Chronic lymphocytic

leukemia
(CLL)
Background:

◼ Chronic lymphocytic leukemia (CLL) is

a monoclonal disorder characterized
by a progressive accumulation of
functionally incompetent lymphocytes.
It is the most common form of
leukemia found in adults in Western
countries.
Peripheral smear of a patient with chronic
lymphocytic leukemia, small lymphocytic
variety.
Bone marrow infiltration in
CLL
B-CLL lymphocyte
Pathophysiology:
◼ The cells of origin in the majority of patients with CLL
are clonal B cells arrested in the B-cell differentiation
pathway, intermediate between pre-B cells and mature
B cells.
◼ Morphologically in the peripheral blood, these cells
resemble mature lymphocytes. B-CLL lymphocytes
typically show B-cell surface antigens, as demonstrated
by CD19, CD20, CD21, and CD23 monoclonal antibodies.
In addition, they express CD5, which is more typically
found on T cells.
Pathophysiology:
◼ CLL cells express extremely low levels of surface
membrane immunoglobulin, most often immunoglobulin
M (IgM) or IgM and immunoglobulin D (IgD).
Additionally, they also express extremely low levels of a
single immunoglobulin light chain (kappa or lambda).
◼ Recent studies have demonstrated that bcl2, a
protooncogene, is overexpressed in B-CLL. The
protooncogene bcl2 is a known suppresser of apoptosis
(programmed cell death), resulting in a long life for the
involved cells.
Pathophysiology:
◼ An abnormal karyotype is observed in the majority of patients
with CLL. The most common abnormality is deletion of 13q,
which occurs in more than 50% of patients. Patients showing
13q14 abnormalities have a relatively benign disease that
usually manifests as stable or slowly progressive isolated
lymphocytosis. The presence of trisomy 12, which is observed
in 15% of patients, is associated with intermediate prognosis.
Deletions of bands 11q22-q23, observed in 19% of patients,
are associated with extensive lymph node involvement and
aggressive disease. The most important poor risk factor is
del17p associated with resistance to purine analogues.
Approximately 2-5% of patients with CLL exhibit a T-cell
phenotype (T-cell prolymphocytic leukemia).
◼ CLL should be also distinguished from prolymphocytic
leukemia, in which more than 65% of the cells are
morphologically less mature prolymphocytes.
Deletion 17 (FISH analysis)
Frequency:

◼ In the US: More than 17,000 new cases are reported

every year.
◼ Internationally: Unlike the incidence of CLL in the
Western countries, which is similar to that of the United
States, the disease is extremely rare in Asian countries
(ie, China, Japan), where it is estimated to comprise
only 10% of all leukemias.
Clinical course:
◼ The natural history is heterogeneous.
◼ Some patients die rapidly, within 2-3 years of diagnosis,
because of CLL complications.
◼ The majority of patients live 5-10 years, with an initial
course that is relatively benign but followed by a
terminal progressive and resistant phase lasting 1-2
years. During the later phase, morbidity is considerable,
both from the disease and from complications of
therapy.
 Incidence:
◼ Race: The incidence is higher among whites compared to
African Americans.
◼ Sex: The incidence is higher in males than in females,
with a male-to-female ratio of 1.7:1.
◼ Age:
◼ CLL is a disease that primarily affects elderly individuals,
with the majority of cases reported in individuals older
than 55 years. The incidence continues to rise in those
older than 55 years. Median years at diagnosis is 72 years
◼ Recently, individuals aged 35 years or younger are being
diagnosed more frequently.
◼ Risk factors: age, CLL in the family history
CLINICAL
◼ History: Patients with CLL present with a wide range of
symptoms and signs at presentation. Onset is insidious,
and it is not unusual for this disorder to be discovered
incidentally after a blood cell count is performed for
another reason.
◼ Predisposition to repeated infections such as
pneumonia, herpes simplex labialis, and herpes zoster
◼ Enlarged lymph nodes
◼ Early satiety and/or abdominal discomfort related to an
enlarged spleen
◼ Mucocutaneous bleeding and/or petechiae secondary to
thrombocytopenia
◼ Tiredness and fatigue secondary to anemia
CLINICAL

◼ Physical:
◼ Localized or generalized
lymphadenopathy
– Splenomegaly (30-40% of cases)
– Hepatomegaly (20% of cases)
– Petechiae
– Pallor
Enlarged lymph nodes in CLL patient
Lab Studies:

• CBC count with differential shows absolute

lymphocytosis with more than 5000 lymphocytes/mL.
Some authors consider this to be a prerequisite for the
diagnosis of CLL and classify cases that would otherwise
meet the criteria as small lymphocytic lymphoma/diffuse
well-differentiated lymphoma.
CBC of CLL patient
Lab Studies:
◼ Microscopic examination of the peripheral blood smear is
indicated to confirm lymphocytosis. It usually shows the
presence of smudge cells, which are artifacts due to
damaged lymphocytes during the slide preparation.
– Peripheral blood flow cytometry is the most valuable
test to confirm CLL.
– It confirms the presence of circulating clonal B-
lymphocytes expressing CD5, CD19, CD20(dim), CD
23, and an absence of FMC-7 staining.
Lab Studies:
• Consider obtaining serum quantitative immunoglobulin
levels in patients developing repeated infections because
monthly intravenous immunoglobulin administration in
patients with low levels of immunoglobulin G (<500 mg)
may be beneficial in reducing the frequency of infectious
episodes.
Imaging Studies:

◼ Liver/spleen scan may demonstrate splenomegaly.

◼ Computed tomography of chest, abdomen, or pelvis
generally is not required for staging purposes. However,
be careful to not miss lesions such as obstructive
uropathy or airway obstruction that are caused by lymph
node compression on organs or internal structures.
Procedures:
• Bone marrow aspiration and biopsy with flow cytometry
is not required in all cases but may be necessary in
selected cases to establish the diagnosis and to assess
other complicating features such as anemia and
thrombocytopenia. For example, bone marrow
examination may be necessary to distinguish between
thrombocytopenia of peripheral destruction (in the
spleen) and that due to marrow infiltration.
Procedures:
• Consider a lymph node biopsy if lymph node(s) begin to
enlarge rapidly in a patient with known CLL to assess
the possibility of transformation to a high-grade
lymphoma. When such transformation is accompanied
by fever, weight loss, and pain, it is termed Richter
syndrome.
Staging:
◼ Two staging systems are in common use, the Rai-
Sawitsky in the United States and the Binet in Europe.
Neither is completely satisfactory, and both have been
often modified. Because of its historical precedent and
wide use, the Rai-Sawitsky system is described first,
followed by the Binet.
Staging:
◼ The Rai-Sawitsky staging system divides CLL into 5
Stages, 0-IV.
– Stage 0 is lymphocytosis in the blood and marrow
only, with a survival of longer than 120 months.
– Stage I is lymphocytosis and adenopathy, with a
survival of 95 months.
– Stage II is lymphocytosis plus splenomegaly and/or
hepatomegaly, with a survival of 72 months.
– Stage III is lymphocytosis plus anemia (hemoglobin
<10 g), with a survival of 30 months.
– Stage IV is lymphocytosis plus thrombocytopenia
(platelets <100,000), with a survival of 30 months.
Staging:
◼ The Binet staging system uses 3 stages, A, B, and C.
– Stage A requires a hemoglobin of greater than or
equal to 100 g/L, platelets greater than or equal to
100 X 10-9, and fewer than 3 lymph node areas
involved (Rai-Sawitsky stages 0, I, II). Survival is
longer than 120 months.
– Stage B requires hemoglobin and platelet levels as in
stage A and 3 or more lymph node areas involved
(Rai-Sawitsky stages I and II). Survival is 61 months.
– Stage C is a hemoglobin less than 100 g/L, platelets
less than 100 X 10-9, or both (Rai-Sawitsky stages
III and IV). Survival is 32 months.
TREATMENT
◼ Medical Care: At the time of diagnosis, most patients
do not need to be treated with chemotherapy unless
they have weight loss of more than 10%, extreme
fatigue, fever related to leukemia, night sweats,
progressive marrow failure, autoimmune anemia or
thrombocytopenia not responding to prednisone,
progressive splenomegaly, massive lymphadenopathy,
or progressive lymphocytosis. Progressive lymphocytosis
is defined as an increase of greater than 50% in 2
months or a doubling time of less than 6 months.
◼ Patients at stage 0 whose disease is stable require only
periodic follow-up. Early treatment has not been
demonstrated to be advantageous.
TREATMENT
◼ Prednisolone alone, usually in a dose of 20-60 mg daily
initially, with subsequent gradual dose reduction, may
be useful in patients with autoimmune manifestations of
the disease.
◼ Nucleoside analogs (ie, fludarabine, cladribine, and
pentostatin) include a group of drugs with major activity
against indolent lymphoid malignancies, including CLL
TREATMENT
– Fludarabine is the most extensively studied and
currently is the most commonly used therapy in CLL.
– Responses to treatment with chlorambucil and
prednisone are observed in 38-47% of patients.
– Patients treated with fludarabine have much higher
rates (80%) of overall responses and a 37%
complete remission rate.
TREATMENT
– The combination of fludarabine and
cyclophosphamide has shown higher response rates,
but direct comparative trials of fludarabine and
cyclophosphamide to fludarabine alone are lacking.
– Various combination regimens have shown improved
response rates in several randomized trials but failed
to show any survival advantage. Common
combination regimens include chlorambucil and
corticosteroids; cyclophosphamide, doxorubicin, and
prednisone (CAP); cyclophosphamide, vincristine,
and prednisone (CVP); and cyclophosphamide,
doxorubicin, vincristine, and prednisone (CHOP).
TREATMENT

◼ Therapy with monoclonal antibodies has been

evaluated in patients with CLL. The most useful
agents are anti-CD20 monoclonal antibodies used in
in combination with standard chemotherapy
Anti-CD20 monoclonal antibodies in CLL
therapy
 Anti-CD20 monoclonal antibodies
in CLL therapy

Rituximab – chimeric monoclonal antibody against the protein

CD20, which is primarily found on the surface of immune system
B cells

➢The direct effects of rituximab include

complement-mediated cytotoxicity (CDC)
and antibody-dependent cell-mediated
cytotoxicity (ADCC) and the indirect effects
include structural changes, apoptosis, and
sensitization of cancer cells to
chemotherapy.

*rycina -http://commons.wikimedia.org
 Anti-CD20 monoclonal antibodies
in CLL therapy

Ofatumumab – is a fully human monoclonal antibody to

CD20, which appears to inhibit early-stage B lymphocyte
activation.

➢ it targets the same antigen as

rituximab, but ofatumumab binds a
novel, membrane-proximal epitope,
and dissociates from its target at a
slower rate compared to rituximab.

➢ it induces higher CDC i ADCC,

than rituximab

pharmacodia.com
 Anti-CD20 monoclonal antibodies
in CLL therapy

Obinutuzumab – a type II humanised anti-CD20

monoclonal antibody of the IgG1 subclass

➢It binds to CD20 on B

cells and causes these
cells to be destroyed by
engaging the adaptive
immune system,
directly activating
intracellular apoptosis
pathways, and
activating the
complement system.

➢
pharmacodia.com
B-Cell Receptor (BCR): Signaling Promotes Proliferation,
Differentiation, and Survival

CD79B
CD79A

• Each B-cell expresses a unique B-cell receptor that specifically

binds to its cognate antigen

• BCR is required for B-cell survival and differentiation at several

stages of B-cell development from the pre-B cell stage and onwards

Kraus M, et al. Cell. 2004;117:787-800.

Niiro H and Clark EA. Nat Rev Immunol. 2002;2:945-956.
▪ Hamowanie przewodnictwa
Tyrosine sygnału
kinase inhibitors przez
in CLL BCR
therapy

inhibits phosphoinositide 3-kinase δ

inhibits Bruton tyrosine kinase

indicated for adults with chronic lymphocytic leukaemia (CLL) who have received
at least one prior therapy, or as first-line treatment in patients with a specific
genetic mutation — the presence of 17p deletion or TP53 mutation — which
makes them unsuitable for chemo-immunotherapy.
 BCR signaling inhibitor
Ibrutinib

◼ Ibrutinib is an oral, once-daily therapy that targets

important pathways in B-cell malignancies
◼ Ibrutinib covalently binds to cysteine 4811,2 near
the BTK active site with a 2–3-hour half-life3

1. Honigberg LA, et al. Proc Natl Acad Sci USA. 2010;107:13075-13080.

2. Pan Z, et al. ChemMedChem 2007;2:58-61. *Of 491 Kinases analysed
 Bruton’s Tyrosine Kinase (BTK):
An Essential Component of the B-Cell Signaling
Pathway

◼ BTK is essential for:

– BCR activation of NF-kB
which regulates
apoptosis1
– BCR activation of
integrins which regulates
B-cell adhesion2
– Chemokine-controlled
B-cell migration and
homing3

1. Davis RE, et al. Nature. 2010;463:88-92.

2. Spaargaren M, et al. J Exp Med. 2003;198:1539-1550. Buggy JJ and Elias L. Int Rev Immunol. 2012;31:119-113.
3. de Gorter DJJ, et al. Immunity. 2007;26:93-104. de Gorter DJJ, et al. Immunity. 2007;26:93-104.
Proposed Mechanism of Action in Chronic Lymphocytic Leukemia
(CLL) and Mantle Cell Lymphoma (MCL):
Ibrutinib Blocks Malignant B-Cell Growth and Proliferation

Buggy JJ and Elias L. Int Rev Immunol. 2012;31:119-113.

 BCR signaling inhibitor
Idelalizyb

◼ Idelalisib is an oral inhibitor of

phosphoinositide 3-kinase (PI3K)
delta, a protein that plays a role in
the activation, proliferation and
viability of B cells, a critical
component of the immune system.
PI3K delta signaling is active in
many B-cell leukemias and
lymphomas, and by inhibiting the
protein,idelalisib blocks several
cellular signaling pathways that
drive B-cell viability. By binding to
these receptors idelalisib blocks an
important pathway that promotes
cell division. lymphomation.org
 BCL-2 inhibitor
Venetoclax

Wenetoklaks
➢ It blocks the anti- BCL-2
apoptotic B-cell
Inicjacja
lymphoma-2 (Bcl-2) apoptozy
protein, leading to Białko pro- BIM
programmed cell apoptotyczne BAX

death of CLL cells. BAK

Overexpression of Śmierć komórki

nowotworowej
BAX

Bcl-2 in some
Aktywacja
lymphoid kaspaz

malignancies has Cytochrom c

sometimes shown to
be linked with
increased resistance
to chemotherapy
1. Leverson JD, et al. Sci Transl Med 2015; 7:279ra40;
2. Czabotar PE, et al. Nat Rev Mol Cell Biol 2014; 15:49–63;
3. Plati J, et al. Integr Biol (Camb) 2011; 3:279–296; 4. Certo M, et al. Cancer Cell 2006; 9:351–365;
5. Souers AJ, et al. Nat Med 2013; 19:202–208; 6. Del Gaizo Moore V, et al. J Clin Invest 2007; 117:112–121.
Thank you for your attention