Median remission duration of CR is around 15 months. 35 \200\22340% of adults with ALL treated with intensive chemotherapy survive 2 years. \200 In contrast to high cure rate in childhood ALL, leukemia-free survival (LFS) in adult ALL in general is <3 0% at 5 years (patients >50 years 10 \200\22320%). LFS after chemotherapy in patients witho ut adverse risk factors is >50% but <10% for very high-risk Ph/BCR-ABL+ ALL; hence latter s hould have an allograft in 1st CR if possible. Prognostic factors Prognosis in adult ALL is much poorer than childhood ALL (cure rate 780% ) due to higher frequency of poor prognostic features and treat- ment-related toxicity. The most important prognostic factors are listed. These are useful for risk stratifi cation to identify patients who require more intensive therapy and SCT in 1st CR. \200 Patient age (<50 years CR >80%, LFS >30%; \211 50 years CR <60%, LFS <20%). High leucocyte count (>30 \227 109/L in B precursor-ALL; >100 \227 109/L in T-ALL) poor risk. Immunophenotype: pro-B-ALL and pro-T-ALL have poorer outcomes; common pre-B-ALL still poor; mature B-cell ALL and T-cell ALL have better outcome s due to the use of more intensive regimens. Cytogenetics: Ph/BCR-ABL+ very poor prognosis: <10% LFS after chemotherapy; Long time to CR (>4 weeks): poor risk. \200 High MRD level after induction (>10 \210\2223 ); persistent/increasing MRD during consolidation: poor risk. Management of relapse \200 Relapse rate highest within fi rst 2 years but may occur after 7 years. \200 20% occur outside BM, generally CNS; testis and other sites occur in 5%. \200 Isolated extramedullary relapse often followed by hematological relapse; these patients require local treatment followed by systemic re-induction therapy. Best predictive factor for response is duration of 1st CR (better >18 months). 50 \200\22360% of patients achieve a short 2nd CR (generally <6 months). \200 Prompt SCT off ers only prospect of LFS and cure. \200 Patients with BCR-ABL+ALL on maintenance imat inib at relapse have prospect (70%) of up to 6 months \200\231 hematological response to dasatinib. Clofarabine and nelarabine-containing regimens can be used. 146 CHAPTER 4 Leukemia References 1. Finiewicz, K.J. and Larson, R.A. (1999). Dose-intensive therapy for adult acu te lymphoblastic leukemia. Semin Oncol, 26, 6 \200\22320. 2. Thomas, X. et al. (2004). Outcome of treatment of adults with acute lymphoblastic leukemia: analysis of the LALA-94 trial. J Clin Oncol, 22, 4075 \200\22386. 3. Pui, C.-H. and Evans, W.E. (2006). Treatment of acute lymphoblastic leukemia. N Engl J Med, 354, 166 \200\22378. 4. Wassmann, B. et al. (2006). Alternating versus concurrent schedules of imatinib and chemotherapy as front-line therapy for Philadelphia-positive acute lymphoblastic leukemia ( Ph+ ALL). Blood, 108, 1469 \200\22377. 5. Lee, E.J. et al. (2001). Brief-duration high-intensity chemotherapy for patients with sm all noncleaved-cell lymphoma or FAB L3 acute lymphocytic leukemia: results of cancer and leukem ia group B study 9251. J Clin Oncol, 19, 4014 \200\22322. 6. Larson, R.A. et al. (1995). A fi ve-drug remission induction regimen with intensive consolidation for adults with acute lymphoblastic leukemia: cancer and leukemia group B stu dy 8811. Blood, 85, 2025 \200\22337. Further reading Lukenbill, J. et al. (2013). The treatment of adolescents and young adults with acute lymphoblastic leukemia. Curr Hematol Malig Rep, 8(2), 91 \200\2237. NCCN (2013). NCCN Guidelines on ALL. Version 1.2013. Fort Washington, PA: NCCN. Mwww.NCCN.org. Salami, K. et al. (2013). Hematopoietic stem cell transplant versus chemotherapy plus tyrosine kina se inhibitor in the treatment of pediatric Philadelphia chromosome-positive acute lymphobla stic leukemia (ALL). Hematol Oncol Stem Cell Ther, 6(1), 34 \200\22341. Swerdlow, S.H. et a l. (2008). WHO Classifi cations of Tumors of Haematopoietic and Lymphoid Tissues, 4th ed. L yon: IARC. Wood, BL. (2013). Flow cytometric monitoring of residual disease in acute leukem ia. Methods Mol Biol, 999, 123 \200\22336. 147 ACUTE LYMPHOBLASTIC leukemia (ALL) 148 CHAPTER 4 Leukemia Chronic myeloid leukemia (CML) Malignant tumor of pluripotent haemopoietic stem cell. The c lonal marker is found in all 3 myeloid lineages and in some B and T lympho- cytes demonstra ting a primitive origin. Characterized by ii granulocytes with left shift and the presence of the Ph chromosome. Incidence Rare disease. Frequency 1.25 per 100,000. Accounts for 15% adult leu- kaemias. Ra re in children. Median age of onset 50 years. Slight \231\202 excess. Etiology Unknown. Irradiation is only known epidemiological factor. BCR-ABL fusion proteins appear to play a role in the pathogenesis of CML and have been shown to transform haemopoi etic progenitor cells in vivo and in vitro. Classi \201 cation Classifi ed as a myeloproliferative disorder (WHO classifi cation) with which it shares a number of clinical features but it also has unique bio- logical features . Natural history \200 Biphasic or triphasic disease: chronic phase (CP), accelerated phase (AP), and blast crisis (BC); 50% transform directly from CP to BC. \200 >85% patients pr esent in CP: defi ned by absence of features of AP or BC. AP characterized by blood counts and organomegaly becoming increasingly refractory to therapy; some have constitutional symptoms. \200 BC resembles acute leukemia with >20% blasts and promyelocytes in blood or marrow; rapidly fatal (Tables 4.6 and 4.7). Clinical symptoms and signs \200 30% asymptomatic at diagnosis; present after routine FBC . \200 Fatigue, lethargy, weight loss, sweats. \200 Splenomegaly in >75%; may cause (L) hypochondrial pain, (early) satiety, and sensation of abdominal fullness. Gout, bruising/bleeding, splenic infarction, and occasionally priapism. \200 hepatomegaly (2%), lymphadenopathy unusual. \200 Occasional signs of leucostasis at presentation. Diagnosis and investigations \200 FBC and blood fi lm show i WBC (generally >25 \227 109 /L, often 100 \200\223300 \227 109/L): predominantly neutrophils and myelocytes; basophili a; sometimes eosinophilia (see Figs. 4.10 and 4.11). Anemia common; platelets typically n or i. \200 Historical: low neutrophil alkaline phosp hatase (NAP) score (no longer used). LDH and urate levels i. \200 BM shows marked hypercellularity due to granulocytic hyperpl asia (blasts <10% in chronic phase; >10% in AP; >20% blasts in BC); trephine biopsy useful to assess marrow fi brosis. \200 Cytogenetic analysis of blood or marrow for t(9;22). 149 CHRONIC MYELOID leukemia (CML) Molecular analysis by real-time quantitative reverse transcription polymerase chain reactio n (RQ-PCR) for BCR-ABL transcripts to obtain baseline for subsequent monitoring. FISH analy sis of blood or marrow will confi rm presence of BCR-ABL. Table 4.6 WHO criteria for accelerated phase Blasts 10 \200\22319% of WBCs in peripheral blood and/or nucleated BM cells Peripheral bloo d basophils \211 20% Persistent thrombocytopenia (<100 \227 109/L) unrelated to therapy o r persistent thrombocytosis (>1000 \227 109/L) unresponsive to therapy i spleen size and i WBC count unresponsive to therapy Cytogenetic evidence of clonal evolution Table 4.7 WHO criteria for blast crisis Blasts \211 20% of peripheral blood WBCs in or of nucleated BM cells Extramedullary blast proliferation Large foci or clusters of blasts in the BM biopsy Fig. 4.10 Peripheral blood fi lm in CML: note large numbers of granulocytic cells at all st ages of diff erentiation (low power) (E see color plate section). 150 CHAPTER 4 Leukemia Fig. 4.11 Peripheral blood fi lm in CML (high power) (E see color plate section). Cytogenetic and molecular analysis \200 Characterized in >80% patients by the presence of the Ph chromosome. Reciprocal translocation between chromosomes 9 and 22, (t9;22)(q34;q11), involv ing 2 genes, BCR and ABL that form a fusion gene BCR-ABL on chromosome 22. This produces an aberrant 210 kDa protein (p210BCR-ABL) that is constitutively active and has greater tyros ine kinase activity than the normal ABL protein. 10% of patients have variant translocations involving chromosome 22 9 and other chromosomes. A further 8% with typical clinical features lack the Ph chromosome, i.e. have Ph- \210\222v e CML; half of these have the hybrid BCR-ABL gene: Ph- \210\222ve, BCR-ABL-+ve CML. Accelerated phase is marked by the acquisition of new cytogenetic abnormalities in 50 \200\22380% of patients. Myeloid blast crisis associated with additional copies of Ph chromosome, +8 and i (17q). Lymphoid blast crisis associated with chromosome 7 anomalies. \200 T315I: mutation predic ting resistance to imatinib, nilotinib or dasatinib. Treatment with ponatinib indicated. Diff erential diagnosis Diff erentiate CP from leukaemoid reaction due to infection, infl a mma- tion, or carcinoma and CMML (absolute monocytosis; trilineage mye- lodysplasia; absent Ph chromosome); 5% present with predominant thrombocytosis and must be diff erentiated fro m ET. 151 CHRONIC MYELOID leukemia (CML) Prognostic scores \200 Sokal score based on age, spleen size, platelet count, and % blast s in blood at diagnosis used to identify good, moderate, and poor prognosis groups; based o n patients treated with chemotherapy (see Table 4.8) Table 4.8 Prognostic scores Sc ore = Exp[0.0116 (age \200\22443.4)] + 0.0345 (spleen size \200\2247.51) + 0.188 ([platelets/70 0]2 \200\2240.563) + 0.0887 (blasts% \200\2242.1) Low risk <0.8 Intermediate risk = 0.8 \200\2231.2 High risk >1.2 Hasford calculation adds eff ect of basophilia and eosinophilia at diagnosis; based on patients treated with interferon- . Now outdated. EUTOS score: predicts complete cytogenetic remission (CCgR) 18 months after the start of th erapy, which is an important predictor for the course of disease. Patients without CCgR at this point of treatment are less likely to achieve one later on and are at a high risk of p rogressing to blastic and accelerated phase disease. Formula: 7 \227 basophils (%) + 4 \227 spleen size (cm under ribcage) If the sum is >87, the patient is at high risk of not a chieving a CCgR at 18 months, while a sum \211 87 indicates a low risk. Early cytogenetic response to imatinib is another important prognostic factor: PCyR at 6 months, 80% probability of CCyR at 2 years; minor or minimal C yR at 6 months, 50% probability; no CyR at 6 months, 15% probability. Treatment \200 Commence allopurinol. \200 Consider leucapheresis in patients with leuco stasis or priapism. \200 Hydroxycarbamide can be used for rapid reduction in white cell count. 1st-line treatment with allogeneic SCT in adults not recommended. \200 TKI: continued ind efi nitely if response. Imatinib: 400mg PO od 1st-line treatment of choice in newly diagnosed patients in CP; conti nue to intolerance, failure or suboptimal response. \200 A small molecule signal transduc tion inhibitor that specifi cally targets BCR-ABL and some other tyrosine kinases. Achieves 96% complete hematological response (CHR), 87% major cytogenetic response (MCyR), and 76% complete cytogenetic response (CCyR);1 50% major molecular response (3 log d).2 152 CHAPTER 4 Leukemia 5-year follow-up of IRIS trial shows 69% CCyR at 12 months i to 87% at 60 months; 7% progressed to AP or BC; 89% overall survival at 5 years.3 Most patients achieve MCyR within fi rst 6 months of therapy; patients with MCyR have lower risk of relapse; CCyR predicts for EFS. Commonest side eff ects: myelosuppression, oedema, nausea, rash, cramps, fatigue, diarrhea, headache, arthralgia, and abnormal LFTs. \200 Consider change to dasatinib, nilotinib, o r clinical trial if not tolerated. Dasatinib: 1st- or 2nd-line treatment: \200 Orally active ABL kinase inhibitor that binds to both active and inactive conformations of ABL kinase domain. START-C trial of 70mg bd in 186 imatinib-resistant or intolerant CP patients: 90% CHR, 52% MCyR; 2% progressed or died after MCyR; 92% PFS after 8 months. Good results also in imatin ib-resistant or intolerant patients in AP (major HR 64%; MCyR 33%) and BC (major HR 733%; M CyR 31% in myeloid BC, 50% in lymphoid BC). The most frequently reported adverse eff ects are fl uid retention, pleural eff usion, diarrhea, skin rash, headache, hemorrhage, fatigue, nausea, dyspnoea, an d myelosuppression. 100mg od recommended for CP patients due to reduced toxicity and improved tolerability. 70mg bd in AP and BC. Nilotinib: 1st or 2nd-line treatment: \200 Orally active (400mg bd), highly selective inh ibitor of BCR-ABL tyrosine kinase; 20 \200\22350 \227 more potent than imatinib in imatini b- resistant cell lines. High response rates in imatinib-resistant or intolerant CP (74% CHR; 40% CCyR) and in AP (24% CHR; 16% CCyR). Low-toxicity profi le. Bosutinib: 3rd-generation TKI. Licensed for use in patients refractory or resistant to imat inib, dasatinib, and/or nilotinib. Mature data is awaited. Mutation screening should be per formed before starting second line treatment. Ponatinib: active and licensed in patients with the T315I mutation. Not used in 1st-line tr eatment. Used once mutation screening is done. Mature data is awaited. De \201 nitions of response to treatment See Tables 4.9 \200\2234.11. Table 4.9 Hematological response Complete (CHR): Platelets <450 \227 109/L WBC <10 \227 109/L Diff erential: no immature g ranulocytes and <5% basophils Non-palpable spleen Monitoring: check 2-weekly until CHR achieved and confi rmed \227 2; then every 3 months 153 CHRONIC MYELOID leukemia (CML) Table 4.10 Cytogenetic response (examination of \211 20 marrow metaphases) Complete (CCyR) Ph+ metaphases 0% Partial (PCyR) Ph+ 1 \200\22335% Major (MCyR) CCyR + PCyR Minor Ph+ 36 \200\22365% Minimal Ph+ 66 \200\22395% Monitoring: check at least every 6 months until CCyR achieved and confi rmed \227 2; then at least every 12 months. Table 4.11 Molecular response (assessed on peripheral blood cells) and cytogenetic response (assessed on BM aspirate) Complete Transcripts not detectable Major (MMolR) \211 0.1% ( \211 3 log reduction against International Scale) Monitoring: check every 3 months; confi rm \227 2; mutational analysis in case of failure, suboptimal response or transcript level increase Disease monitoring \200 Disease monitoring is critical to modern management of CML and selection of appropriate risk-adjusted therapy. Goals of therapy in order are CHR, CCyR, MMolR and \200\230complete \200\231 molecular response. BM cytogenetics of value until CCyR; RQ-PCR for BCR-ABL transcripts more sensitive for patients in CCyR with imatinib (>75%). 3-month evaluation \200 CHR essential. \200 BCR-ABL \211 10% and/or partial cytogeneti c response or better: continue same dose of current TKI. Not in CHR and/or no minimal cytogenetic response: switch to alternate TKI; evaluate for SCT depending on response to 2nd-line treatment. 6-month evaluation (including BM cytogenetics) \200 BCR-ABL <1% and/or complete cytogenet ic response: continue same dose of current TKI. BCR-ABL >10% and/or less than a partial cytogenetic response: switch to alternate TKI; evaluate for SCT depending on response to 2nd-line treatment. 12-month evaluation (including BM cytogenetics) \200 Major molecular response or better: continue same dose of current TKI. BCR-ABL>1% and/or less than complete cytogenetic response: change to alternate TKI, or continue same dose, or increase dose of imatinib as tolerated ( max. 600 \200\223800mg). 154 CHAPTER 4 Leukemia At any time \200 Major molecular response: continue current TKI. \200 Loss of major mol ecular response, loss of complete cytogenetic response or loss of complete hematological re sponse: switch to alternate TKI and evaluate for SCT depending on response to 2nd-line trea tment. New development of clonal chromosomal abnormalities as per Table 4.12. Patients in CCyR \200 RQ-PCR for BCR-ABL transcript levels every 3 months (consider BM cytogenetics every 12 \200\22318 months for clonal cytogenetic abnormalities). MMolR after 12 months associated with a better EFS and PFS;4 rise in level associated with mutations or loss of response. Repeat RQ-PCR in 1 month if rising transcript level (1 log i). If confi rmed, monitor monthly; perform ABL kinase domain mutation analysis. Signifi cance of mutations unclear; not consistently associated with relapse; several associated with resistance to imatinib. T315I mutation associated with resistance to imatinib, dasatinib, and nilotinib. Responsive to ponatinib. Table 4.12 Defi nitions of failure and optimal and suboptimal response (ELN 2013 update) Time Optimal response Failure Warnings Diagnosis N/A N/A High-risk score Major route CCA/Ph+a 3 months BCR-ABL \211 10% and/or Ph+ \211 35% (PCyR) No CHR and/or Ph+>95% BCR-ABL >10% and/or Ph+ 36 \200\22395% 6 months BCR-ABL<1% and/or Ph+ 0% (CCyR) BCR-ABL >10% and/or Ph+>35% BCR-ABL 1-10% and/or Ph+ 1 \200\22335% 12 months MMolR (BCR-ABL \211 0.1%) BCR-ABL >1% and/or Ph+>0% BCR-ABL 0.1 \200\2231% CCA/Ph \200\223 ( \210\2227 or 7q \210\222) Then at any time MMR or better Loss of CHR Loss of CCyR Loss of MMolRb Mutations CCA/Ph+ a Major route CCA/Ph+: major route clonal chromosomal abnormalities/Ph+: trisomy 8, 2nd Ph+ (+der(22)t(9,22)(q34;q11)), isochromosome 17 (i(17)(q10)), trisomy 19, and ider(22)(q10)t( 9;22)(q34;q11). b Confi rmed in 2 consecutive tests. 155 CHRONIC MYELOID leukemia (CML) Actions \200 Intolerance to TKI: consider SCT; interferon- cytarabine or novel agent. Failure: change to alternate TKI and evaluate for SCT. \200 Suboptimal response: re-asses s and consider imatinib dose-escalation or treatment change now or in near future. Warnings: features suggesting possible incipient resistance to TKI and/or progression to advanced phase; needs closer monitoring and consideration of dose esc alation, SCT, or other/investigational agents. Failure: mutation analysis should be done including T315I mutation. Other agents \200 Hydroxycarbamide, busulfan: may be used to control leucocytosis or thro mbocytosis and may \200\230normalize \200\231 FBC and reduce spleen size in CP in elderly patients TKI intolerant. No eff ect on cytogenetics or natural history. Interferon alfa (IFN- ) at a dose of 3 million IU SC 3 times weekly corrects hematological abnormalities in 75% and produces 10 \200\22315% CCyR and 15 \200 \22330%. MCyR. Role in SCT-ineligible, TKI intolerant patients: \200 Treatment with IFN- is associated with longer time to progression and longer survival (27 \200\22353% at 10 years) than hydroxycarbamide treatmen t, most signifi cantly in patients with CCyR and MCyR. IFN- side eff ects (malaise, febrile reactions, anorexia and weight loss, depression) red uce quality of life and are not tolerable for many patients. Allogeneic SCT \200 SCT remains a 1st-line treatment choice for pediatric patients. \200 Best outcomes in patients aged <30 years in CP <1 year from diagnosis. Reduced intensity conditioning lowers treatment-related toxicity in older patients. Relapse after SCT has been successfully treated with imatinib, dasatinib, or nilotinib. DLIs: 60 \200\22380% response in molecular or cytogenetic relapse. GvHD is a side eff ect of DLI but is less frequent with incremental doses. Complications \200 Modest i infection risk \200\224sometimes atypical organisms. \200 P rogression to BC (75% myeloid, 25% lymphoid). \200 Lymphoid BC: treat with TKI or modifi ed ALL protocol (may survive >12 months). Follow with SCT where possible. Myeloid BC usually refractory to conventional chemotherapy, survival 2 \200\2235 months; ma y get brief response with TKI. SCT where possible. Treatment of advanced phase CML5,6 \200 Patients presenting in AP or BC not previously tr eated with a TKI should receive imatinib, nilotinib, or dasatinib. Patients who progress on imatinib may respond to other TKI. SCT should be off ered where possible. 156 CHAPTER 4 Leukemia SCT off ers eligible patients with advanced phase CML the only prospect of prolonged surviv al and possible cure. Results are signifi cantly less good than for SCT in CP (0 \200\22310 % 5-year survival in BC) though achievement of 2nd CP pre-SCT improves results after BC. References 1. Jaff e, E.S. et al. (2001). Tumors of Haematopoietic and Lymphoid Tissues. World Health Org anization Classifi cation of Tumors. Lyon: IARC Press. 2. Hughes, T.P. et al. (2003). Frequency of major molecular responses to imatinib or interf eron alfa plus cytarabine in newly diagnosed chronic myeloid leukemia. N Engl J Med, 349, 1 421 \200\22332. 3. O \200\231Brien, S.G. et al. (2003). Imatinib compared with interferon and low dose cyta rabine for newly diagnosed chronic phase chronic myeloid leukemia. N Engl J Med, 348, 994 \200\2231004 4. Druker, B.J. et al. (2006). Five-year follow-up of patients receiving imatinib for chron ic myeloid leukemia. N Engl J Med, 355, 2408 \200\22317. 5. Goldman, J. (2007). Recommendations for the Management of BCR-ABL-Positive Chronic Myelo id Leukemia. M www.bcshguidelines.com/pdf/CML_guidelines_270707.pdf 6. NCCN Practice Guidel ines (2007). M www.nccn.org/professionals/physician_gls/PDF/ cml.pdf Further reading Baccarani, M. et al. (2013). European LeukaemiaNet recommendations for the management of CML. Blood, 122, 872 \200\22384. Chahardouli, B. et al. (2013). Evaluation of T315I mutation frequency in chronic myeloid leukemia patients after imatinib resistance. H ematology, 18(3), 158 \200\22362. Hasford, J. et al. (1998). New prognostic score for survi val of patients with chronic myeloid leukemia treated with interferon alfa. Writing Committ ee for the Collaborative CML Prognostic Factors Project Group. JNCI J Natl Cancer Inst, 90( 11), 850 \200\2239. Jain, P. et al. (2013). Early responses predict better outcomes in pati ents with newly diagnosed chronic myeloid leukemia: results with four tyrosine kinase inhib itor modalities. Blood, 121(24), 4867 \200\22374. Khan, A.M. et al. (2014). BCR-ABL inhibit ors: updates in the management of patients with chronic-phase chronic myeloid leukemia. Hem atology, 19(5), 249 \200\22358. Radich, J.P. (2013). Monitoring response to tyrosine kinase inhibitor therapy, mutational analysis, and new treatment options in chronic myelogenous l eukemia. J Natl Compr Canc Netw, 11(Suppl. 5), 663 \200\2236. Sokal, J.E. et al. (1984). Pr ognostic discrimination in \200\234good-risk \200\235 chronic granulocytic leukemia. Blood , 63(4), 789 \200\22399. 157 CHRONIC MYELOID leukemia (CML) 158 CHAPTER 4 Leukemia Chronic lymphocytic leukemia (B-CLL) Progressive accumulation of mature-appearing, function ally incompe- tent, B lymphocytes in peripheral blood, BM, lymph nodes, spleen, liver, and sometimes other organs. Incidence Most common leukemia in Western adults (25 \200\22330% of all leukaemias). 2.5/10 0,000 per annum. 20 \200\22330 \227 more common in Western Caucasian and black populations than in India, China, and Japan. Predominantly disease of elderly (in over 70s, >20/100,00 0). Median age at diagnosis 65 years. \231\202: \231\200 ratio 72:1. Etiology Unknown. No causal relationship with radiation, chemicals, or viruses. Small propo rtion familial: i lymphoid malignancies in 1st- and 2nd- degree relatives of patients with CLL. Clinical features and presentation \200 70 \200\22380% asymptomatic; lymphocytosis (>5.0 \227 109/L) on routine FBC. With more advanced disease: lymphadenopathy: painless, often symmetrical, splenomegaly (66% ), hepatomegaly and ultimately BM failure due to infi ltration causing anemia, neutropenia, and thrombocytopenia. Recurrent infection due to acquired hypogammaglobulinaemia: esp. herpes zoster. Patients with advanced disease: weight loss, night sweats, general malaise. Autoimmune phenomena occur; DAT +ve in 10 \200\22320% cases, warm antibody AIHA in <50% these cases. Autoimmune thrombocytopenia in 1 \200\2232%. Diagnosis FBC: lymphocytosis >5.0 \227 109/L; usually >20 \227 109/L, occasionally >400 \227 109/L; anemia, thrombocytopenia, and neutropenia absent in early stage CLL; autoimmune haemolysis thrombocytopenia may occur at any stage. Blood \201 lm: lymphocytosis with \200\230mature \200\231 appearance; characteristic art e- factual damage to cells in fi lm preparation produces numerous \200\230smear cells \200 \231 (note: absence of smear cells should prompt review of diagnosis); spherocytes, polychr omasia and i retics if AIHA; d platelets if BM failure or ITP. In 15% of patients morpholog y is \200\230atypical \200\231 with >10% prolymphocytes (CLL/PLL) (see Figs. 4.12 \200\223 4.14). Immunophenotyping: diff erentiates CLL from other lymphocytoses First line panel: CD2; CD5; CD19; CD23; FMC7; SmIg ( / ); CD22 or CD79b. CLL characteristically: \200 CD2 and FMC7 \210\222ve. \200 CD5, CD19, and CD23 +ve. \200 SmIg, CD22, CD79b weak; or light chain restricted. 159 CHRONIC LYMPHOCYTIC leukemia (B-CLL) Immunoglobulins: immuneparesis (hypogammaglobulinaemia) common; monoclonal paraprotein (usu ally IgM) <5%. BM: >30% \200\230mature \200\231 lymphocytes. Trephine biopsy: provides prognostic informa tion: infi ltration may be nodular (favorable); interstitial; mixed; diff use (unfavorable) . Lymph node biopsy: rarely required; appearances of lymphocytic lym- phoma; may be useful if diagnosis uncertain or to exclude transforma- tion to lymphoma in patients with bulky lymp hadenopathy. Cytogenetics: prognostic value; abnormalities in >80% using FISH. Clonal evolution over tim e. 11q \210\222 and 17q \210\222 associated with advanced disease. 11q \210\222, 17q \210 \222 very unfavorable; isolated 13q \210\222 favorable; isolated 6q \210\222 intermediate. \200 13q \210\222 (55%) if isolated (14 \200\22340%), favorable, median OS 133 months. \200 11q \210\222 (18%; ATM gene), median OS 79 months; fl udarabine refractory. 12q+ (16%) if isolated, neutral prognostically. \200 17p \210\222 (7%; p53 mutation), med ian OS 32 months; fl udarabine refractory. 6q \210\222 (7%) associated with plasmacytoid lymphoid cells. \200 +12 associated with at ypical morphology and disease progression. Other tests: direct antiglobulin test; reticulocyte count; U&E; urate; LFTs; LDH; 2-micro globulin; imaging e.g. CXR, CT, or ultrasound as neces- sary for symptoms; newer prognostic indicators CD38 and/or Zap 70 expression by fl ow cytometry or immunochemistry. Fig. 4.12 Blood fi lm in CLL showing smear cells (bottom of fi eld) (E see color plate sect ion). 160 CHAPTER 4 Leukemia Fig. 4.13 Blood fi lm in CLL. Fig. 4.14 FISH showing trisomy 12 (3 bright spots in each nucleus, each of which represents chromosome 12). Reproduced with permission from Souhami, R.L. et al (2001). Oxford Textboo k of Oncology, 2e. Oxford University Press, Oxford. Diff erential diagnosis Morphology and immunophenotyping will usually diff erentiate CLL fr om other chronic lymphoproliferative disorders. Scoring system in B-cell lymphoproliferative disorders Devised to facilitate diagnosis base d on the antigen profi le of CLL using a panel of 5 monoclonal antibodies, the \200\230CLL -score \200\2311 (see Table 4.13). Table 4.13 Scoring system for CLL diagnosis Marker (Score) (Score) Smlg weak (1) moderate/strong (0) CD5 positive (1) negative (0) CD23 positive (1) negative (0) FMC7 negative (1) positive (0) CD22/79b weak (1) Strong (0) Total scores for CLL range from 3 \200\2235 and for non-CLL cases from 0 \200\2232. 161 CHRONIC LYMPHOCYTIC leukemia (B-CLL) Poor prognostic factors2,3 \200 \231\202 sex. \200 Advanced clinical stage. \200 Ini tial lymphocytosis >50 \227 109/L. \200 >5% prolymphocytes in blood fi lm. \200 Diff u se pattern of infi ltrate on trephine. \200 Blood lymphocyte doubling time <12 months. \200 Cytogenetic abnormalities 11q \200\223, 17p \200\223, or complex. \200 p53 mutation s (occurs in 10 \200\22315%) \200\224correlates with refractory CLL. \200 Unmutated IgVH genes ( \211 2%) \200\224predicts advanced/progressive disease. Cytoplasmic ZAP 70 expression (>20%) \200\224correlates with IgVH status. \200 CD38 expre ssion (>30%) \200\224independent of IgVH status. \200 i serum 2-microglobulin \200\224c orrelates with stage and poor response. \200 i serum LDH. \200 Poor response to therapy . Atypical CLL Includes those with >10% prolymphocytes \200\230CLL/PLL \200\231 which may show an aberran t phenotype (SmIg strong +ve, FMC7/CD79b +ve) is associated with trisomy 12 and p53 abnorma lities and a more aggressive course. Monoclonal B-cell lymphocytosis (MBL) Lymphocyte count <5000/mm3 (but clonal population), n o anemia or thrombocytopenia: observe only. Clinical staging 2 systems are used to classify patients as low, intermediate, or high risk \200\224 Rai modifi ed staging (Table 4.14) and Binet clinical staging (Table 4.15). Table 4.14 Rai modifi ed staging Level of risk Stage Median survival (% of patients) Low 0 Lymphocytosis alone (>15,000/ microL and >40% in BM) >13 years (30%) Intermediate I Stage 0 + lymphadenopathy 8 years (25%) II Stage 0 \200\223I with spleno-, or hepatomegaly or both 5 years (25%) High III Stage 0 \200\223II with anemia (Hb <11.0g/dL)a 2 years (10%) 1 year (10%) IV Stage 0 \200\223III with thrombocytopenia (<100 \227 109/L)a a Not due to autoimmune anemia or thrombocytopenia. 162 CHAPTER 4 Leukemia Table 4.15 Binet clinical staging Stage Clinical features Median survival (% of patients) A Hb \211 10g/dL and platelets \211 100,000 and <3 lymphoid regions enlarged 12 years (60%) B Hb \211 10g/dL and platelets \211 100,000 and \211 3 lymphoid regions enlarged 5 years (30%) C Hb \211 10g/dL and/or platelets <100,000 and any number of enlarged areas 2 years (10%) Clinical management \200 Choice between observation, traditional alkylator-based palliati on, or in fi t patients, aiming for CR. If response duration was adequate, the same treatment could be used again. Management of a patient with CLL is based on: \200 Age, performance status, and co-morbid ities. \200 Clinical stage, presence of symptoms, disease activity, and prognostic factors. Early stage CLL \200 Patients with asymptomatic lymphocytosis should be observed. \200 Evidence that treatment improves outcome only in Rai stage III and IV or Binet stage B and C: monitor Rai stage 0 \200\223II or Binet stage A patients until treatment indicated for p rogressive or symptomatic disease. \200 Note: some patients have very indolent, \200\230 smoldering CLL \200\231: Binet stage A, non-diff use BM involvement; lymphocytes <30 \227 109/L, Hb >12g/dL, lymphocyte d oubling time >12 months; Binet stage A with somatic mutation of IgVH gene, median survival 25 years. iwCLL indications for treatment 4 \200 Constitutional symptoms due to CLL: \211 10% weig ht loss in 6 months; extreme fatigue; fevers >38 C for \211 2 weeks without infection; ni ght sweats without infection. Progressive marrow failure: development of or worsening anemia and/or thrombocytopenia. Autoimmune haemolytic anemia and/or thrombocytopenia unresponsive to steroids. Massive (>6cm below LCM) or progressive splenomegaly. \200 Massive (>10cm nodes or cluste rs) or progressive lymphadenopathy. \200 Progressive lymphocytosis with i >50% over 2 mon ths or anticipated doubling time of <6 months. 163 CHRONIC LYMPHOCYTIC leukemia (B-CLL) Treatments Initial decision is to adopt a \200\230palliative \200\231 approach treating sy mptomatic disease with minimum toxicity or to aim for prolonged disease-free sur- vival wit h hope of improved overall survival. Chlorambucil: alkylating agent; traditional \200\230palliative \200\231 1st-line therapy; dose 6 \200\22310mg/d (0.1 \200\2230.2mg/kg/d) PO for 7 \200\22314d in 28d cycles until dis ease stabilized (usually 6 \200\22312 cycles). Improves FBC and shrinks lymph nodes and spl een in 45 \200\22386%; CR 3 \200\2237%. Median response 71 year. No eff ect on survival (75 0% at 5 years). Prior responders to chlorambucil often respond on 1 or more further occasio ns. Further responses usually poorer and shorter. Resistance inevitably develops. Only 7% r espond when fl udarabine resistant. \200 Side eff ect: myelosuppression. Prolonged use i risk of myelodysplasia or 2 leukemia. rituximab. \200 Role in treatment of older, frail patients. Remains popular in Europe. R-FC: rituximab, \202 udarabine, and cyclophosphamide: overall response (OR) 95%, with CR in 72%, nodular PR in 10%, PR due to cytopenia in 7%, and PR due to residual disease in 6% . Median follow-up of 6 years OS was 77% and PFS, 51%. The German CLL Study Group (GCLLSG) CLL8 trial showed a signifi cant improvement in response rates and duration of response wit h R-FC compared with FC alone. \200 Standard treatment for fi t and younger patients. \200 May be given in reduced doses. \200 Purine analogs cause profound lymphodepletion w ith risk of opportunistic infection due to P. jirovecii, M. tuberculosis, herpes zoster, an d other organisms. Patients should receive co-trimoxazole prophylaxis (480mg bd tiw) throug hout therapy and for 3 months post therapy and irradiated cellular blood products indefi ni tely to prevent GvHD. Alemtuzumab: achieves 39% OR rate in fl udarabine-resistant patients and appears eff ective in some refractory patients with 17p \210\222/p53 mutations. Not eff ective in bulky nodal disease (>5cm). Humanized anti-CD52 monoclonal antibody (30mg IV or SC tiw up to 18 weeks) ; preferentially eliminates CLL cells from blood, marrow, and spleen; 81% OR and 19% CR as initial therapy. \200 Side eff ects: immunosuppression and virus reactivation (HZV and CM V \200\224monitor weekly during and after treatment by CMV-PCR). Irradiate cellular blood products indefi nitely to prevent GvHD. \200 Co-trimoxazole prop hylaxis of P. jirovecii for 6 months after treatment. Recommended for use for initial therapy for CLL with 17p \210\222 and fl udarabine-refractory CLL. Bendamustine rituximab: B 70mg/m2 in cycle 1 i to 90mg/m2 if toler- ated rituximab. H igh response rates and well tolerated. Rituximab monotherapy: achieves only limited responses as a single agent in previously trea ted CLL. 164 CHAPTER 4 Leukemia Ofatumumab: also known as HuMax-CD20. Human monoclonal anti- body (for the CD20 protein) wh ich appears to inhibit early-stage B lymphocyte activation. Approved by the FDA for CLL ref ractory to fl udarabine and alemtuzumab. Approved in Europe in refractory CLL. R-CHOP: sometimes used in CLL. High-dose methylprednisolone: 1g/m2/d \227 5d every 28d; ac hieves up to 77% OR rate; median duration 9 months. May be of particular use in patients re fractory to fl udarabine with bulky disease and/or p53 muta- tions. Infection frequent. Con traindicated in patients with active peptic ulceration. Caution with diabetes and CCF. Assessment of response See Table 4.16 Table 4.16 NCI-WG response criteria for CLL4 Criteria Complete response Partial response Progressive disease Symptoms None Richter \200\231s syndrome Lymph nodes None \211 50% decrease \211 50% increase or new nodes Liver/spleen Not palpable \211 50% decrease \211 50% increase or new \211 4.0 \227 109/L \211 50% decrease \211 50% increase Lymphocytes Hemoglobin >110g/L (untransfused) >110g/L (untransfused) or 50% improvement* \211 1.5 \227 109/La >100 \227 109/La \211 1.5 \227 109/L >100 \227 109/L Neutrophils Platelets BM aspirate <30% lymphocytes BM trephine No interstitial or nodular infi ltrate May be residual lymphoid nodules a \211 1 of these features required for PR; features should be present for \211 2 months for CR or PR. Stable disease is defi ned as all other patients. 165 CHRONIC LYMPHOCYTIC leukemia (B-CLL) Stem cell transplantation Whether a SCT is indicated and at what point in a patient \200 \231s treatment remains a big challenge. As most CLL patients are elderly this does often n ot cause any concerns. The European Bone Marrow Transplant guidelines outline indications for SCT in CLL and the u se of allogeneic SCT: \200 Recommended in patients requiring treatment for CLL who have p53 abnormalities. Prognosis here is poor and they merit the risk of transplantation in 1st CR. These patients should be referred early to transplant centers. Allogeneic SCT is also recommended for some young(er) patients with CLL who fail to respond to 1st-line combination chemotherapy. Autologous SCT is not generally recommended. Treatment of complications \200 Advise patients to report infection promptly as immunocom promised. Highest risk in elderly, advanced stage, and fl udarabine treatment. Prophylactic antibioti cs or monthly IV immunoglobulin replacement therapy may reduce recurrent infections in pati ents with hypo- gammaglobulinaemia but has no eff ect on survival. Autoimmune cytopenias: manage symptomatic AIHA or ITP with corticosteroids in the 1st instance; IVIg, chemotherapy, rituximab, or splenectomy may be r equired; test patients with pure red cell aplasia for parvovirus infection; treat with pred nisolone, ciclosporin, or ATG. Radiotherapy helpful for persistent or bulky lymphadenopathy; splenic irradiation is sometimes helpful palliation in frail patients with symptomatic sple nomegaly who are unfi t for splenectomy. Splenectomy may sometimes be useful for massive splenomegaly, hypersplenism or refractory cytopenia (RR 50 \200\22388%). Lymphomatous transformation (Richter \200\231s syndrome) occurs in <10%; occurs in all stages; median interval from diagnosis 24 months; abrupt onset; progressive L N i; fever; weight loss; high LDH; usually diff use large B-cell NHL but 710% Hodgkin-like histology; chemoresistant; median survival 4 months with CHOP, better with ABVD for Hodgkin -like. Prognosis CLL remains an incurable disease with current therapy apart from a few allografte d patients. Most patients with early stage, asymptomatic CLL die of other unrelated causes. Infection is a major cause of morbidity and mortality in symptomatic patients. Advanced st age patients eventu- ally develop refractory disease and BM failure. 166 CHAPTER 4 Leukemia Cell markers in chronic lymphoproliferative disorders See Tables 4.17 and 4.18. Table 4.17 Mature B-cell lymphoproliferative disorders Marker CLL PLL HCL SMZL FL MCL Surface Ig Weak ++ ++ ++ ++ + CD5 ++ \210\222/+ \210\222 \210\222 \210\222 ++ CD10 \210\222 \210\222/+ \210\222 \210\222 + \210\222 CD11c \210\222/+ \210\222 + +/ \210\222 \210\222 \210\222 CD19 ++ ++ ++ ++ ++ ++ CD20 \210\222/+ ++ + ++ ++ ++ CD22 \210\222/weak ++ ++ ++ +/ \210\222 +/ \210\222 CD23 ++ +/ \210\222 \210\222 \210\222/+ \210\222/+ \210\222 CD25 +/ \210\222 \210\222 ++ \210\222/+ \210\222 \210\222 CD79b weak/ \210\222 ++ + ++ ++ ++ FMC7 \210\222/+ + + ++ ++ ++ CD103 \210\222 \210\222 + \210\222/+ \210\222 \210\222 HC2 \210\222 \210\222 + \210\222/+ \210\222 \210\222 Cyclin D1 \210\222 + \210\222/weak \210\222 \210\222 ++ CLL, chronic lymphocytic leukemia; PLL, prolymphocytic leukemia; HCL, hairy cell leukemia; SMZL, splenic marginal zone lymphoma; FL, follicular lymphoma; MCL, mantle cell lymphoma. 167 CHRONIC LYMPHOCYTIC leukemia (B-CLL) Table 4.18 Mature T-cell lymphoproliferative disorders Marker TdTa T-LGLL NK-LGLL T-PLL ATL SS \210\222