Morphological and immunophenotypic features of chronic lymphocytic leukemia

In this review, we summarize the morphological features and immunophenotypic profile of chronic lymphocytic leukemia (CLL) cells, discuss the value of these investigations as front line diagnostic tests, and emphasize their correlation with the clinical features, disease progression, molecular genetics and pathogenesis of CLL. In CLL, the morphology of the circulating cells is characteristic and typical in the majority of cases. However, 15% of patients, either at diagnosis or during the course of the disease, show atypical morphology reflected by either (1) an increased (> 10%) number of circulating prolymphocytes, designated CLL/PL, or (2) an increased (> 15%) number of circulating lymphoplasmacytic and cleaved cells, designated 'atypical' CLL. There is strong evidence of a close association between atypical morphology (CLL/PL) and atypical (CLL) and clinical features, e.g. disease progression, advanced stage and survival, molecular genetics, particularly trisomy 12, but also the rare cases with t(11;14) or t(14;19), p53 abnormalities, unmutated immunoglobulin (Ig) VH genes and origin of the cell (naive, pregerminal center cell). CLL cells have a distinct immunological repertoire different from that of other lymphoproliferative disorders. The typical CLL phenotype is CD5+, CD23+, FMC7-, weak expression of surface Ig (sIg) and weak or absent expression of membrane CD22 and CD79b. The latter marker identifies an extracellular epitope of the B-cell receptor (BCR) beta chain and its weak or absent expression in CLL may derive from the expression of a truncated form. This, together with the low expression of CD22, might explain the abnormal signal transduction of CLL cells similar to that of anergic B lymphocytes. Because no single marker is specific for CLL, a composite phenotype considering this set of 5 or 6 markers compounded into a scoring system helps to distinguish CLL from the other B-cell malignancies. Immunophenotypic analysis has also been shown to be useful for minimal residual disease detection and adds valuable prognostic information because the expression of certain markers, such as FMC7 or CD38, seems to be associated with a poor outcome. In addition, CLL cells express a variety of Bcl-2 family proteins with a profile that favors inhibition of apoptosis which, together with the interaction with microenvironmental (e.g. stromal) cells and the release of cytokines, explains the long life span and subsequent accumulation of CLL cells in various organs. Despite controversies relating to the expression of adhesion molecules (selectins and integrins) in CLL cells, it appears that some of these molecules do play a role in the pathogenesis, biology and clinical patterns of the disease. In conclusion, morphology and immunophenotype are the two essential investigations, which must be carried out in all cases of CLL. Both provide relevant information in terms of diagnosis, course of the disease, prognosis and pathogenesis.     

Lymphocyte surface marker studies in the diagnosis of unexplained lymphocytosis.

Fifty-six patients with unexplained lymphocytosis were investigated with a panel of antibodies to lymphocyte surface antigens. In 23 the distribution of cell surface markers suggested reactive lymphocytosis. The remaining 33 patients showed a distribution of cell surface markers that indicated or suggested a diagnosis of B-cell lymphoproliferative disease. Two illustrative case reports show how such studies performed early in the investigation of unexplained lymphocytosis may permit earlier diagnosis of the underlying mechanism.     

Determination of antiplatelet antibodies on the surface of platelets by direct radioimmune method in patients with different types of immune thrombocytopenia

Direct radioimmune assay (RIA) have been developed for detection of antibodies associated wild platelet membrane. Platelets from 12 patients with idiopathic thrombocytopenic purpura (ITP) and 27 patients with chronic lymphocytic leukemia (CLL) (platelet count (100,000 in 1 microliters) have been tested. Antibodies on platelets surface have been detected in all 12 patients with ITP and in 21 patients with CLL. In 6 CLL patients the number of immunoglobulins associated with platelets surface does not increase control level. It is possible, that in some CLL patients development of thrombocytopenia is mediated not only by platelet associated antibodies but by other mechanisms, one of which can be linked with the depression of megakaryocytes growth in bone marrow. Direct RIA for measurement of antibodies on platelet surface detect antiplatelet antibodies with higher frequency than indirect enzyme-linked-immunosorbent-assay (ELISA), developed earlier for assessment of antiplatelet antibodies in serum. Increase of platelet count in CLL patients after steroid and cytostatic treatment correlated with the decrease of platelet surface associated antibodies.     

Therapeutic potential and challenges of targeting receptor tyrosine kinase ROR1 with monoclonal antibodies in B-cell malignancies

Background

Based on its selective cell surface expression in chronic lymphocytic leukemia (CLL) and mantle cell lymphoma (MCL), receptor tyrosine kinase ROR1 has recently emerged as a promising target for therapeutic monoclonal antibodies (mAbs). To further assess the suitability of ROR1 for targeted therapy of CLL and MCL, a panel of mAbs was generated and its therapeutic utility was investigated.

Methodology and Principal Findings

A chimeric rabbit/human Fab library was generated from immunized rabbits and selected by phage display. Chimeric rabbit/human Fab and IgG1 were investigated for their capability to bind to human and mouse ROR1, to mediate antibody-dependent cellular cytotoxicity (ADCC), complement-dependent cytotoxicity (CDC), and internalization, and to agonize or antagonize apoptosis using primary CLL cells from untreated patients as well as MCL cell lines. A panel of mAbs demonstrated high affinity and specificity for a diverse set of epitopes that involve all three extracellular domains of ROR1, are accessible on the cell surface, and mediate internalization. The mAb with the highest affinity and slowest rate of internalization was found to be the only mAb that mediated significant, albeit weak, ADCC. None of the mAbs mediated CDC. Alone, they did not enhance or inhibit apoptosis.

Conclusions and Significance

Owing to its relatively low cell surface density, ROR1 may be a preferred target for armed rather than naked mAbs. Provided is a panel of fully sequenced and thoroughly characterized anti-ROR1 mAbs suitable for conversion to antibody-drug conjugates, immunotoxins, chimeric antigen receptors, and other armed mAb entities for preclinical and clinical studies.     

Cell-marker studies in CLL with monoclonal OKT antisera and lactic dehydrogenase isoenzyme analysis

In 16 patients with B-type CLL, the T and B cell compartment was analysed using the monoclonal anti-T-cell antisera OKT1, 3, 4 and 8 and the lactic dehydrogenase enzyme marker. Pertinent findings were: the presence on the CLL cells in 15 out of 16 patients of the antigen determined by the OKT1 antiserum, and, in all patients, a lower total LDH content on a per cell basis combined with a higher percentage-activity in the LDH-3 band as compared to the normal B-cell. Furthermore, the T-cell compartment was also disturbed in these patients, as the ratio of OKT4+ to OKT8+ cells was significantly depressed accompanied by a significant decrease of the LDH-1 percentage-activity in favour of LDH-3 and 4. These findings argue for the B-cell being immature and confirm the recent evidence that the T-cell compartment is changed in B-CLL.     

Is targeted chemotherapy an alternative to immunotherapy in chronic lymphocytic leukemia?

Although molecular remission is now detected, it is still unknown whether we have the tools to cure B cell chronic lymphocytic leukemia (referred to as CLL). Nonetheless, several new therapeutic approaches have been introduced in cancer therapy during the last decade, including antiangiogenic therapy, apoptosis-inducing treatment and inhibition of heat shock proteins, farnesyl transferase, tyrosine kinases and proteasomes. These modalities may also be considered in CLL, but additional experimental characterization is required. Further characterization and development of CLL animal models should be a part of this preclinical work (especially xenografting in NOD/SCID animals, but also murine leukemia) to allow a more extensive evaluation prior to clinical trials. Animal models are particularly important for preclinical comparison of pharmacological effects between different disease compartments and for in vivo evaluation of antileukemic immune reactivity. However, T cell targeting therapy seems to have several advantages in comparison to other approaches: (1) based on the current clinical experience one would expect low toxicity for several of these strategies, especially vaccine treatment; (2) several studies have demonstrated that autologous T cells can recognize CLL cells; (3) experimental and clinical evidence suggests that immunotherapy can be combined with chemotherapy. Thus, T cell therapy has a relatively strong scientific basis that justifies further clinical studies of immunotherapy in CLL. Although several of the new pharmacological agents seem to have immunosuppressive effects, at least some of them (e.g. heat shock protein 90 inhibitors, proteasome inhibitors, inhibition of angiogenesis) appear to affect T cells only at relatively high concentrations and may thus be used in combination with immunotherapy.     

Blast crisis of Philadelphia chromosome-positive chronic myelocytic leukemia (CML). Treatment results of 69 patients

We have studied the clinical courses of 69 patients with blastic crises of Philadelphia chromosome positive CML to identify parameters that were associated with an increased response rate or survival. Cytogenetic analysis at the time of blastic transformation revealed additional chromosome changes in 70% of the patients tested. Bone marrow fibrosis was detected in 58% of evaluable patients. Lymphoblastic transformation was seen in 28% of the patients tested with cell surface marker analysis. The value of 5'-nucleotidase as a marker for distinguishing lymphoid from non-lymphoid blast crisis was confirmed. Of 57 evaluable patients, 23 (40%) responded to therapy (CR/PR longer than 14 days). Median survival was 75 days. Longer survival was related to the following factors: Ph1-chromosome as the only detectable cytogenetic abnormality; lymphoblastic transformation; no bone marrow fibrosis; high percentage of blasts and promyelocytes in the bone marrow, and response to therapy. No prognostic significance was associated with age, sex, Tdt, LDH, spleen size, duration of the chronic phase of the disease, white blood cell count, Hb, platelet count and percentages of basophils, eosinophils, erythroblasts and blasts and promyelocytes in the peripheral blood. These data confirm the poor prognosis of patients with blastic crisis of CML treated by conventional chemotherapy.     

Functional properties of T cells in patients with chronic T gamma lymphocytosis and chronic T cell neoplasia

The expanded T cell populations of 10 patients with either T gamma lymphocytosis (five patients) or proven chronic T cell malignancy (five patients) were analyzed with respect to functional activity in vitro, including proliferative responses to mitogens, cytotoxic activity (killer [K] and natural killer [NK] cell activity), and regulatory activity on pokeweed mitogen- (PWM) induced immunoglobulin (Ig) synthesis (help and suppression) in comparison with marker phenotypes. In each of the five patients with T gamma lymphocytosis, only one out of three functionally distinct cell types was found: T gamma-K cells, T gamma-S cells, or T gamma-NK/K cells, which mediated K-cell activity, suppressive activity, and both NK and K cell activity, respectively. An expanded T gamma-K cell population was demonstrated in three patients with neutropenia with or without recurrent infections. T gamma-S cells were found in a patient with severe hypogammaglobulinemia, and T gamma-NK/K cells in one patient with asymptomatic lymphocytosis. T gamma-K and T gamma-S cells had a similar surface-marker profile (E+ or E-, Fc gamma+, OKT1-3+4-8+I1-M1-), whereas that of T gamma-NK/K cells was different (E+, Fc gamma+, OKT1-3-4-8-I1+M1+). Longitudinal studies of three untreated patients with T gamma-K lymphocytosis showed that the abnormalities were persistent but not progressive. In contrast, five patients with chronic T cell malignancy (two with T-CLL, two with cutaneous T cell lymphoma [CTCL], and one with T-PLL) all had progressive disease. The neoplastic cells in these cases were E+, Fc gamma-OKT1+4+6- with variable expression of the OKT3 and OKT8 markers. The only functional activity observed in these cells was suppressive activity by OKT3-4+8- cells from a patient with CTCL.     

Chronic lymphocytic leukemia and prolymphocytic leukemia: a clinicopathological reappraisal

A series of 300 cases of chronic B-cell leukemia was studied in relation to clinical and laboratory features, and three groups were identified on the basis of the percentage of circulating prolymphocytes (%PROL): typical CLL less than or equal to 10% PROL, 174 cases; PLL greater than 55% PROL, 42 cases; and an intermediate group CLL/PL (11%-55% PROL), 84 cases. Some features of the CLL/PL group resemble those of PLL, such as a disproportionate splenomegaly in relation to the degree of lymphnode involvement. However, membrane markers suggested a closer affinity of CLL/PL with CLL [high percentage of M rosettes, expression of the P67 (T1) antigen, and low reactivity with the McAb FMC7], although high-density SmIg was found in one-third of CLL/PL, as well as in the majority of the PLL cases. Cells volume measurements demonstrated that the prolymphocytes of both PLL and CLL/PL are significantly larger than the homogeneous population of small lymphocytes of typical CLL. Followup studies of the PB picture in CLL and CLL/PL showed that the majority of patients maintain a relatively stable percentage of PROL, but a progressive prolymphocytoid transformation to a PLL-like disease may occur in some cases. On univariate analysis of survival, seven features of disease had a high prognostic values for the whole group of patients: %PROL, absolute number of PROL (ABS PROL), WBC, spleen size, M rosettes, SmIg intensity, and age. However, only ABS PROL (greater than 15 X 10(9)/l) and spleen size (greater than 8 cm) were shown to be independent prognostic features on a multivariate regression analysis. The median survival time of patients with PLL (3 years) was significantly shorter than the median of 8 years for patients with CLL. Within the heterogeneous CLL/PL group, patients with ABS PROL greater than 15 X 10(9)/l (two-thirds) had a median survival time as bad as for PLL patients, whereas the median has not been reached for those with ABS PROL less than 15 X 10(9)/l.     

Interdependent regulation of p53 and miR-34a in chronic lymphocytic leukemia

Chronic lymphocytic leukemia (CLL) has an incidence 4/100 000 people in the western world and is one of the first cancers reported to be associated with deregulated miRNA expression. microRNAs are small non coding RNAs that are important regulators of protein expression through binding to their untranslated 3'-UTR region. The miR-34 family was demonstrated to be induced by the tumor suppressor p53 and to elicit p53-like responses like senescence, cell cycle arrest and apoptosis depending on the cell type. We have shown in a recent paper that miR-34a is severely increased in the TCL1-mouse model of CLL. This finding was reflected in human CLL. Moreover, it is demonstrated that its expression is dependent on the presence of the SNP309 in the intronic promoter of the MDM2 gene. In addition, low miR-34a expression was associated with shorter time to treatment (log-rank P = 0.003) in CLL. When reintroduced into CLL cells, miR-34a was able to induce apoptosis. Interestingly, this was dependent on an intact p53 pathway. Here, we present data showing that knockdown of p53 in HCT-116 cells severely reduces miR-34a induced apoptosis. In conclusion, miR-34a is proposed as a marker for the activity of the p53 pathway in CLL.     

Helper cell function of Leukemic Leu-2a+, histamine receptor+, T gamma lymphocytes

Leukemic cells from a patient with an 11-yr history of chronic lymphocytic leukemia (CLL) were found to have the surface phenotype Leu-1+, Leu-2a+, Leu-3a-, sheep erythrocyte rosette+, IgGFc receptor+. The cells also bore a receptor for histamine inhibitable by cimetidine (H-2). The clonal nature of the proliferation was documented by the presence of a consistent marker chromosome (22-trisomy) in metaphases elicited by culture with T cell growth factors. Although the surface phenotype suggested that these cells might function as suppressor lymphocytes, they had an enhancing effect on the pokeweed- mitogen- (PWM) driven generation of plasma cells and reverse hemolytic plaque-forming cells in vitro. This helper activity was modified neither by irradiation of the leukemic cells nor by removal of a minor population of Leu-3a+ cells, suggesting that the effects were attributable to the CLL cells themselves. In addition to these functions, the CLL cells were active in antibody-dependent cellular cytotoxicity (ADCC) assays in association with expression of Fc receptors for IgG. The ADCC was diminished when a transient loss of the Fc receptor expression was observed. No activity in natural killer cell assays employing K-562 cells or herpes simplex virus- (HSV) infected cells as targets could be attributed to the leukemic clone. These studies indicate that the cell surface phenotype, as defined by monoclonal antibodies, may not always predict the functional state of a particular cell, and suggest that within the Leu-2a+ (TH-2+) population of human lymphocytes, some helper as well as suppressor/cytotoxic cells are to be found.     

C1.7 antigen expression on CD8+ T cells is activation dependent: increased proportion of C1.7+CD8+ T cells in HIV-1-infected patients with progressing disease.

The C1.7 Ag is a surface marker previously shown to be expressed on all NK cells and on a subset of CD8+ T cells. We report in this study that C1.7 Ag expression on peripheral blood-derived CD8+ T cells overlaps with activation markers S6F1high and CD29high and is reciprocally expressed with CD62L. C1.7 Ag expression can be induced in vitro on CD8+ T cells by anti-CD3 cross-linking, suggesting that C1.7 Ag is activation dependent. In contrast to NK cells, C1.7 Ag does not signal on CD8+ T cells, nor does it induce redirected lysis upon ligation. The proportion of C1.7 Ag+CD8+ T cells is increased in HIV-infected patients compared with healthy donors. In 69 HIV-infected patients, we observed a significant inverse correlation between the percentage of C1.7 Ag-expressing CD8+ T cells and the absolute CD4+ T cell count. Two-year clinical follow-up of patients with initial CD4+ T cell count of >400 cells/mm3 and a normal proportion of C1.7 Ag+CD8+ T cells revealed that these patients were clinically stable with minimal HIV-associated symptoms. In contrast, 10 of 12 patients with CD4+ T cell counts of >400 cells/mm3 and an elevated proportion of C1.7 Ag+CD8+ T cells were symptomatic. ANOVA analysis of patients indicates that C1.7 Ag is a better predictor of disease progression than CD4 count. Overall, our findings indicate that C1.7 Ag is the first described marker for activated/memory CD8+ T cells and a useful parameter for evaluating the level of CD8+ T cell activation in vivo.     

Use of Immunologic Markers in Obscure Hematologic Disease

Tumor cells from two patients with very different clinical diseases were evaluated using immunologic techniques. The first patient had a persistent T-cell lymphocytosis and other symptoms suggestive of T-cell malignancy. She also had an adnexal mass. Following surgical excision, the mass was identified as a benign teratoma that contained thymic tissue. The T-cell lymphocytosis subsided following removal of the mass. The second patient had leukemia, the cells of which were morphologically identified as myelomonocytic. Surface marker studies, however, showed the presence of monoclonal surface immunoglobulins. Enzymatic digestion of the cells showed that the antibodies were cytophilic and not produced by the tumor population. These studies emphasize the value of immunologic techniques in characterizing tumor cells.     

Effect of tetracycline on lymphocyte antigen expression

Nowadays the existence of bearing both T and B marker lymphocytes has generally been accepted, but their role and nature is still unknown. The effect of tetracycline on lymphocytes was examined in 26 patients with different, mainly respiratory infections. Examinations were carried out on lymphocyte populations with T and B cell count using E rosette and surface immunoglobulin as a marker. It has been shown that on the lymphocytes of patients receiving tetracycline, regularly high number of D cells are found.     

Evaluating the mechanism underlying antitumor effect of interleukin 27 on B cells of chronic lymphocytic leukemia patients

Chronic lymphocyte leukemia (CLL) is a B-cell malignancy resisted to apoptosis. Recently, some studies indicated that cytokines such as interleukin 27 (IL-27) can reduce B-cell proliferation. The aim of this study is to evaluate the mechanism underlying the proapoptotic effect of IL-27 on B cells of patients with CLL in comparison with B cells of normal subjects. The effect of IL-27 on the antitumor activity of natural killer (NK) and T cells was also evaluated. Peripheral blood mononuclear cells (PBMCs) were isolated from 35 patients with CLL and 15 normal subjects. B cells and PBMCs were cocultured with IL-27 and B cells apoptosis to evaluate proliferation. Both messenger RNA and protein expression of IL-27 and IL-27 receptor were determined using flow cytometry and real-time polymerase chain reaction analysis. To evaluate the apoptotic effect of IL-27 on B cells of patients with CLL, Annexin V-FITC and 7-AAD (BioLegend) fluorescent dyes were used. In addition, the IL-27 effect on activation of T cell and NK cell was determined by determining CD96 molecule expression. IL-27 and IL-27 receptor expression in patients with CLL was significantly lower than that of normal subjects (p < .05). IL-27 enhanced apoptosis of B cells in patients with CLL (p < .05) but this effect was not significantly observed in B cells of normal subjects (p > .05). Consequently, IL-27 reduced the proliferation of B cells and enhanced NK cell activity (p < .05). IL-27, through inducing apoptosis, can exert an inhibitory effect on cancer B cells of CLL patients with minimal effect on normal B cells.     

Chronic lymphocytic leukemia lymphocytes lack the capacity to repair UVC-induced lesions

Cells from chronic lymphocytic leukemia (CLL) patients and from healthy individuals were irradiated with UVC and incubated for varying periods of time. The number of single strand breaks and alkali-labile sites was determined by comet analysis. Unirradiated CLL and healthy cells exhibited no significant numbers of single strand breaks. The extent of DNA damage was found to increase with dose for both healthy and CLL cells. However, the CLL cells had much more extensive DNA fragmentation than healthy cells at each dose. Deoxyribonucleoside supplemented medium inhibited comet formation in both cell types. Thymidine alone produced the same effect. In healthy cells, repair of lesions was complete after 4 h of incubation as indicated by the absence of comet formation. The CLL cells exhibited no significant repair even after 48 h. CLL lymphocytes are killed by very low doses of UVC radiation. The results reported here suggest that this hypersensitivity results from the inability of CLL cells to repair UVC-induced DNA damage and a contributing factor is the low amounts of intracellular deoxyribonucleosides.     

Serological detection of B-cell ("Ia-like") antigens in serum of normal donor and in some sera of leukaemic patients

Some sera from normal donors (1/18) and from leukaemic patients (2/7 with acute myeloid leukaemia [AML], 1/4 with chronic lymphatic leukaemia [CLL], 0/3 with acute lymphoblastic leukaemia [ALL]; with high numbers of leukaemic cells expressing Ia-like p28,33 antigen on the leukaemic cell surface) inhibited the complement mediated cytotoxic activity of highly specific xenogenous anti Ia-like sera (which were prepared by immunization of rabbits with insoluble membrane fractions of B-type lymphoid lines) at a titre 1:4 or less. This effect was not observed with antisera directed against other membrane marker determinants (e.g. T lymphocyte specific antigens). These results suggest that at least a small proportion of membrane bound Ia-like antigens can be released from cell surfaces and in some patients these Ia-like moieties are detectable (by sensitive inhibition assays) in the serum.     

Use of mean platelet volume improves detection of platelet disorders

Classification of platelet disorders has been based on the platelet count. Addition of a second variable, mean platelet volume (MPV), to the routine blood count allows classification of patients into 9 categories: high, low, or normal MPV, and high, low or normal platelet count. We studied 1,244 adult inpatients. 1,134 had both platelet values normal. 11 patients had high MPV and low platelet count: all had hyperdestructive causes. 15 patients had high MPV and normal platelet count: 12 had heterozygous thalassemia, and three had iron deficiency. Seven patients had high MPV and high platelet count: causes included myeloproliferative disorders, inflammation, iron deficiency, and splenectomy, 25 patients had high platelet counts and normal MPV: the causes were inflammation, infection, sickle cell anemia, iron deficiency, or chronic myelogenous leukemia. 52 patients had an MPV that was inappropriately low for the platelet count (high, normal, or low). All had sepsis, splenomegaly, aplastic anemia, chronic renal failure, or a disease being treated with myelosuppressive drugs. High MPV thus appears correlated with myeloproliferative disease or thalassemia; and low MPV, with cytotoxic drugs or marrow hypoplasia. Addition of MPV to the platelet count allows subtler disorders to be detected (when the platelet count is normal), and allows distinction of the cause of thrombocytopenia.