CHRONIC LYMPHOCYTIC

LEUKEMIA (CLL)
 ALL CLL Lymphomas MM
naïve

B-lymphocytes

Plasma
Lymphoid cells
progenitor T-lymphocytes

AML Myeloproliferative disorders

Hematopoietic Myeloid Neutrophils
stem cell progenitor

Eosinophils

Basophils

Monocytes

Platelets

Red cells
 CLL - VH Mutation

• Naive B cells have unmutated V regions

– Make the initial IgM that bind Ag poorly
• Somatic hypermutation of V region creates
memory B cells
– Make Ab with higher affinity for Ag
 CLL - VH Mutation

Naïve B cells Memory B cells

Unmutated VH Mutated VH

CLL CLL
Fast progression Slow Progression
Short survival Long Survival
 WHO classification
B-Cell
B-Cellneoplasms
neoplasms T-cell
T-celland
andNK-cell
NK-cellneoplasms
neoplasms
- -Precursor
PrecursorB-cell
B-cellneoplasm:
neoplasm: - -Precursor T-cell neoplasm:
Precursor T-cell neoplasm:
B-lymphoblastic
B-lymphoblasticleukemia/lymphoma
leukemia/lymphoma T-lymphoblastic
T-lymphoblasticlymphoma/leukemia
lymphoma/leukemia
- -Mature (peripheral) B-cell neoplasms:
Mature (peripheral) B-cell neoplasms: - -Mature
Mature (peripheral) T-cellneoplasms:
(peripheral) T-cell neoplasms:
B-cell
B-cellchronic
chroniclymphocytic
lymphocyticleukemia/small
leukemia/small T-cell prolymphocytic leukemia
T-cell prolymphocytic leukemia
lymphocytic lymphoma T-cell
lymphocytic lymphoma T-cellgranular
granularlymphocytic
lymphocyticleukemia
leukemia
B-cell
B-cell prolymphocyticleukemia
prolymphocytic leukemia Aggressive NK-cell leukemia
Aggressive NK-cell leukemia
Lympfoplasmacytic
Lympfoplasmacyticlymphoma Adult
lymphoma AdultT-cell
T-celllymphoma/leukemia
lymphoma/leukemia(HTLV1 (HTLV1+)+)
Splenic
Splenic marginal zoneB-cell
marginal zone B-celllymphoma
lymphoma Extranodal
ExtranodalNK/T-cell
NK/T-celllymphoma,
lymphoma,nasal nasaltype
type
(+(+/-/-villous
villouslymphocytes)
lymphocytes) Enteropathy-type T-cell lymphoma
Enteropathy-type T-cell lymphoma
Hairy
Hairycell
cellleukemia Hepatosplenic
leukemia Hepatosplenicgamma-delta
gamma-deltaT-cell T-celllymphoma
lymphoma
Plasma
Plasma cellmyeloma/plasmacytoma
cell myeloma/plasmacytoma Subcutaneous panniculitis-like T-cell
Subcutaneous panniculitis-like T-cell
Extranodal
Extranodal marginalzone
marginal zoneB-cell
B-cell lymphoma
lymphoma
lymphoma of MALT type Mycosis
lymphoma of MALT type Mycosisfungoides/Sezary
fungoides/Sezarysyndrome syndrome
Nodal
Nodalmarginal
marginalzone zoneB-cell
B-celllymphoma Anaplastic
lymphoma Anaplastic large-cell lymphoma,T/null
large-cell lymphoma, T/nullcell,
cell,
(+/— monocytoid B
(+/— monocytoid B cells) cells) primary cutaneous type
primary cutaneous type
Follicular
Follicularlymphoma Peripheral
lymphoma PeripheralT-cell
T-celllymphoma,
lymphoma,not nototherwise
otherwise
Mantle-cell characterized
Mantle-celllymphoma
lymphoma characterized
Diffuse Angioimmunoblastic
AngioimmunoblasticT-cell T-celllymphoma
Diffuse largeB-cell
large B-celllymphoma
lymphoma lymphoma
Mediastinal Anaplastic
Anaplastic large-cell lymphoma,T/null
large-cell lymphoma, T/nullcell,
Mediastinal largeB-cell
large B-celllymphoma
lymphoma primary systemic type
cell,
Primary effusion lymphoma
Primary effusion lymphoma primary systemic type
Burkitts
Burkittslymphoma/Burkitt
lymphoma/Burkittcell cellleukemia
leukemia
 CLL - Definition
• in 98% of patients the leukemic cells are a monoclonal population of
mature B lymphocytes with low-density surface immunoglobulin
• T cell CLL can occur rarely - endemic in Japan, connected with HTLV1
infection

• B-CLL is a neoplastic disease characterized by proliferation and

accumulation of small, mature, long-living lymphocytes in blood, marrow
and lymphoid tissues (lymph nodes, spleen)
• Results in prolonged cell survival despite of low proliferate index.

• This lymphocytosis leads to specific clinical and laboratory symptoms of

B-CLL

• The neoplastic lymphocytes have on their surface the special B-cell line
antigens – CD19, CD20 and also CD5, CD23, and a very weak expression
of surface immunoglobulin (SIg)
 CLL - Epidemiology
• Most common leukemia of Western world.
• Less frequent in Asia and Latin America.
• Male to female ratio is 2:1.
• Median age at diagnosis is 65-70 years.
• Uncommon (10%) in patients under 50 years
• In US population incidence is similar in
different races.
• CLL is predominently an indolent disorder of late
middle-aged or elderly individuals
• In its least aggressive pattern, patients die of causes
unrelated to CLL at a rate that closely follows actual
norms for their age.
• In its most aggressive form, patients may die within 1 to
2 years after diagnosis.
• When the patients come to the doctor for the first time,
they are often asymptomatic.
• As the disease advances, the following may appear:
increasingly elevated lymphocyte counts; progressive
lymphadenopathy and hepatosplenomegaly; and more
severe anemia, granulocytopenia, or thrombocytopenia.
• Late in the course of the disease,
hypogammaglobulinemia and progressive
splenomegaly are prevalent. Infections are common
with disease progression and are the leading cause
of death in patients with CLL.

• Most CLL patients die of infection or illness

unrelated to the leukemia.

• Long-term consequences of CLL include the

development of autoimmune phenomena and/or
transformation.
 CLL - Etiology
• The cause of CLL is unknown

• There is increased incidence in

– farmers,
– rubber manufacturing workers,
– asbestos workers,
– tire repair workers

• Genetic factors have been postulated to play a role in

the high incidence of CLL in some families
 Cytogenetics - clonal chromosomal abnormalities are detected in
approximately 50% of CLL patients. The most common clonal
abnormalities are:
• trisomy 12
• structural abnormalities of chromosomes 13, 14, 17 and 11
– patients with abnormal karyotypes have a worse prognosis

• Immunoglobulin genes - monoclonal surface immunoglobulin is

expressed on lymphocytes kappa/lambda restriction (60% kappa and
40% lambda light chains)

• Immunologic abnormalities
– autoimmune disease (hemolytic anemia and thrombocytopenia)
– hypogammaglobulinemia
– cellular immune defects
 CLL – Initial symptoms
• Approximately 40% are asymptomatic at
diagnosis – discovered by a CBC
• In symptomatic cases the most common
complaint is fatigue
• B symptoms – fever, sweats, weight loss
• Less often the initial complaint is related to
enlarged nodes or the development of an
infection (bacterial)
 CLL - Clinical findings
• Most symptomatic patients have enlarged lymph nodes (more
commonly cervical and supraclavicular) and splenomegaly
• The lymph nodes are usually discrete, freely movable, and
nontender
• Hepatomegaly may occur
• Less common manifestation are
– infiltration of tonsils,
– mesenteric or retroperitoneal lymphadenopathy,
– skin infiltration
• Patients rarely present features of anemia, and bruising or
bleeding
 Investigations
• Pretreatment studies of patients with CLL should include
examination of:
– complete blood count
– peripheral blood smear
– reticulocyte count
– Coomb’s test
– renal and liver function tests
– serum protein electrophoresis
– immunoglobulin levels
• immunophenotyping should be carried out to confirm
the diagnosis
• Bone marrow biopsy and cytogenetic analysis is not
routinely performed in CLL
 CLL – Lab findings
a) Blood test lymphocytosis ≥ 5 000/mm3 (4 weeks)

b) Morphology population of small mature lymphocyte

c) B-cell CLL phenotype clonal population of lymphocyte CD

19, CD20, CD23, low SIg, CD5+

d) Markers of clonality κ/λ light chain restriction;

e) Bone marrow infiltrate > 30% ly of nuceated cells on aspirate

f) Lymph node diffuse infiltration of small lymphocyte

 Monoclonal B lymphocytosis (MBL)
• occurs in healthy adults
• peripheral blood clonal B lymphocytes but fewer than the
minimum of 5000 cells/mm3 required to diagnose CLL
• These patients lack other features of CLL such as adenopathy
or constitutional symptoms, and 1% to 2% cases of MBL
progress to CLL per year.
• Monoclonal B lymphocytosis occurs in 5.1% of all people with
normal complete blood cell counts and 13.9% of patients with
lymphocytosis.
• It is not known if MBL and CLL have similar molecular features
or cytogenetic abnormalities, but recent reports suggest that
most patients with CLL have a preceding MBL phase
 CLL – Lab findings
• Morphology:
– Leucocytosis with monoclonal lymphocytosis of greater than
5.000/ul.
– anemia
• Because of „displacement ”
• and/or autoimmunohemolic (10-20% of patients have a positive
direct antiglobulin test; AIHA is commonly connected with the
presence of warm auto- antibodies IgG class – rapidly
increasing fatigue, skin getting yellow, anemia with enlarged
reticulocytosis, higher level of bilirubin)
– thrombocytopenia
• Because of „displacement ”
• and/or immunologic (about 5% of B-CLL patients have anty-
platelet antibodies)
Absolute lymphocytosis
Lymphs = B cells
Thin cytoplasm
Dense nucleus
Partially aggregated chromatin
No recognizable nucleoli
Smudge cells
Gumprecht nucleus shadows
 B-CLL laboratory features

Immunophenotype:
– CD19+/CD23+/CD20+

– CD5+

– Kappa/lambda restriction

– sometimes also CD38+

 B-CLL laboratory features

• Cytogenetic examinations - clonal chromosomal abnormalities are

detected in approximately 50% of CLL patients
– deletion 13 (13q14.3)
– trisomy 12
– structural abnormalities of chromosomes 11 (11q-), 14, 17p-
 CLL – staging system RAI/Binet

06/27/2024 24
 Staging: Rai and Binet staging systems for CLL

Clinical staging systems for CLL

Stage
Value Rai Binet Median survival
Lymphocytosis 150 months
(>5,000/mm3) 0 - (12.5 years)

Lymphocytosis plus I A <3 101-108 months

nodal involvement node groups (8.5-9 years)

Lymphocytosis plus >3 60-71 months

II B
organomegaly node groups (5-6 years)
Hgb <10 g/dL
Anemia (RBCs) III 19-24 months
Hgb <11 g/dL (1.5-2 years)
C
Lymphocytosis plus IV
thrombocytopenia PLT <100,000/mm3
(platelets) PLT <100,000/mm3
Differential diagnosis
MBL
Other chronic lymphoproliferative disorders
• Prolymphocytic leukemia - >55% proly
• Hairy cell leukemia (thin extension)
• Lymphoma Hodgkin/nonHodgkin
– Generally normal CBC
– Asimetric lymphadenopathy
– Immunophenotype
– Positive diagnosis needs lymph node biopsy with:
• Histopathological exam
• Immunohistochemistry
• Cytogenetic
• Molecular analysis
 CLL : ZAP-70
ZAP70 is an intracellular protein which is strongly correlated with the VH
status in CLL
 Prognosis: effect of VH gene mutations on
survival
100 Unmutated VH gene
90 Median = 117 months
Mutated VH gene
Percent surviving (%)

80
Median = 293 months
70
60
50
40
30
20
10
0
0 25 50 75 100 125 150 175 200 225 250 275 300 325

Months

1. Hamblin TJ, et al. Blood. 1999;94:1848-1854.

 Complications
• Infections
• Autoimmune – hemolytic anemia / immune trombocytopenia
• Prolymphocytic transformation
• Second malignancies
– nonhematological
• Lung cancer
• Skin cancer (melanoma)
• Breast cancer
– hematological - acute leukemia

Richter’s Syndrome
– Is transformation of CLL into an aggressive Lymphoma – diffuse large
cell lymphoma (DLCL) or Hodgkin‘s lymphoma
– usually evolves after a long indolent course
– has a poor prognosis
 CLL – treatment
We have to remember:
– B-CLL – indolent lymphoma but incurable

– Outside of clinical trials, the therapeutic goal for most patients

with CLL who require treatment has been palliation of symptoms

– Elderly patients – risk of additional diseases

– Course of the disease can be very long, indolent for many years,
patients can die because of another reason which is not
connected to B-CLL.

Decision about treatment depends on

- clinical stage
- prognostic factors
- patient’s condition
 CLL – treatment
• Watch and wait
• Monotherapy
– Glucocorticoids (autoimmunological complications)
– alkylating agents (Chlorambucil, Cyclophosphamide)
– purine analogues (Fludarabine, Cladribine, Pentostatin)
• Combination chemotherapy
– Chlorambucil/Cyclophosphamide + Prednisone
– purine analog (Fludarabine) + Cyclophosphamide
– CVP, CHOP (Cyclophosphamide, Doxorubicin, Vincristin, Prednisone)
• Monoclonal antibodies (monotherapy and in combination)
– Rituximab (anti-CD20) = Mabthera
– Obinutuzumab
– Ofatumumab
IBRUTINIB (Imbruvica)
Ibrutinib is not a chemotherapy drug but one of what are termed "targeted
therapies.“
Ibrutinib inhibits the function of Bruton's tyrosine kinase (BTK). BTK is a key
signaling molecule of the B-cell receptor signaling complex that plays an
important role in the survival of malignant B cells. Ibrutinib blocks signals that
stimulate malignant B cells to grow and divide uncontrollably.
 Indications to Initiate Treatment for CLL

• Constitutional symptoms referable to CLL (B-symptoms)

• Progressive marrow failure
• Autoimmune anemia and/or thrombocytopenia poorly
responsive to corticosteroids
• Massive or progressive splenomegaly
• Massive or progressive lymphadenopathy
• Rapid lymphocyte doubling time (< 6 months)
 CLL – treatment
• Hematopoietic stem cell transplantation
– autologous - still no cure with auto-SCT
– allogeneic with reduced intensity conditioning
• Even RIC-SCT is still a risky procedure - indicated only in high-
risk disease
• Can allo-SCT cure CLL? - YES
• Supportive therapy (allopurinol, G-CSF, blood and platelet transfusion,
immunoglobulins, antibiotics)
 Response criteria

• Complete response (for at least 2 months)

– clinical features – normal
– morphology – normal (Hb>11 g/dl; Pt>100 000 /ul, lymphocytes <4000
G/l; neutrofiles >1500 G/l))
– bone marrow - lymphocytosis less than 30%
• Partial response
• Stable Disease
• Progressive Disease

• MRD
Chronic myeloid leukemia is characterized by:
a. Pancytopenia with <5% blasts in bone marrow
in chronic phase
b. Philadelphia chromosome in 100% of cases
c. Fusion gene BCR-ABL in 95% of cases
d. BCR-ABL encodes p190 protein
e. Large splenomegaly correlates with
granulocyte blood counts
The clinical manifestations in the
leukostasis syndrome are:
a. Dyspnea
b. Priapism
c. Bleeding
d. Renal impairement
e. Headache, dizziness
Asymptomatic patient, goes through a routine check-up and
they discover a splenomegaly and hemoglobin 12,7 g/dl,
leucocytes 98 000/mm3, platelets 620 000/mm3 . Leucocytic
formula: myeloid precursors, myeloblasts < 5%, basophilia and
eosinophilia, lymphocytes 25%. Which of the following
statements regarding the diagnosis are true?
a. It is AML because blast cells are in peripheral blood
smear.
b. It is CLL because the lymphocytes count is high, 24
500/mm3.
c. The immunophenotype analysis is mandatory in order to
establish the diagnosis.
d. Cytogenetic or molecular exams are mandatory, because
the suspected diagnosis is CML.
e. Bone marrow aspirate is not mandatory for the
diagnosis, because 5% blast cells in peripheral blood are enough
for an acute leukemia diagnosis.
Blastic phase in CML:
a. Is lymphoblastic in 80% of cases
b. Is characterized by > 20% blasts in bone
marrow
c. Has an average duration between 3-18
months
d. Anemia is caused by the presence of red
blood cell antibodies
e. The treatment uses acute leukemia
chemotherapy or a higher dose of TKI compared
with the chronic phase
Regarding CML it is true that:
a. Is a Ph1 positive myeloproliferative disorder
b. First line therapy uses monoclonal antibodies
(anti CD20).
c. Only alloSCT cures the disease
d. RMM means a 3 log reduction in the BCR-
ABL/BCR level
e. TKI can induce complete molecular response
(CMR) which is similar with curability
Which of the following complications can appear in
CML:
a. Pulmonary or cerebral leukostasis in the
chronic phase when leucocytes > 100 000/mm3
b. Spleen infarction
c. Restrictive cardiomyopathy
d. Vena cava syndrome
e. Thrombocytosis with clots formation in the
blastic phase
Patients with CML chronic phase can have:
a. Frequent infections due to
immunosuppression
b. Bone marrow blasts between 5-19%
c. Grade 3, 4 or 5 splenomegaly
d. Spleen infarct or spleen fracture post trauma
e. Thrombocytopenia
In CML, the lab tests mandatory for diagnosis are:
a. CBC
b. Bone marrow aspirate with morphologic and
cytogenetic exams.
c. Immunophenotype analysis of bone marrow
aspirate
d. Molecular analysis in order to identify the BCR-
ABL gene
e. LDH serum level
Which of the following statements are true?
a. The BCR-ABL gene encodes p210 protein
synthesis with high tyrosin kinase activity
b. TKI can induce complete but temporary
cytogenetic remission.
c. Ponatinib is recommended in CML as first line
therapy
d. All CML young patients < 45, in chronic phase,
must receive alloSCT, because it is the only curative
treatment
e. A complete hematologic response is obtained
after 3 months since starting the treatment
Known CML patient, treated with Imatinib for 4 years,
complaining of asthenia, progressive splenomegaly,
nonresponsive to treatment.Lab tests: hemoglobin 9 g/dl,
leukocytes 22 000/mm3, platelets 67 000/mm3. Leukocytic
formula: myeloblasts 15% and basophils 25%. Which of the
following statements are not true?
a. The suspicion is transformation to blastic phase and
Imatinib must be changed with another TKI.
b. The suspicion is transformation to accelerated or blastic
phase but the bone marrow aspirate is necessary to confirm this.
c. Patient is immediately refered to alloSCT
d. Patient is immediately refered to autoSCT
e. The cytogenetic exam can show other cytogenetic
abnormalities which indicate disease clonal evolution.