for identifying novel molecular lesions implicated in RS that might represent a suitable target for future therapeutic strategies.

IGHV gene rearrangements as outcome predictors for CLL patients: experience of Ukrainian group

Important characteristics of chronic lymphocytic leukaemia (CLL) cells are biased immunoglobulin variable heavy chain (IGHV) gene repertoire and expression of stereotyped B-cell receptors (BCRs); however, their prognostic value (in contrast to the impact of IGHV gene mutational status) is less clear. To evaluate the impact of separate IGHV gene usage and expression of stereotyped BCRs in CLL prognosis. Clinical data and IGHV gene configuration were analysed in 319 consecutive patients with CLL. We found that the majority of clinical parameters of patients were defined by IGHV mutational status. Our data also provided new evidence supporting the prognostic relevance of separate IGHV genes or stereotyped BCR in CLL, namely: (a) a restricted non-mutated (UM) IGHV gene repertoire in CLL patients with autoimmune haemolytic anaemia (AIHA) (more frequent expression of UM IGHV1-69, IGHV3-11 and IGHV4-59 genes, P = 0.001), a shorter period of AIHA development for expressors of these genes (P = 0.001) and a tendency towards expression of a stereotypic HCDR3 (P = 0.029), (b) a high incidence of second solid tumour development in IGHV3-21-expressing patients (P = 0.005) and (c) differences in overall survival (OS) of UM CLL patients depending on the BCR structure. Further research of specific IGHV gene usage and subsets of stereotyped BCRs in CLL may be helpful in more precise prediction of CLL prognosis in individual patients.

MDR-1 gene polymorphisms G2677T and C3435T in a case of Hodgkin's variant of Richter's syndrome

Richter's syndrome is defined as the transformation of low-grade lymphoma to a more aggressive high-grade malignant form, usually diffuse large B-cell lymphoma. Hodgkin's lymphoma variant of Richter transformation is relatively rare, and only approximately 100 cases have been reported in the literature. This study examined a case of a 53-year-old woman who developed Hodgkin's lymphoma almost 5 years after the diagnosis of chronic lymphocytic leukemia (CLL). The major points of interest regarding CLL with Hodgkin's transformation were also considered, such as the potential role of MDR-1 gene polymorphisms. The patient was evaluated for two MDR-1 gene polymorphisms, G2677T polymorphism in exon 21 and silent C3435T polymorphism in exon 26, to ascertain whether polymorphisms affect the risk of Hodgkin's lymphoma variant of Richter transformation and whether genomic polymorphisms provide prognostic information on the clinical progression of the disease. According to the data obtained, the analysis of polymorphisms in the MDR1 gene exons 21 and 26 revealed that the T2677T and T3435T alleles are not a predisposing factor to Richter transformation, while the presence of the wild-type genotype may be associated with a more favorable response to therapy.

Age at diagnosis and the utility of prognostic testing in patients with chronic lymphocytic leukemia

BACKGROUND

A study was undertaken to analyze the survival of chronic lymphocytic leukemia (CLL) patients relative to age-matched individuals in the general population and determine the age-stratified utility of prognostic testing.

METHODS

All 2487 patients diagnosed with CLL between January 1995 and June 2008 and cared for in the Mayo Clinic Division of Hematology were categorized by age at diagnosis and evaluated for differences in clinical characteristics, time to first treatment, and overall survival (OS).

RESULTS

Among Rai stage 0 patients, survival was shorter than the age-matched general population for patients aged <55 years (P < .001), 55 to 64 years (P < .001), and 65 to 74 years (P < .001), but not those aged ≥75 years at diagnosis (P = not significant). CD38, IGHV mutation, and ZAP-70 each predicted time to first treatment independent of stage for all age groups (all P < .04), but had less value for predicting OS, particularly as age increased. IGHV and fluorescent in situ hybridization (FISH) predicted OS independent of stage for patients aged <55 years (P ≤ .001), 55 to 64 years (P ≤ .004), and 65 to 74 years (P ≤ .001), but not those aged ≥75 years. CD38 and ZAP-70 each predicted OS independent of stage for only 2 of 4 age categories. Among Rai 0 patients aged <75 years, survival was shorter than the age-matched population only for IGHV unmutated (P < .001) patients or those with unfavorable FISH (P < .001).

CONCLUSIONS

Survival of CLL patients aged <75 years is shorter than the age-matched general population regardless of disease stage. Among patients aged <75 years, the simple combinations of stage and IGHV or stage and FISH identifies those with excess risk of death relative to the age-matched population. Although useful for predicting time to first treatment independent of stage for patients of all ages, prognostic testing had little utility for predicting OS independent of stage among patients aged ≥75 years.

A systematic review on Richter syndrome: what is the published evidence?

A systematic and comprehensive search of literature was performed using MEDLINE databases from 1st January 1978 to 2nd November 2009 and hand search of references. A search performed by combining the Medical Subject Headings (MESH) terms 'Richter's syndrome' and 'chronic lymphocytic leukemia' (CLL) yielded 143 citations. Ten additional case-control studies judged relevant for the purpose of study were also included. In total, 45 case reports, 18 case series, and 9 case-control studies were identified. For the purpose of this review, only case series and case-control studies were considered. The following conclusions could be drawn from the studies analyzed in this review: (i) some biological markers (i.e. CD38 expression and genotype, absence of del13q) or clinical features (i.e. bulky lymph node involvement), although not validated in prospective trials, may be considered for close monitoring and a careful biopsy policy; (ii) PET, is not yet standardized in RS, however, it may be useful in the diagnosis and to choose the site for biopsy; (iii) when diagnosed RS should be treated with a combination of rituximab and polychemotherapy; (iii) younger patients who respond to initial therapy should be offered allogeneic SCT, if feasible. Despite the paucity of data, it is important to note that this article represents the first systematic review of the entire body of available clinical evidence useful for an appropriate management of Richter transformation.

Statin and non-steroidal anti-inflammatory drug use in relation to clinical outcome among patients with Rai stage 0 chronic lymphocytic leukemia

Statins and non-steroidal anti-inflammatory drugs (NSAIDs) are among the most commonly prescribed medications. In vitro studies suggest that statins and NSAIDs may have potential as anticancer therapies in low-grade non-Hodgkin lymphomas including chronic lymphocytic leukemia (CLL), and a recent observational study found statin use was associated with improved event free survival in patients with follicular lymphoma. Other studies have suggested that statins reduce the efficacy of rituximab by inhibiting binding to CD20. We therefore conducted an observational cohort study of 686 patients with newly diagnosed Rai stage 0 CLL to evaluate whether statin or NSAID use was related to their clinical outcome or influenced the efficacy of rituximab therapy. At diagnosis, 136 (20%) patients took statins and 230 (34%) scheduled daily aspirin, ibuprofen, or naproxen. No difference in time to treatment was observed based on statin or NSAID use. Among patients receiving a rituximab-containing first-line therapy, no difference in time to salvage treatment was observed based on statin use. Although previous studies suggested statins may improve event free survival among patients with follicular lymphoma, we find no impact of statins on time to initial therapy in this large study of patients with Rai stage 0 CLL. The in vitro observation that statins reduce rituximab efficacy does not appear to have clinical significance in CLL care.

Richter syndrome: molecular insights and clinical perspectives

Richter syndrome (RS) represents the clinico-pathologic transformation of chronic lymphocytic leukaemia (CLL) to an aggressive lymphoma, most commonly diffuse large B-cell lymphoma (DLBCL). The clinical definition of RS is heterogeneous, and encompasses at least two biologically different conditions: (i) CLL transformation to a clonally related DLBCL, that accounts for the majority of cases; (ii) development of a DLBCL unrelated to the CLL clone. In clonally related RS, the pathogenetic link between the CLL and the DLBCL phases is substantiated by the acquisition of novel molecular lesions at the time of clinico-pathologic transformation. RS is not a rare event in the natural history of CLL, since the cumulative incidence of RS at 10 years exceeds 10%. Prompt recognition of RS is known to be clinically useful, and may be favoured by close monitoring of CLL patients harbouring clinical and/or biological risk factors of RS development. Conventional risk factors that are independent predictors of RS development at the time of CLL diagnosis include: (i) expression of CD38; (ii) absence of del13q14 and (iii) lymph node size > or =3 cm. Other risk factors of RS development include CD38 genotype and usage of specific immunoglobulin variable genes. The molecular pathogenesis of RS has been elucidated to a certain extent. Acquisition of TP53 mutations and/or 17p13 deletion is a frequent molecular event in RS, as it is in other types of transformation from indolent to aggressive B-cell malignancies. Additional molecular alterations are being revealed by genome wide studies. Once that transformation has occurred, RS prognosis may be predicted by the RS score, based on performance status, LDH, platelet count, tumour size and number of prior therapies. Depending on patient's age and RS score, the therapeutic options for RS may range from conventional immunochemotherapy to allogeneic bone marrow transplantation.

Validation of a new prognostic index for patients with chronic lymphocytic leukemia

BACKGROUND

The clinical course of chronic lymphocytic leukemia (CLL) is highly variable. A prognostic index based on widely available clinical and laboratory features was recently developed to predict survival among patients with previously untreated CLL. This index requires validation in an independent series of patients before widespread use can be recommended.

METHODS

The Mayo Clinic CLL database was used to evaluate the validity and reproducibility of the new prognostic index.

RESULTS

A total of 440 patients with newly diagnosed CLL who were seen at the Mayo Clinic within 12 months of diagnosis and for whom data were available with which to calculate index score were identified. Patients were classified as low, intermediate, or high risk using the prognostic index. The estimated median survival times were: not reached for low risk, 10.1 years for intermediate risk, and 7.2 years for high risk. The estimated median and 5-year survival by prognostic index risk category were similar to those originally reported. The prognostic index risk category added predictive value beyond that of Rai risk alone (P=.004). The prognostic index risk category remained a predictor of survival when analysis was limited to Rai stage 0 (P=.03) and nonreferred patients (P<.0001) and also predicted time to treatment (P<.0001).

CONCLUSIONS

The results of the current study confirm the ability of a newly developed prognostic index to predict survival among patients with previously untreated CLL. The study also extended the utility of the index by demonstrating that it is useful at diagnosis, retains prognostic value when applied exclusively to Rai stage 0 patients, is effective in nonreferred patients, and predicts time to treatment.

Intracerebral Hodgkin's lymphoma in a patient with chronic lymphocytic leukemia/small lymphocytic lymphoma: a case report and literature review

Richter's syndrome is defined as the transformation of low grade lymphoma to more aggressive high grade malignant form, usually diffuse large B cell lymphoma. Primary or metastatic cerebral Hodgkin's lymphoma and Hodgkin's lymphoma variant of Richter transformation are extremely rare. We report a case of 65-year old man who developed isolated intracerebral Hodgkin's lymphoma almost 8 years after the diagnosis of chronic lymphocytic leukemia/small lymphocytic lymphoma, and we reviewed the related literature. The patient had resection of his CNS lesion, followed by radiation and chemotherapy. The patient eventually died with progressive disease.

B-cell count and survival: differentiating chronic lymphocytic leukemia from monoclonal B-cell lymphocytosis based on clinical outcome

The diagnosis of chronic lymphocytic leukemia (CLL) in asymptomatic patients has historically been based on documenting a characteristic lymphocyte clone and the presence of lymphocytosis. There are minimal data regarding which lymphocyte parameter (absolute lymphocyte count [ALC] or B-cell count) and what threshold should be used for diagnosis. We analyzed the relationship of ALC and B-cell count with clinical outcome in 459 patients with a clonal population of CLL phenotype to determine (1) whether the CLL diagnosis should be based on ALC or B-cell count, (2) what lymphocyte threshold should be used for diagnosis, and (3) whether any lymphocyte count has independent prognostic value after accounting for biologic/molecular prognostic markers. B-cell count and ALC had similar value for predicting treatment-free survival (TFS) and overall survival as continuous variables, but as binary factors, a B-cell threshold of 11 x 10(9)/L best predicted survival. B-cell count remained an independent predictor of TFS after controlling for ZAP-70, IGHV, CD38, or fluorescence in situ hybridization (FISH) results (all P < .001). These analyses support basing the diagnosis of CLL on B-cell count and retaining the size of the B-cell count in the diagnostic criteria. Using clinically relevant criteria to distinguish between monoclonal B-cell lymphocytosis (MBL) and CLL could minimize patient distress caused by labeling asymptomatic people at low risk for adverse clinical consequences as having CLL.

Role of histone deacetylase inhibitor-induced reactive oxygen species and DNA damage in LAQ-824/fludarabine antileukemic interactions

The role of reactive oxygen species (ROS) production on DNA damage and potentiation of fludarabine lethality by the histone deacetylase inhibitor (HDACI) LAQ-824 was investigated in human leukemia cells. Preexposure (24 h) of U937, HL-60, Jurkat, or K562 cells to LAQ-824 (40 nmol/L) followed by fludarabine (0.4 micromol/L) dramatically potentiated apoptosis (>or=75%). LAQ-824 triggered an early ROS peak (30 min-3 h), which declined by 6 h, following LAQ-824-induced manganese superoxide dismutase 2 (Mn-SOD2) upregulation. LAQ-824/fludarabine lethality was significantly diminished by either ROS scavengers N-acetylcysteine or manganese (III) tetrakis (4-benzoic acid) porphyrin or ectopic Mn-SOD2 expression and conversely increased by Mn-SOD2 antisense knockdown. During this interval, LAQ-824 induced early (4-8 h) increases in gamma-H2AX, which persisted (48 h) secondary to LAQ-824-mediated inhibition of DNA repair (e.g., down-regulation of Ku86 and Rad50, increased Ku70 acetylation, diminished Ku70 and Ku86 DNA-binding activity, and down-regulated DNA repair genes BRCA1, CHEK1, and RAD51). Addition of fludarabine further potentiated DNA damage, which was incompatible with cell survival, and triggered multiple proapoptotic signals including activation of nuclear caspase-2 and release of histone H1.2 into the cytoplasm. The latter event induced activation of Bak and culminated in pronounced mitochondrial injury and apoptosis. These findings provide a mechanistic basis for understanding the role of early HDACI-induced ROS generation and modulation of DNA repair processes in potentiation of nucleoside analogue-mediated DNA damage and lethality in leukemia. Moreover, they show for the first time the link between HDACI-mediated ROS generation and the recently reported DNA damage observed in cells exposed to these agents.

Intrinsic and treatment-related immune alterations in chronic lymphocytic leukaemia and their impact for clinical practice

BACKGROUND

Chronic lymphocytic leukaemia patients harbour important impairments in both their cellular- and humoral-mediated immunity, which accounts for their notorious susceptibility to a multitude of infections and various autoimmune cytopenias. It has also been shown that the rate of second cancers is increased in chronic lymphocytic leukaemia.

OBJECTIVE

The aim of this study was to review the immune alterations in untreated and treated chronic lymphocytic leukaemia and define their impact for clinical practice.

METHODS

The author gives a comprehensive review of the most relevant preclinical and clinical studies pertaining to various immune abnormalities and infectious complications in both untreated and treated chronic lymphocytic leukaemia. Landmark clinical trials involving the contemporary chronic lymphocytic leukaemia chemo- and immunotherapies, alone or in combination, as well as the main epidemiological studies establishing the increased rate of second cancers in chronic lymphocytic leukaemia are also discussed.

RESULTS/CONCLUSIONS

Iatrogenic immunosuppression in chronic lymphocytic leukaemia alters the pattern of opportunistic infections, can cause autoimmune cytopenias and might further increase the rate of second malignancies in patients whose disease already places them at a greater risk. Careful consideration of existing risk factors in chronic lymphocytic leukaemia could establish the optimal screening and follow-up schedule for chronic lymphocytic leukaemia patients as its therapeutics evolves.

Multiple myeloma emerging after chemotherapy for non-small-cell lung cancer

A 67-year-old man underwent total resection of the left lung because of adenocarcinoma, with no evidence of extra-thoracic spread of the cancer. On follow-up, metastatic bone disease was documented and chemotherapy (CMT) which included cisplatin, docetaxel, vinorelbine, and topotecan was administered. Six months after completion of CMT, a rise in total serum protein was noted. Bone marrow biopsy revealed the diagnosis of an IgG lambda myeloma. We report a case of a man with adenocarcinoma of the lung who presented multiple myeloma after completion of chemotherapy.

Comprehensive Management of the CLL Patient: A Holistic Approach

The current management of B-chronic lymphocytic leukemia (CLL) is no longer straightforward for the practicing hematologist. Rapid advances in diagnostic precision, methods of predicting prognosis, understanding of natural history of CLL, recognition of clinical complications, clarification of the quality of life (QOL) issues facing the CLL patient, and the exciting array of novel treatment approaches have made the care of the CLL patient more demanding. This review is focused on summarizing these advances in order to provide a framework for integrating this knowledge into routine hematologic practice.

Comprehensive management of the CLL patient: a holistic approach

The current management of B-chronic lymphocytic leukemia (CLL) is no longer straightforward for the practicing hematologist. Rapid advances in diagnostic precision, methods of predicting prognosis, understanding of natural history of CLL, recognition of clinical complications, clarification of the quality of life (QOL) issues facing the CLL patient, and the exciting array of novel treatment approaches have made the care of the CLL patient more demanding. This review is focused on summarizing these advances in order to provide a framework for integrating this knowledge into routine hematologic practice.