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Histologic Transformation of Chronic Lymphocytic Leukemia/Small Lymphocytic

Lymphoma

Rose Lou Marie C. Agbay, MD1, Nitin Jain, MD2, Sanam Loghavi, MD1,

L. Jeffrey Medeiros, MD1, and Joseph D. Khoury, MD1†

Department of Hematopathology1,The University of Texas MD Anderson Cancer

Center, Houston, Texas, USA; Department of Leukemia2,The University of Texas MD

Anderson Cancer Center, Houston, Texas, USA


Corresponding author:
Joseph D. Khoury, MD

The University of Texas MD Anderson Cancer Center

Department of Hematopathology

1515 Holcombe Boulevard, MS-072

Houston, Texas 77030

United States of America

E-mail: jkhoury@mdanderson.org

Telephone: (713) 563-9171

Fax: (713) 794-1800

This article has been accepted for publication and undergone full peer review but has not been
through the copyediting, typesetting, pagination and proofreading process which may lead to
differences between this version and the Version of Record. Please cite this article as an
‘Accepted Article’, doi: 10.1002/ajh.24473

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Running title: CLL/SLL transformation

Conflict of interest disclosure: None of the authors has declared any competing

financial interests.

Key words: CLL/SLL, lymphoma, leukemia, mutations, genomic, transformation, TP53,

NOTCH1

Manuscript statistics:

Manuscript word count: 3498

Abstract word count: 100

Manuscript pages: 34

Figures: 3

Tables: 3

Supplemental Data: 1

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ABSTRACT

Although generally considered a clinically indolent neoplasm, CLL/SLL may undergo

transformation to a clinically aggressive lymphoma. The most common form of

transformation, to DLBCL, is also known as Richter syndrome. Transformation

determines the course of the disease and is associated with unfavorable patient

outcome. Precise detection of transformation and identification of predictive biomarkers

and specific molecular pathways implicated in the pathobiology of transformation in

CLL/SLL will enable personalized therapeutic approach and provide potential avenues

for improving the clinical outcome of patients. In this review, we present an overview of

the pathologic features, risk factors and pathogenic mechanisms of CLL/SLL

transformation.

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INTRODUCTION

The concept of transformation in patients with chronic lymphocytic leukemia (CLL) was

initially suggested in a case report published in 1928 by Maurice Richter.

(Supplementary figure 1) He described the autopsy findings of a 46-year-old man with

non-tender swelling of the left side of the neck, which gradually increased in size.

Lymphadenopathy was accompanied by occasional pain in the epigastric and

suprapubic regions and weight loss. The laboratory findings included lymphocytosis,

and degenerated white blood cells in the peripheral blood smear. Significant autopsy

findings included generalized lymphadenopathy, hepatosplenomegaly, and a small ulcer

in the ileum. Microscopic examination of the lymph nodes and liver showed two

histologic lesions termed as “leukemic cells” and “tumor cells”. The leukemic cells were

described as small lymphoid cells and the tumor cells as large lymphoma cells. The

bone marrow was comprised mostly of small neoplastic lymphocytes, whereas the ileal

lesion consisted of large lymphoma cells. As such, the simultaneous occurrence of two

lesions of different histologic grades was demonstrated, although their genetic

relationship was not established.[1]

In 1964, Lortholary and colleagues in France coined the term Richter’s syndrome.

(Supplementary figure 2) The authors presented four autopsy reports of patients

presenting initially with CLL. The patients presented with fever, weight loss,

lymphadenopathy, hepatosplenomegaly, and/or lymphocytosis. The CLL was treated

initially with either radiotherapy alone, or radiotherapy and prednisone. All patients

eventually developed a malignant lymphoma such as so-called reticular cell sarcoma

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(most likely diffuse large cell lymphoma) or Hodgkin disease (lymphoma). A mixed

proliferation of small neoplastic lymphoid cells and large lymphoma cells were observed

on histologic sections of the lymph nodes. Fifteen published articles from 1928 until

1963, including the case report by Richter, were reviewed by Lortholary and colleagues

as a part of their manuscript that described cases of concurrent CLL/SLL and a

histologically high-grade malignant lymphoma. The authors proposed that such an

association be known as Richter syndrome and this term remains in current use.[2]

Richter syndrome (RS) refers to a setting in which a patient with CLL/SLL also develops

diffuse large B-cell lymphoma (DLBCL) and, most often, is a manifestation of histologic

transformation. Richter transformation is another term often used as a synonym. Richter

syndrome is also loosely applied to CLL/SLL patients who develop less common

lymphoid neoplasms such as Hodgkin lymphoma (HL), plasmablastic lymphoma or B-

lymphoblastic leukemia/lymphoma. Whereas histologic transformation occurs in patients

with other types of low-grade B-cell neoplasms [3], the term RS is only used in the

context of CLL/SLL.

In this review, we present an overview of the pathologic features, risk factors and

pathogenic mechanisms of Richter syndrome.

CLINICAL FEATURES

Transformation of CLL/SLL into DLBCL or another uncommon type of aggressive

lymphoma is typically suspected when a patient with CLL/SLL develops sudden onset of

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B symptoms, often accompanied by enlarging lymph nodes detected by physical

examination or imaging studies. Commonly, work-up for such a scenario includes 18-

fluorodeoxyglucose-positron emission tomography (18FDG-PET/CT) which detects a

relative increase in metabolic activity, expressed quantitatively as standardized uptake

value (SUV). In a patient with suspected RS, the identification of any lesion (nodal or

extranodal) with increased 18FDG avidity (SUV>5.0) by PET/CT is an indication for

tissue evaluation. Whereas the absence of lesions detectable by 18FDG-PET is highly

sensitive in excluding RS, with a negative predictive value of up to 97%, the positive

predictive value of 18FDG-PET/CT for RS is generally proportional to the SUV; an

SUV>10 is predictive of the presence of aggressive lymphoma with 80% confidence,

and an SUV>13 with >90% confidence.[4-7]

Laboratory studies commonly associated with RS include a substantially elevated

serum lactate dehydrogenase (LDH) level >1.5 times the upper limit of normal and an

elevated serum beta-2 microglobulin (β2M) level >2 mg/L. Hypercalcemia, new onset of

absolute lymphocytosis ≥5.0x109/L, and thrombocytopenia <100x109/L often

accompany RS, but these findings are not by themselves a reliable predictor of RS.[8-

19]

HISTOLOGIC VARIANTS OF RICHTER TRANSFORMATION

DIFFUSE LARGE B-CELL LYMPHOMA

Diffuse large B-cell lymphoma is the most frequent histologic variant of histologic

transformation in patients with CLL/SLL. The development of DLBCL occurs 1.8 to 4.0

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years from the time of initial CLL/SLL diagnosis and can arise before or subsequent to

CLL/SLL therapy. Among patients with newly diagnosed CLL/SLL, the annual incidence

rate of DLBCL is 0.5 %; whereas among patients who have received treatment for

CLL/SLL the annual incidence rate of DLBCL is ~1%.[15] Up to 10.7% of all CLL/SLL

patients progress to DLBCL (RS-DLBCL).[11, 12, 14, 15, 20-23] (Supplementary table

1) The incidence rate for DLBCL reported in the literature is highly variable, likely

attributable to many factors including the heterogeneity of the patient population

studied, duration of clinical follow-up, and diagnostic criteria used to define development

of DLBCL (clinical/imaging vs. biopsy-proven). DLBCL may arise in any demographic

subset of CLL/SLL patients, but is most common in men over 60 years of age. (Table 1)

Factors associated with RS-DLBCL predisposition

A number of factors are likely involved in predisposing CLL/SLL patients to developing

RS-DLBCL, as are summarized in Table 2. On the basis of stereotyped BCR, CLL/SLL

can be segregated into various subsets. In one study, a subset associated with the

IGHV4-39/IGHD6-13/IGHJ5 stereotype was associated with the highest risk for RS, and

stereotyped BCR as well as IGHV4-39 were independent predictors of RS. Interestingly,

the stereotyped BCR of RS-DLBCL is not observed in de novo DLBCL.[24] Telomeres

play an important role in ensuring genetic stability and regulating critical cellular

functions, including proliferation and replicative senescence.[25] Others have reported

that the 5-year risk of developing RS may be higher in patients with CLL/SLL associated

with shorter (<5000 bp) telomere length (18.9% vs. 6.4%). In the same study, it was

observed that significantly shorter telomeres are present in CLL/SLL with unmutated

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IGVH genes, as well as in CLL/SLL associated with increased telomerase activity.

These findings point to a higher number of antecedent cell replications and thus a

higher chance to acquire additional genetic alterations.[26] Other biological risk factors

of CLL/SLL transformation to RS-DLBCL include expression of CD38[10, 14, 15], ZAP-

70[10, 12-15], and CD49d.[15] Cytogenetic abnormalities, such as del(11q22.3),

del(17p13), del(15q21.3), del(9p21), and/or add(2p25.3), have been also associated

with RS.[10, 15, 27] Heritable germline polymorphisms in BCL2[28], CD38[29] and

LRP4[30] have been reported to impart a higher risk for transformation, although the

functional mechanisms underlying these associations remain to be determined.

Additional factors predictive of the development of RS remain largely unknown.

Konoplev et al[23] showed that CLL/SLL patients with increased serum thymidine

kinase 1 (TK1), a key cellular enzyme involved in DNA synthesis, are at higher risk for

developing RS. Increased serum TK1 level is associated significantly with male sex,

elevated serum β2M level, unmutated IGVH, ZAP-70 expression, and lack of

del(13q14.3). Furthermore, RS patients with a higher serum TK1 level tended to be at a

higher risk of death. These observations were further corroborated by Szantho et al[31]

who showed that increased serum TK1 levels in CLL patients are associated with

advanced Rai stage, CD38 and ZAP-70 expression, and higher levels of absolute

lymphocytosis.

Pathologic features of RS-DLBCL

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Most cases of RS-DLBCL show diffuse effacement of lymph nodes or extranodal sites

by sheets of large cells with centroblastic morphology; a minority of cases have

immunoblastic features. Mitotic figures and apoptotic bodies are usually frequent, and a

starry-sky pattern and tumor necrosis are common.[32] Typically, the neoplastic cells

are positive for the B-cell markers - CD19, CD20, CD22, and PAX5 - as well as

monotypic surface immunoglobulin light chain. CD38, ZAP70, and CD49d are often

positive, whereas CD5 and CD23 expression is retained to a varying extent.[14, 15]

Approximately 80% of RS-DLBCL have a non-germinal center B-cell-like (non-GCB)

immunophenotype (negative for CD10 and positive for MUM1), whereas about 20%

have a GCB immunophenotype (positive for CD10 and/or BCL6+, MUM1-).[10, 33]

Other features often seen in RS-DLBCL include TP53 overexpression and a high

(>70%) Ki-67 proliferation index. (Figure 1) Epstein-Barr virus (EBV)-encoded RNA

transcripts may be detected in some cases.[15, 32]

Clonal relationship

The clonal relationship between CLL/SLL and RS-DLBCL was first established through

primary structural analyses of the IG genes.[34] About 70% to 80% of RS-DLBCL

cases are clonally related to the underlying CLL/SLL and can have similar unmutated or

mutated immunoglobulin heavy chain variable region (IGVH) sequences.[33]

Commonly, RS-DLBCL arises from a dominant CLL/SLL clone after having acquired

additional somatic mutations.[10] The molecular characteristics of the B-cell receptor

(BCR) have been suggested to have an impact on the risk for transformation. CLL/SLL

patients with unmutated IGVH genes are at an increased risk for RS compared with

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those with mutated IGVH.[9, 15] A fraction of CLL/SLL cases share common IGVH

complementary determining region 3 motifs (stereotyped BCR) as a result of

nonrandom recombination predispositions involving the V-D-J regions.

Molecular biology of RS-DLBCL

Despite morphologic and immunophenotypic overlap between RS-DLBCL and de novo

DLBCL, these diseases diverge significantly at the molecular level.[10, 27, 35]

The molecular profile of RS-DLBCL is complex. Two major transformation models have

been suggested to lead to development of RS from CLL/SLL.[27] Most RS-DLBCL

cases follow a “linear” model of transformation by which the transformed clone is a

direct progeny of the “parent” CLL/SLL clone; whereas in a minority of cases, a

“branched” model of evolution is implicated in which distinct genetic lesions direct a

common precursor cell to give rise to the CLL and RS clones independently (Figure 2).

Leukemic presentation of RS is associated with the latter model.

The most common chromosomal copy number alteration (CNA) linked to the

development of RS is loss of 17p (~40%) resulting in inactivation of TP53, which in turn

facilitates the development of additional genetic lesions, including additional genome-

wide somatic mutations and chromosomal rearrangements. Biallelic loss of

19p21/CDKN2A/B is frequently observed in RS (~30%) and is associated with the

“branched” model of evolution.[10] Of note, disruptions of TP53 and CDKN2A often

coexist with MYC-activating events. Other recurrent chromosomal CNAs implicated in

the pathogenesis of RS include trisomy 12, del(7q31.31-36.6), del(8p), and del(14q23.2-

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q32.33) as well as high-level amplifications of chromosomes 8, 11, 13, and 18.[10, 27,

36] Absence of del(13q14) also has been associated with an increased risk for

transformation to RS. Rearrangements involving the MYC locus (8q24), very rare in

CLL/SLL, may be gained during the course of disease, and have been suggested as a

secondary event in disease progression, particularly in patients who harbor 8q24/MYC

rearrangement in the context of a complex karyotype[12, 37]. Another possible

mechanism of MYC involvement in CLL/SLL, also associated with a shorter clinical

course, is 8q24/MYC amplification. Brown and colleagues sequenced exon 1 of MYC in

188 CLL/SLL samples and found one case with a MYC p.T58A mutation, and a

heterozygous insertion mutation that duplicates nine amino acids of the N-terminal

interaction and transactivation domain in another sample. Although MYC amplification is

a frequent event, considered to be acquired during transformation, this study showed

that MYC amplification in CLL/SLL without high-grade transformation may occur.[38]

Several genes involved in a host of cellular and biological programs have been

identified to be recurrently mutated in RS. [39-43] Genes involved in proliferation,

apoptosis, and cell cycle regulation seem to stand out. The most commonly mutated

genes implicated in the pathogenesis of RS include TP53 (tumor suppressor), NOTCH1

and MYC (proliferation), and CDKN2A/B (cell cycle regulation), together accounting for

up to 90% of alterations seen in RS-DLBCL.[27] Unlike TP53 and CDKN2A/B,

NOTCH1 mutations and other lesions associated with MYC activation are mutually

exclusive.[40] Notably, TP53 mutations and activating NOTCH1 mutations are less

common in de novo DLBCL. Additional signaling pathways involved in the emergence of

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RS-DLBCL include the MAPK, Wnt, NF-κB, and TGF-β pathways. Cases of de novo

DLBCL and RS-DLBCL share a minor subset of genes as a part of their genetic

signatures - including MYC activation (GCB-derived DLBCL), MYD88 mutations and

CDKN2A/B loss (activated B-cell-derived DLBCL). However, RS-DLBCL lacks other

abnormalities common in de novo DLBCL, such as inactivation of CREBBP/EP300,

β2M, PRDM1/BLIMP1, and TNFAIP3/A20, as well as BCL2 and BCL6

translocations.[27]

Accelerated phase CLL

The term accelerated phase of CLL/SLL has been proposed to describe a biopsy

specimen that shows increased large cells and a high proliferation rate, but without

clear-cut histologic evidence of DLBCL. Patients may or may not have clinical

symptoms of transformation. Patients with CLL/SLL in accelerated phase often,

although not always, have a more aggressive clinical course. In a study by Gine et al,

the authors suggest that the diagnosis of accelerated phase CLL/SLL can be based on

any of three morphologic criteria: (1) expanded proliferation centers (broader than a x20

microscopic field); (2) increased mitotic activity (>2.4 mitotic figures/proliferation center);

or (3) an increased proliferation index within proliferation centers as indicated by high

Ki-67 labeling (>40%). In their study, the median survival of patients with accelerated

phase CLL/SLL was shorter than patients with typical CLL/SLL. In addition, the median

survival from the time of biopsy according to the morphologic patterns of “non-

accelerated” CLL, “accelerated” CLL, and DLBCL transformation was 76 months, 34

months, and 4.3 months, respectively.[44]

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PLASMABLASTIC LYMPHOMA

Plasmablastic lymphoma (PBL) is an aggressive B-cell malignancy, thought to be

related to DLBCL, in which the lymphoma cells exhibit morphologic and

immunophenotypic features of plasma cell differentiation.[45](Supplementary figure 3)

These neoplasms most commonly arise de novo in the setting of immunodeficiency,

however, a few cases of plasmablastic lymphoma (RS-PBL) arising in patients with

CLL/SLL has been reported.[18, 19, 46] Most patients who develop RS-PBL are men,

52 to 77 years of age. A serum or urine paraprotein can be detected in some

patients.[18] In addition to typical plasmablastic features, residual CLL/SLL cells may

be identified in some areas. The neoplastic cells of RS-PBL often express CD38, ZAP-

70, CD138, BLIMP1, IRF4/MUM1, and XBP1. CD5, CD20, PAX5, and IRF8 are

commonly negative. Molecular studies have shown monoclonal IGH[18] and MYC

rearrangement.[46] The prognosis of patients with RS-PBL is grim. The few CLL/SLL

patients with RS-PBL reported in the literature died within 3 to 6 months after

transformation.[18, 19, 46]

B-LYMPHOBLASTIC LEUKEMIA/LYMPHOMA

B-lymphoblastic leukemia/lymphoma (B-LBL) is a neoplasm derived from progenitor B-

lymphoid cells often involving bone marrow, peripheral blood, and less commonly lymph

nodes.[47] Acute lymphoblastic transformation of CLL/SLL (RS-LBL) is rare, although

several cases have been reported. Most patients are men, with a reported age range of

42 to 76 years. The reported interval between CLL/SLL diagnosis and RS-LBL ranges

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from 2 months to 7 years; although simultaneous presentation of CLL/SLL and RS-LBL

may occur.[48-56] RS-LBL is characterized by numerous lymphoblasts in a background

of cells typical of CLL/SLL. The blasts are intermediate size, with indented nuclei, fine

chromatin, one or two small nucleoli, and scant cytoplasm. The neoplastic cells express

HLA-DR, surface Ig, pan-B cell markers and TdT[50, 51, 54-56]; a TdT-negative case

also has been reported.[53] There is variable expression of CD5, CD10, CD22 and

CD23.[50, 51, 53-56]

Early studies supported clonal evolution from CLL/SLL to RS-LBL based on surface

immunoglobulin expression, cytogenetic findings,[50, 54] and molecular analysis of the

IG heavy and light chains.[49, 51, 53, 56] A recent study described an analysis of paired

CLL/SLL and B-LBL specimens from 2 patients with Philadelphia chromosome-positive

B-LL and showed that the CLL/SLL and B-LBL cells used different IGHV families and

were clonally unrelated. In addition, the IGHV gene was unmutated in both CLL/SLL

and B-LBL cells in one of these 2 cases, and IGHV was mutated in CLL/SLL cells but

not in B-LBL cells. These data suggest that B-LBL can occur in patients with CLL/SLL

associated with either mutated or unmutated IGHV. Furthermore, the authors suggested

that B-LBL may represent a secondary neoplasm and not evidence of histologic

transformation in a subset of patients.[55] Cytogenetic studies also have shown the

presence of 8q24 translocation acquired at the time of transformation to B-LBL in some

patients.[50, 51] Some authors use the term Burkitt-like lymphoblastic transformation for

those occurrence.[56] Overall, compared with typical B-LBL, cases of blastic

transformation of CLL/SLL show distinctive clinical features including a poor prognosis,

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and likely a different pathogenesis. In our opinion, classifying these cases as B-ALL or

B-LBL without further comment may be misleading to clinicians and patients and

therefore the pathology report needs to indicate that the neoplasm represents

transformation of CLL/SLL and not de novo disease. We suggest using terms such as

“TdT-positive blastoid lymphoma” or “high-grade TdT-positive blastic B-cell

leukemia/lymphoma” for these tumors.

HODGKIN LYMPHOMA

Less than 1% of patients with CLL/SLL develop Hodgkin lymphoma (RS-HL).[16, 57,

58] Patients with CLL/SLL are typically in the seventh decade of life (range, 30 to 88

years) when they undergo transformation to RS-HL and most are men. The median

interval between CLL/SLL diagnosis and RS-HL is 4 to 6 years (Table 3). Of note,

patients with CLL/SLL who are treated with purine nucleoside analogs (fludarabine,

cladribine) and later on develop RS-HL seem to have worse outcomes compared with

other CLL/SLL patients who develop RS-HL.[59, 60] It has been postulated that

exposure to immunosuppressive chemotherapy in patients with CLL may increase the

risk for HL transformation. The presumed etiologic process is the marked and prolonged

reduction of CD4-positive and CD8-positive T-cells, which likely permits the proliferation

and accumulation of EBV-positive B-cells, eventually resulting in a high-grade

lymphoma.[59, 61]

Hodgkin transformation is characterized by Hodgkin and Reed-Sternberg (HRS) cells in

a polymorphous inflammatory background distinct from the CLL/SLL.[17] (Figure 3) The

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inflammatory background consists of T-cells and histiocytes, with or without abundant

eosinophils. Tumor necrosis is a common finding.[32] Any of the histologic subtypes of

HL can be seen, with the mixed cellularity subtype being most common.[59]

An unusual pattern that raises the possibility of HL transformation is the occurrence of

HRS cells scattered in a monomorphous background of CLL cells. In some patients,

follow-up biopsy specimens show unequivocal CHL as described above, but in other

patients there is no subsequent HL. These lesions have been referred to in the literature

as CLL/SLL with HRS cells.[62-65] A recent study [66] suggests that this pattern can be

considered as an early event in the transformation and appears to have the potential to

progress to the type of RS-HL wherein HRS cells are in a polymorphous inflammatory

background distinct from the CLL/SLL. The same study showed that the overall survival

for these two types of morphology is similar.

By immunohistochemistry, HRS cells express CD30, CD15, and PAX5 (dim), and these

cells are commonly positive for EBV (Table 4).[33] HRS cells may be positive for CD20,

usually with variable intensity, in 20% to 30%of cases.[59]

In about 80% of patients with RS-HL, the CLL/SLL cells have mutated IGVH. This is a

much higher frequency than that observed among patients who develop RS-DLBCL or

have no transformation.[33] In addition, it has been demonstrated that similar VH gene

rearrangements can be seen in HRS and CLL/SLL cells, implying that the two

populations of cells were derived from a common precursor B-cell.[67, 68] A recent

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study showed that most of the CLL/SLL that is ZAP-70 positive is IGHV unmutated,

whereas ZAP-70 negative cases are IGHV mutated. HRS cells from all IGHV unmutated

(ZAP-70 positive) CLL/SLL cases were clonally unrelated, while HRS cells from IGHV

mutated (ZAP-70 negative) CLL/SLL cases frequently share clonal origin with the

associated CLL.[66]

T-CELL LYMPHOMAS
Rarely patients with CLL/SLL develop T-cell lymphomas. In general, the relationship

between CLL/SLL and these neoplasms is poorly understood.[69, 70] These rare

patients are usually not included under the umbrella term of RS in the literature. A few

relevant papers are cited, but these patients are not the focus of this review.

Treatment

Patients with RS generally have a poor prognosis. Most data for treatment for RS is

derived from single-arm phase I-II studies, and retrospective analyses.[13, 71-78] The

standard therapy for RS is chemoimmunotherapy with a median survival after therapy

of less than 1 year.[79] MD Anderson Cancer Center has used oxaliplatin-based

regimen (OFAR: oxaliplatin, fludarabine, Ara-c [cytarabine], rituximab) for patients with

RS.[13, 71] OFAR regimen led to an overall response rate (ORR) of 50% with a 20%

CR rate.[71] However, the median progression-free survival (PFS) was only 4 months,

and the median OS was 8 months. Langerbeins and colleagues reported outcomes in

15 patients with RS who received rituximab, cyclophosphamide, doxorubicin, vincristine,

prednisone (R-CHOP).[74] Two-thirds of the patients responded, with a median PFS of

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10 months and a median OS of 21 months. Ibrutinib, a BTK inhibitor, is approved for

patients with CLL.[80, 81] Anecdotal reports have suggested the activity of ibrutinib in

patients with RS.[82-84] Pembrolizumab, a PD-1 monoclonal antibody, has also been

reported to have encouraging activity in patients with RS.[85] Several other targeted

agents such as PI3K inhibitors, antibody-drug conjugates, or bi-specific antibodies may

have a role in patients with RS, and need further evaluation. Allogeneic stem cell

transplantation (allo-SCT) remains an important therapeutic modality for patients with

RS.[86, 87] Although allo-SCT is indicated for treating RS patients who undergo

remission, and is the only modality that offers a potential for cure, many patients do not

qualify because of their older age or inadequate response to induction therapy. For

Hodgkin’s transformation, treatment is with multidrug chemotherapy such as

doxorubicin, bleomycin, vinblastine, dacarbazine (ABVD).[88]

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Figure Legends

Figure 1. Diffuse large B cell lymphoma transformation of CLL/SLL. (A, B) CLL

involving the bone marrow. (A) CLL with cytologically atypical morphology in a bone

marrow aspirate smear with a population of small and medium-sized cells. (B) Bone

marrow space replaced by sheets of small lymphocytes. A proliferation center is

present. (C to F) Concurrent nasal mass biopsy involved by DLBCL. (C) Diffuse

growth of large neoplastic lymphoid cells and a conspicuous starry sky pattern. (D)

Neoplastic cells with immunoblast-like and centroblast-like morphology. (E) The

neoplastic cells are positive for PAX5 and negative for CD5. (F) Ki-67

immunohistochemistry demonstrates a high proliferation rate. (A, wright-giemsa stain; B

to D, hematoxylin-eosin; E and F, IHC with hematoxylin counterstain)

Figure 2. Patterns of clonal evolution in CLL/SLL transformation. In the linear

model (A) of transformation, more common among patients with RS-DLBCL, DLBCL

originates directly from the major CLL/SLL clone following the acquisition of additional

genetic alterations. In this model, the DLBCL and CLL/SLL clones show similar IGVH

mutation profiles. In the branched model (B), clones derive directly from a common

precursor cell (CPC) by way of acquiring distinct genetic lesions. Note that both clones

share a subset of alterations with the CPC and with each other in addition to harboring

distinct genetic lesions. In both models, a minor subclone arising from the CPC and

already equipped with transformation-specific gene signatures may be present at the

time of diagnosis and may later declare itself as bona fide transformation.

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Figure 3. Hodgkin lymphoma transformation of CLL/SLL. (A and B) Lymph node

involved by CLL/SLL (dark areas) and Hodgkin lymphoma (light/pale areas) indicating

transformation. (C) Low-grade component composed of small lymphocytes (D) with

CD5 expression. (E) Hodgkin and Reed-Sternberg (HRS) cells in a polymorphous

inflammatory background composed of T cells, histiocytes and eosinophils. (F) HRS

cells are CD30+. (A to C, E, hematoxylin-eosin; D and F, IHC with hematoxylin

counterstain)

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Tables

Table 1: Summary of current studies on clinical features of CLL patients with Richter syndrome

Study Age Gender LDH β2M TK1 Absolute Platelets


Male Female (>1.5 times lymphocyte <100x109/L
% % the upper count >
limit) 5.0x109/L
Tsimberidou 53% NR NR 47% 40% NR 37% 57%
et al (87) (>60 years) (>3 x UNL) (> 5x109/L) (<100x109/L)
Rossi et al 70 years 64.7 35.3 35% 3 mg/L NR NR 204
(12) (64-73) (2.3-3.7) (150-232)
Tsimberidou 66 50 50 55% 55% NR 20% NR
et al (13) (34-77) (>2 x ULN) (>30x109/L)
Rossi et al 65% 62.7 NR 45% NR NR 51.2% 30.5%
(9) (>60 years) (> 5x109/L) (<100x109/L)
Fan et al 37.5% 62.5 37.5 31% 4.35 mg/L 37.5% 18.75% NR
(14) (>60 years) ( 2.0-16.7) (> 2.0 pmol/L) (> 5x109/L)
Chingrinova 70% 56 NR 50% NR NR 44% 24%
et al (10) (>60 years) (> 5x109/L) (<100x109/L)
Parikh et al 61 78 NR NR 3.1 mg/L NR 9.1x109/L 190
(15) years (1.2-13.1) (0.7 to 415.5) (71-493)
(21-85)
NR: not reported; UNL: upper normal limit; LDH: Lactate dehydrogenase; β2M: Beta 2 microglobulin; TK1: Thymidine
kinase 1

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Table 2: Summary of factors reported to be associated with risk for RS in patients with CLL/SLL

Frequency in RS patients (%) References

Biological characteristics Unmutated IGVH 89 Tsimberidou et al (13)

66.7 Fan et al (14)

76 Parikh et al (15)

Stereotyped B-cell receptors 49.3 Rossi et al (24)

Short telomere length (≤5000 bp) 47 (90/191) Rossi et al (26)

ZAP-70+* 89 Tsimberidou et al (13)

66.7 Fan et al (14)

61 Chigrinova et al (10)

58 Parikh et al (15)

CD38+* 93 Fan et al (14)

57 Parikh et al (15)

46 Chigrinova et al (10)

CD49d+* 77 Parikh et al (15)

Genetic characteristics del(11q) 20 Tsimberidou et al (13)

26.7 Fan et al (14)

21 Parikh et al (15)

del(17p) 33 Tsimberidou et al (13)

26.7 Fan et al (14)

25 Parikh et al (15)

40 Fabbri et al (27)

del (9p21) ~30 Fabbri et al (27)

add(2p25.3) 14 Chigrinova et al (10)

TP53** disruption*** 60 (12/20) Chigrinova et al (10)

47 Rossi et al (9)

36 Fabbri et al (27)

MYC** aberrations 18 Chigrinova et al (10)

26 Rossi et al (9)

CDKN2A disruption ~30 Fabbri et al (27)

Trisomy 12** 40 Tsimberidou et al (13)

26.7 Fan et al (14)

21 Parikh et al (15)

~30 Fabbri et al (27)

NOTCH1** Fabbri et al (27)


*By immunohistochemistry or flow cytometry.
**Among the 4 most commonly altered aberrations ~90% of RS cases.
***Includes deletion and/or mutation.
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Table 3: Summary of major studies of Hodgkin transformation in patients with CLL

Study Study Type of study Age, years Gender Median time to Frequency of EBV
period (range) Male Female development Hodgkin positive
% % of Hodgkin transformation RS
transformation, cells
years (range)
Bockorny 1975- Meta-analysis 65.7 76.5 23.5 4.3 86 cases in 36 70.6%
et al (60) 2011 (34-85) (0-26) years
Parikh et 1995- Cohort 68 81 NR 6.2 0.05%/year 67%
al (58) 2011 (45-88) (0-24.5)
Tadmor et 1996- Retrospective 58 75 25 5.9 13% 50%
al (16) 2010 (30-77) (0.8-11.9) (16 of 119)

NR: Not reported

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Figure 1. Diffuse large B cell lymphoma transformation of CLL/SLL

194x156mm (300 x 300 DPI)

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Figure 2. Patterns of clonal evolution in CLL/SLL transformation.

193x116mm (300 x 300 DPI)

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Figure 3. Hodgkin lymphoma transformation of CLL/SLL.

195x157mm (300 x 300 DPI)

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