A prognostic algorithm including a modified version of MD Anderson Cancer Center (MDACC) score predicts time to first treatment of patients with clinical monoclonal lymphocytosis (cMBL)/Rai stage 0 chronic lymphocytic leukemia (CLL)

We propose an algorithm based on a slightly modified version of MD Anderson Cancer Center (MDACC) score (i.e., mutational status of IgVH, LDH, presence of high-risk FISH abnormalities), β₂-microglobulin and separation of clinical monoclonal B-cell lymphocytosis (cMBL) from chronic lymphocytic leukemia (CLL) to predict time to first treatment (TTFT) of a prospective multicentre cohort including 83 cMBL and 136 CLL Rai stage 0 patients. Patients with MDACC score point ≥38, at any level of β₂-microglobulin and irrespective of whether they fulfilled 2008 International Workshop on CLL (IWCLL) criteria for CLL Rai stage 0 or cMBL, experienced the worst clinical outcome (5-year TTFT, 24 %) and formed the high-risk group. In contrast, subjects with a diagnosis of cMBL, MDACC score point <38 and β₂-microglobulin ≤ UNL had the best clinical outcome (5-year TTFT, 100 %) and constituted the low-risk group. The intermediate group included patients in Rai stage 0, MDACC score point <38, and any level of β₂-microglobulin, and patients with cMBL, MDACC score point <38, and β₂-microglobulin ≥ UNL. Cases showing these features can be grouped together to form the intermediate-risk group (5-year TTFT, 65 %). Although the separation between cMBL and Rai stage 0, as proposed by the 2008 IWCLL guidelines, has clinical implications, the model we propose may help to classify patients with cMBL and Rai stage 0 into more precise subgroups suggesting that a prognostic separation of these entities based solely on clonal B-cell threshold may be unsatisfactory.     

Baff serum level predicts time to first treatment in early chronic lymphocytic leukemia

We analyzed the correlation between well‐established biological parameters of prognostic relevance in B‐cell chronic lymphocytic leukemia (CLL) [i.e. mutational status of the immunoglobulin heavy chain variable region (IgVH), ZAP‐70 and CD38 expression] and serum levels of B cell–activating factor (BAFF of the TNF family) by evaluating the impact of these variables on the time to first treatment (TFT) in a series of 169 previously untreated CLL patients in Binet stage A. Higher levels of BAFF were more frequently associated with female gender (P = 0.02), younger age (P = 0.01), Rai stage 0 (P = 0.002), higher platelet count (P = 0.005), mutated IgVH disease (P = 0.002), higher occurrence of normal cytogenetic profile or presence of 13q deletion (P = 0.02), low ZAP‐70‐ (P = 0.003), and CD38‐expression (P = 0.02). Maximally selected log‐rank statistic plot identified a serum BAFF concentration of 0.313 ng/mL as the best cut‐off (P < 0.0001). This threshold recognized two subsets of patients with different TFT (P < 0.0001). Because in multivariate analysis soluble BAFF [Hazard ratio (HR), 8.23; confidence Interval (CI) 95%,3.0–22.6, P < 0.0001] and mutational status of IgVH (HR = 2.60; CI 95% 1.10–6.14, P = 0.03) maintained the discriminating power their combined effect on clinical outcome was assessed. When three groups were considered: ( 1 ) low‐risk (n = 93), patients with concordant IgVH_mut and higher soluble BAFF; ( 2 ) intermediate‐risk (n = 50), patients with IgVH_mut and low BAFF levels or IgVH_unmut and soluble higher BAFF;( 3 ) high‐risk (n = 26), patients with concordant IgVH _unmut and low soluble BAFF, the 2‐yr TFTs were, respectively, 95%, 85%, and 41% (P < 0.0001). In conclusion, our results indicate that in early B‐cell CLL, the biological profile including among other parameters soluble BAFF may provide a useful insight into the complex interrelationship of prognostic variables.     

Cytomegalovirus infection does not impact on survival or time to first treatment in patients with chronic lymphocytic leukemia

Human cytomegalovirus (HCMV) is a widely prevalent herpes virus which establishes a state of chronic infection. The establishment of CMV‐specific immunity controls viral reactivation and leads to the accumulation of very large numbers of virus‐specific T cells which come to dominate the immune repertoire. There is concern that this may reduce the immune response to heterologous infections and HCMV infection has been associated with reduced survival in elderly people. Patients with chronic lymphocytic leukemia (B‐CLL) suffer from a state of immune suppression but have a paradoxical increase in the magnitude of the CMV‐specific T cell and humoral immune response. As such, there is now considerable interest in how CMV infection impacts on the clinical outcome of patients with B‐CLL. Utilizing a large prospective cohort of patients with B‐CLL (n = 347) we evaluated the relationship between HCMV seropositivity and patient outcome. HCMV seropositive patients had significantly worse overall survival than HCMV negative patients in univariate analysis (HR = 2.28, 95% CI: 1.34–3.88; P = 0.002). However, CMV seropositive patients were 4 years older than seronegative donors and this survival difference was lost in multivariate modeling adjusted for age and other validated prognostic markers (P = 0.34). No significant difference was found in multivariate modeling between HCMV positive and negative patients in relation to the time to first treatment (HR = 1.12, 95% CI: 0.68–1.84; P = 0.65). These findings in a second independent cohort of 236 B‐CLL patients were validated. In conclusion no evidence that HCMV impacts on the clinical outcome of patients with B‐CLL was found. Am. J. Hematol. 91:776–781, 2016. © 2016 Wiley Periodicals, Inc.     

Downstaging Rai stage III B-chronic lymphocytic leukemia patients with the administration of recombinant human erythropoietin

BACKGROUND AND OBJECTIVES: To investigate the effectiveness of recombinant human erythropoietin (r-HuEPO) on disease-related anemia in patients with B-chronic lymphocytic leukemia (B-CLL) and to explore whether improvement of anemia could delay the initiation of cytotoxic therapy. DESIGN AND METHODS: Twenty five B-CLL patients (12 males and 13 females; median age 70 years) with disease-related anemia were treated with r-HuEPO. Patients were either on no treatment or on a standard regimen, and had at least Rai stage III disease, with a hematocrit (Hct) <32%. Eleven were newly diagnosed, whereas 14 developed anemia during follow-up. Treatment induction lasted for a maximum of 3 months, during which patients were receiving 150 IU/kg of r-HuEPO s.c. t.i.w. with an escalation to 300 IU/kg t.i.w. if response was slow after one month. Responding patients were placed on maintenance r-HuEPO with 150 IU/kg s.c. once weekly, continuously. Complete response (CR) was defined as an increase of Hct to 38% or more and partial response (PR) as an increase of >6% from pretreatment level. RESULTS: CR was observed in 18/25 (72%) and PR in 2/25 (8%) of the patients. Six patients were downstaged to stage Rai 0, 9 to Rai I and 4 to Rai II. Response was sustained with maintenance therapy. At a median follow-up of 32 months only 4 of the responders required antileukemic treatment. The median survival of responders has not been reached, and 3-year survival is 84%. INTERPRETATION AND CONCLUSIONS: r-HuEPO was efficient in downstaging Rai stage III B-CLL patients, and delayed the initiation of antileukemic therapy. Whether this effect can be translated into better survival rates remains to be clarified in randomized trials.     

A proliferation-inducing ligand (APRIL) serum levels predict time to first treatment in patients affected by B-cell chronic lymphocytic leukemia

Purpose: A proliferation‐inducing ligand (APRIL), a tumor necrosis factor superfamily member involved in B‐lymphocytes differentiation and survival, plays a role in protecting B‐Cell Chronic lymphocytic leukemia (B‐CLL) cells from apoptosis. Having observed that APRIL serum (sAPRIL) levels were higher in B‐CLL patients with CLL at diagnosis as compared to healthy donors (14.61 ± 32.65 vs. 4.19 ± 3.42 ng/mL; P < 0.001), we tested the correlation existing in these patients between sAPRIL, clinical–biological parameters and disease progression. Experimental design: sAPRIL levels were measured by ELISA in 130 patients with B‐CLL at diagnosis and in 25 healthy donors. Results: sAPRIL levels did not correlate with gender, age, clinical stage, blood cell counts, β2‐microglobulin (β2M) levels, ZAP‐70 and CD38 expression. Using median sAPRIL natural logarithm (ln) as cutoff, we distinguished two groups of patients (APRIL_LOW and APRIL_HIGH) who were comparable with regard to clinical–biological parameters and overall survival, but different with regard to time to the first treatment (TTFT; P = 0.035). According to univariate analysis, high lymphocyte count, high β2M, Binet stage B–C, ZAP‐70 expression and ln(sAPRIL) above median were associated with earlier TTFT. Advanced clinical stage, high β2M, ZAP‐70 expression and ln(sAPRIL) above median remained independently predictive of shorter TTFT at multivariate analysis. Moreover, sAPRIL increased its prognostic significance when patients were stratified according to independent favorable clinical–biological characteristics (low β2M, stage A and lack of ZAP‐70 expression). Conclusions: sAPRIL is a novel indicator of shorter TTFT in B‐CLL and a predictor of progression especially in patients otherwise considered at low risk according to validated prognostic factors.     

Significantly shorter telomeres in T-cells of patients with ZAP-70+/CD38+ chronic lymphocytic leukaemia

In contrast to other B-cell neoplasias, chronic lymphocytic leukaemia (CLL) is characterized by increased non-leukaemic T-cells. In order to assess their replicative history, telomere length was analyzed in subsets of leucocytes from CLL patients. Naive and memory T-cells from ZAP-70(+)/CD38(+) patients exhibited significantly shorter average telomere lengths than ZAP-70(-)/CD38(-) patients. Compared to the age-related percentiles of telomere length values from healthy individuals practically all values of the naive and memory T-cells from the ZAP-70(+)/CD38(+) CLL patients fell below the 50th percentile. This indicated an extensive expansion and a role for T-cells in ZAP-70(+)/CD38(+) CLL patients.     

Mcl-1 and Bcl-2/Bax ratio are associated with treatment response but not with Rai stage in B-cell chronic lymphocytic leukemia

Although both Bcl-2/Bax ratio and Mcl-1 have been identified to be of clinical relevance in B-cell chronic lymphocytic leukemia (CLL), there is controversy regarding their role; further, their relative importance is not well delineated. Expression of Bcl-2, Bax, the Bcl-2/Bax ratio, and Mcl-1 in 51 consecutive previously untreated CLL patients and 16 controls was determined by Western blotting. Only 37 patients were treated, all with chlorambucil and prednisone initially. Six patients achieved complete response (CR), 14 were non-responders (NR), and 17 had a partial response (PR), as defined by NCI criteria. There was considerable inter-patient variability in protein expression and overlap with healthy volunteers (P > 0.05). All patients with CR had low Mcl-1 levels compared to the PR + NR group (0.07 +/- 0.02 vs. 0.14 +/- 0.07, P = 0.043). Higher Mcl-1 expression as determined by dichotomizing the data was associated with a failure to achieve CR (P = 0.021). The Bcl-2/Bax ratio was significantly associated with treatment response only when CR and PR were considered together (0.89 +/- 0.53 [CR + PR] vs. 3.38 +/- 4.47 [NR], P = 0.0118). There was no association with Rai stage. Low Mcl-1 appears to be a requirement for CR, while low Bcl-2/Bax ratio is indicative of some response to conventional treatment.     

The chronic lymphocytic leukemia international prognostic index predicts time to first treatment in early CLL: Independent validation in a prospective cohort of early stage patients

The chronic lymphocytic leukemia International Prognostic Index (CLL‐IPI) combines 5 parameters (age, clinical stage, TP53 status [normal vs. del(17p) and/or TP53 mutation], IGHV mutational status, serum β2‐microglobulin) to predict survival and time‐to‐first‐treatment (TTFT) in CLL patients. We performed an observational study in 337 prospectively collected, Binet stage A patients to validate the ability of the CLL‐IPI to predict TTFT in an independent cohort of early stage CLL patients. The CLL‐IPI score stratified Binet stage A patients into three subgroups with different outcome. Since the CLL‐IPI was originally developed to predict survival, we next investigated the optimal cut‐off score to predict TTFT in Binet stage A patients. Recursive partitioning analysis identified three subsets with scores of 0 (n = 139), 1 (n = 90), and ≥ 2(n = 108). The probability of remaining free from therapy 5 years after diagnosis was 85%, 67% and 46% in these three categories (P < 0.0001.; C‐statistic:c = 0.72; 95% CI:0.58‐0.81). This optimized CLL‐IPI scoring for TTFT was subsequently validated in an independent cohort of Binet A patients from the Mayo Clinic (n = 525). The ability of either original or optimized CLL‐IPI to predict TTFT was equivalent to other prognostic models specifically designed for this endpoint (2011 MDACC score and O‐CLL1 score). Although originally developed to predict suvival, the CLL‐IPI is useful for predicting TTFT in early stage CLL patients. Am. J. Hematol. 91:1090–1095, 2016. © 2016 Wiley Periodicals, Inc.     

Recombinant interferon-alpha 2A as maintenance treatment for patients with advanced stage chronic lymphocytic leukemia responding to chemotherapy.

Forty-five patients suffering from advanced B-CLL were randomized to receive interferon-alpha (IFN alpha) or no treatment after achieving complete remission or partial response, following a chemotherapy protocol called MiNa. The two groups were fully comparable in terms of clinical characteristics and level of response obtained by chemotherapy. IFN alpha was given at a dose of 3 megaunits three times a week intramuscularly for 1 year. The IFN-treated patient group showed a significantly longer duration of response and a less frequent incidence of infections as compared to the no treatment group. A minority of patients who had had partial response to chemotherapy obtained complete remission while on therapy with IFN alpha. Toxicity was mild and patient compliance was excellent. We conclude that IFN alpha may have a role as maintenance therapy in CLL for patients responding to chemotherapy.     

The utility of a prognostic index for predicting time to first treatment in early chronic lymphocytic leukemia: the GIMEMA experience

Background

A prognostic index based on widely available clinical and laboratory features was recently proposed to predict survival in patients with previously untreated chronic lymphocytic leukemia. We assessed the utility of this index for predicting time to first treatment in early chronic lymphocytic leukemia.

Design and Methods

An observational database of the GIMEMA (Gruppo Italiano Malattie EMatologiche dell’Adulto), which included 310 patients with newly diagnosed Binet stage A chronic lymphocytic leukemia who were observed at different primary hematology centers during the period 1991 – 2000, was used for the purpose of this study.

Results

The new prognostic index enabled Binet stage A patients to be divided into two subgroups that differed with respect to time to first treatment (P=0.003). The original prognostic index was derived from a database that included cases observed at a reference academic center; these patients were younger (P<0.0001) and had more advanced disease (P<0.0001) than those in the current investigation, which studied community-based patients whose data were recorded at presentation. With this in mind, we used an optimal cut-off search to determine how best to split patients with Binet stage A disease into different prognostic groups. According to the recursive partitioning (RPART) model, a classification tree was built that identified three subsets of patients who scores were 0–2 (low risk), 3–4 (intermediate risk) and 5–7 (high risk). The probability of remaining free from therapy at 5 years was 100% in the low risk group, 81.2% in the intermediate risk group and 61.3% in the high risk group (P<0.0001).

Conclusions

The results of this study confirm the utility of a new prognostic index for predicting time to first treatment in a large sample series of community-based patients with early stage chronic lymphocytic leukemia at presentation. Our effort to develop a revised scoring method meets the need to separate Binet stage A patients into different prognostic groups in order to devise individualized and tailored follow-up during the treatment-free period.     

50例慢性淋巴细胞白血病患者临床分期和免疫表型的研究

目的探讨慢性淋巴细胞白血病的免疫表型,临床分期以及它们之间的相互关系。方法采用CD45／SSC双参数散点图设门,应用三色流式细胞术对50例慢性淋巴细胞白血病的骨髓或外周血标本进行免疫分型,并根据临床资料进行临床分期。结果50例中绝大部分慢性淋巴细胞白血病患者表达CD19及CD20阳性率分别为96％和98．0％,T系相关抗原CD,阳性率为71．3％,HLA-DR的阳性率为100％;CD38的表达与临床分期存在显著的统计学差异（P〈0．05）。FMC-7与CD30共表达（P〈0．05）。35例随访病人中,14例死亡。死亡患者与存活患者CD23表达与否存在明显差异（P〈0．05）。结论Binet分期比Rai分期简便易行。CD5,CD19,CD20是B-慢性淋巴细胞白血病特异的免疫表型,CD5、FMC-7、CD13作为预后标志缺乏特异性,CD23和CD38可作为评价病人预后的指标。     

Can the response to interferon treatment be predicted in patients with chronic active hepatitis C?

Twenty-one of 40 patients with chronic non-A, non-B hepatitis (37 anti-HCV positive) were randomised to receive interferon α2b (3 million units subcutaneously thrice weekly for 24 weeks) and then to be observed for six months. Among the other 19 patients (controls) randomised to be observed without treatment for 12 months, eight have subsequently been treated with interferon for six months. One treated patient and three controls were lost to follow-up. A return to normal serum alanine aminotransferase levels which lasted until the end of the treatment period occurred in 18 (64%) of the 28 patients given interferon (and in 13 of 21 (62%) randomised to treatment), but only in one of the 16 untreated controls (p < 0.001). Multivariant analysis indicated that, compared with the ten nonresponders, the 18 patients who responded to interferon were more likely to have acquired infection by intravenous drug abuse than by blood transfusion (p < 0.05), and were more likely to have histologically less severe chronic liver disease (p < 0.01). Thus, all 13 patients with less severe liver disease histologically responded to interferon, but only five of 15 patients with cirrhosis or bridging fibrosis responded. Among 17 responders followed for more than four months, five (28%) are still in remission a median of 13 months (range four months to 24 months) after stopping interferon. The characteristics which favoured a response during treatment also appeared to distinguish those who experienced sustained post-treatment remission. Thus, five of 12 patients with less severe chronic hepatitis C histologically appear to have a sustained remission of disease activity after treatment for six months with interferon, whereas none of five patients with cirrhosis or bridging fibrosis has had a sustained remission after interferon treatment. It is proposed that continued treatment with interferon may be required for long-term suppression of chronic active hepatitis C among patients with bridging fibrosis or cirrhosis, but one course of interferon may provide a lasting response in 40% of patients with less severe disease.     

Reverse-engineering the genetic circuitry of a cancer cell with predicted intervention in chronic lymphocytic leukemia

Cellular behavior is sustained by genetic programs that are progressively disrupted in pathological conditions—notably, cancer. High-throughput gene expression profiling has been used to infer statistical models describing these cellular programs, and development is now needed to guide orientated modulation of these systems. Here we develop a regression-based model to reverse-engineer a temporal genetic program, based on relevant patterns of gene expression after cell stimulation. This method integrates the temporal dimension of biological rewiring of genetic programs and enables the prediction of the effect of targeted gene disruption at the system level. We tested the performance accuracy of this model on synthetic data before reverse-engineering the response of primary cancer cells to a proliferative (protumorigenic) stimulation in a multistate leukemia biological model (i.e., chronic lymphocytic leukemia). To validate the ability of our method to predict the effects of gene modulation on the global program, we performed an intervention experiment on a targeted gene. Comparison of the predicted and observed gene expression changes demonstrates the possibility of predicting the effects of a perturbation in a gene regulatory network, a first step toward an orientated intervention in a cancer cell genetic program.     

Presence of heterozygous ATM deletion may not be critical in the primary response of chronic lymphocytic leukemia cells to fludarabine

Objectives: Abnormalities of the TP53 or ATM, cooperating tumor‐suppressor genes, significantly worsen the treatment options for chronic lymphocytic leukemia (CLL) patients. Although the aberrations seem to be mutually exclusive in this leukemia, inactivation of the former gene leads to worse prognosis. We tested the in vitro sensitivity of the CLL samples with heterozygous ATM deletion to fludarabine and combination of fludarabine and rituximab; the responses were compared with the TP53‐abnormal and wild‐type (wt) cells to delimitate relative significance of ATM deletion. Methods: In vitro analysis was performed on fifty‐nine characterized CLL samples using viability assay WST‐1. Western blot and real‐time RT‐PCR were used to monitor the activation of the ATM/p53 pathway. Results and conclusions: At the clinically relevant concentration of fludarabine, TP53‐abnormal samples exhibited markedly higher resistance to fludarabine than the remaining CLL samples (P = 0.012); cohort with ATM deletion was not more resistant than wt cells. A similar induction of the p53 protein and its downstream target genes PUMA and BAX in ATM‐deleted and wt cells confirmed that the former subgroup has preserved a critical pro‐apoptotic response. Proportions of the samples, which had been sensitized to fludarabine by rituximab pretreatment, were insignificantly lower (P = 0.22) in the TP53‐abnormal and ATM‐deleted subgroups compared to the wt cases (30%; 29%; 50%, respectively). The presence of ATM (11q22–23) deletion in the CLL cells should not be considered an indication of resistance to fludarabine or its combination with rituximab.