Developing Molecular Signatures for Chronic Lymphocytic Leukemia

Chronic lymphocytic leukemia (CLL) is a clonal malignancy of mature B cells that displays a great clinical heterogeneity, with many patients having an indolent disease that will not require intervention for many years, while others present an aggressive and symptomatic leukemia requiring immediate treatment. Although there is no cure for CLL, the disease is treatable and current standard chemotherapy regimens have been shown to prolong survival. Recent advances in our understanding of the biology of CLL have led to the identification of numerous cellular and molecular markers with potential diagnostic, prognostic and therapeutic significance. We have used the recently developed digital multiplexed gene-expression technique (DMGE) to analyze a cohort of 30 CLL patients for the presence of specific genes with known diagnostic and prognostic potential. Starting from a set of 290 genes we were able to develop a molecular signature, based on the analysis of 13 genes, which allows distinguishing CLL from normal peripheral blood and from normal B cells, and a second signature based on 24 genes, which distinguishes mutated from unmutated cases (LymphCLL Mut). A third classifier (LymphCLL Diag), based on a 44-gene signature, distinguished CLL cases from a series of other B-cell chronic lymphoproliferative disorders (n = 51). While the methodology presented here has the potential to provide a "ready to use" classification tool in routine diagnostics and clinical trials, application to larger sample numbers are still needed and should provide further insights about its robustness and utility in clinical practice.     

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.     

Quantitative monitoring of lymphoid malignancies. Application and findings in chronic lymphocytic leukemia

The present study investigated the surface immunoglobulin (Ig) phenotypic pattern in 64 cases of chronic lymphocytic leukemia (CLL). The fluorescence activated cell sorter techniques were modified to provide sensitive and highly reproducible detection and quantification of the otherwise faint surface immunoglobulins on the cells in CLL. In over 98% of the cases of CLL, light chain of the surface Ig could be identified and measured. Serial measurements were shown to be highly reproducible. The phenotypic pattern and density identified on the surface of the circulating lymphocytes precisely reflected the findings in any given patient when other lymphoid tissue (bone marrow, lymph node or spleen) was sampled. Intraclonal heterogeneity detected by surface Ig was seen in some cases of CLL in spite of a relatively uniform morphology by other classical techniques. Three patterns of cell-to-cell variation were seen: 1) that of a non-Gaussian distribution of surface light Ig staining intensity 2) that of the presence of increased surface light Ig chain on a portion of the cells with a subpopulation of CLL cells showing an additional class of heavy chain, and 3) that of anisotropy where the surface Ig quantitatively did not correlate with cell size. Immunoglobulin phenotypic characterization of the cases of CLL was correlated with their clinical stage of disease activity. The distribution of surface light chain phenotype did not relate to any pattern of clinical stage of activity of the disease. By contrast, cases where the cells had a predominance of surface IgM were associated with a more advanced stage of CLL and a poorer clinical prognosis. When surface IgG was predominant, a lesser degree of clinical activity of disease was identified. The phenotypic pattern of the surface Ig on the lymphocytes in CLL mirrors the pattern of differentiation in the murine model of B-cell differentiation, and clinical aggressiveness appears to correlate with the character and degree of B-cell differentiation.     

Patterns of adenosine deaminase, ecto-5'-nucleotidase, poly(A)polymerase and surface light chain expression in chronic lymphocytic leukemias

The levels of activity of three enzymes have been measured in the circulating malignant lymphocytes of 47 patients with B chronic lymphocytic leukemia (CLL). These were the purine degradative enzymes, adenosine deaminase (ADA) and ecto-5'-nucleotidase (5'NT) and the enzyme responsible for the polyadenylation of mRNA, poly(A) polymerase. The patterns of activity of the above enzymes and the expression of surface immunoglobulin light chains were examined. A heterogeneity in the specific activity of the enzymes was observed which could not be attributed to variations of the percentage of B lymphocytes. A positive correlation was found between ADA and poly(A)polymerase activity (r = 0.383, p less than 0.01). Furthermore, the expression of immunoglobulin light chain phenotype was inversely related to 5'NT specific activity; CLL cases in which less than 20% of the cells expressed lambda chain phenotype, presented 5'NT specific activity of 16.7 +/- 3.3 (S.E.) nmol/h/10(6) cells, whereas in CLL cases with more than 20% of the cells expressing this phenotype the enzyme specific activity was 4.8 +/- 1.6 (S.E.) nmol/h/10(6) cells (p less than 0.02). These findings suggest that the simultaneous determination of enzymatic activities and immunological markers, might be useful in defining subsets in CLL and the subsequent clinical treatment.     

Methylation markers identify high risk patients in IGHV mutated chronic lymphocytic leukemia

Chronic lymphocytic leukemia (CLL) exhibits a highly variable clinical course. Altered DNA methylation of genes has shown promise as a source of novel prognostic makers in a number of cancers. Here we have studied the potential utility of a panel of methylation markers (CD38, HOXA4 and BTG4) in 118 CLL patients. Each of the three loci assessed exhibited frequent methylation, as determined by COBRA analysis and individually correlated with either good (CD38, BTG4 methylation) or poor (HOXA4 methylation) prognosis. Using a combined approach to produce an overall methylation score, we found that methylation score was significantly associated with time to first treatment in CLL patients. Multivariate Cox regression analysis revealed that methylation score was the strongest predictor of time to first treatment and was independent of IGHV gene mutational status and CD38 expression. This study provides proof of principle that a panel of methylation markers can be used for additional risk stratification of CLL patients.Key words: DNA methylation, prognostic marker, leukemia, CD38, HOXA4, BTG4Chronic lymphocytic leukemia (CLL) is the most commonly diagnosed form of leukemia in the UK and exhibits a highly variable clinical course.¹ While some patients rapidly succumb to the disease, others can survive for well over ten years, often without the need for treatment. This extreme variability in clinical course among patients presenting with early CLL emphasizes the need for good prognostic markers to help direct patient treatment.^1,2 A number of molecular markers are already in frequent use, most notably IGHV mutational status.¹ In addition, other markers, such as protein expression of ZAP70 and CD38 and genomic abnormalities are also commonly used.² However, the group of patients defined as having a good prognosis through the use of current markers is still large (about 60% of CLL patients³) and these patients still exhibit a wide variety in outcome. Thus, additional markers are needed to aid clinical management in these cases.Altered DNA methylation, especially at promoter associated CpG islands, is one of the hallmarks of cancer.⁴ The high frequency of DNA methylation changes, associated with the relative ease and sensitivity with which DNA methylation can be detected, have led to increasing interest in the use of methylation based markers for diagnosis and prognosis.⁵ A number of methylated genes have already been shown to correlate with clinical features of CLL. For example, TWIST2 has been reported to exhibit frequent hypermethylation in CLL with mutated IGHV genes, which have a good prognosis. It is, however, rarely methylated in unmutated CLL cases, which have a poorer prognosis.⁶ Methylation of ZAP70 was strongly correlated with lack of ZAP70 expression and, similarly to TWIST2 methylation, was also strongly correlated with mutation of IGHV.⁷ In contrast, we recently showed that the HOXA4 gene was a frequent target for hypermethylation in CLL but, in this case, methylation of the gene was associated with the poor prognosis IGHV unmutated cases.⁸ While in many cases the functional role of the altered methylation still remains to be clearly demonstrated, the association between differential methylation and specific subsets of CLL patients raises the possibility that altered gene methylation could be used to identify patient populations with differing clinical outcome.In this report we have more closely examined the relationship between methylation of specific candidate marker genes and patient outcome, using a panel of genes we have identified as frequently methylated in CLL. In addition to the previously described methylation of the HOXA4⁸ gene, we have also found frequent methylation, as determined by COBRA analysis, of two further genes (CD38 and BTG4). All three genes independently exhibit a correlation with patient outcome. However, a combined approach using all three markers produced the strongest correlation with patient outcome. This combined marker was independently prognostic in multivariate analysis and identified a subset of patients with IGHV mutated genes (i.e., those regarded as good prognosis) who had a significantly greater likelihood of disease progression.     

Differential bone marrow homing capacity of VLA-4 and CD38 high expressing chronic lymphocytic leukemia cells

Background

VLA-4 and CD38 predict a poor clinical outcome in chronic lymphocytic leukemia (CLL). We used CLL samples with discordant VLA-4/CD38 risk to address their individual roles in human bone marrow infiltration (BM), CLL cell homing to murine BM, and in supportive CLL cell-stromal cell interactions.

Methods

VLA-4, CD38, and Ki-67 expression was measured in CLL cells from peripheral blood (PB) and bone marrow (BM) aspirates. CLL BM infiltration rates, routinely determined by Pathology, were correlated to VLA-4 and CD38 expression. Short-term homing capacity of CLL cells was evaluated by adoptive transfer experiments. CLL cell viability and adhesion in stromal cell co-culture was determined.

Results

About 20% of CLL samples in our cohort displayed discordant VLA-4 and CD38 risk, with either high VLA-4 and low CD38 risk or vice versa. Using particularly such samples, we observed that VLA-4, and not CD38, was responsible for recirculation of CLL cells to murine BM. Human BM infiltration was also significantly higher in patients with high VLA-4 risk but not high CD38 risk. However, both molecules acted as independent prognostic markers. While both VLA-4 and CD38 expression were increased in BM-derived CLL cells, and VLA-4+ and CD38+ subpopulations showed enriched Ki-67 expression, VLA-4 did not contribute to CLL cell protection by stromal cells in vitro.

Conclusions

Our data argue for a prominent role of VLA-4 but not CD38 expression in the homing of CLL cells to BM niches and in human BM infiltration,but only a limited role in their protection by stromal cells.     

Scintigraphically detected "hot" thyroid nodules in the specimens from patients of the Thyroid Disease Clinic in Gda'nsk--clinico- histopathological analysis

A group of 153 patients with scintigraphically detected autonomic "hot" nodules of the thyroid has been subjected to clinical and histopathological analysis. Substantial part of these patients (30.1%) had hyperthyroidism, partly (in 19.9% of cases) in the form of the thyrocardiac syndrome. A most frequent histopathological lesion found within "hot" nodules was follicular adenoma. The occurrence of malignancy in the form of highly differentiated thyroid carcinoma was observed in 2.6% of cases. The incidence of thyroid carcinoma within "hot" nodules was in our material only two and half times smaller than in a previously analyzed group of patients with "cold" nodules of the thyroid.     

Antibody and Plasmablast Response to 13-Valent Pneumococcal Conjugate Vaccine in Chronic Lymphocytic Leukemia Patients – Preliminary Report

Background

Chronic lymphocytic leukemia (CLL) leads to significant immune system dysfunction. The predominant clinical presentation in 50% of patients involves recurrent, often severe, infections. Infections are also the most common (60–80%) cause of deaths in CLL patients. The scope of infections varies with the clinical stage of the disease. Treatment-naive patients typically present with respiratory tract infections caused by encapsulated bacteria Streptococcus pneumoniae and Haemophilus influenzae. Since 2012, the 13-valent pneumococcal conjugate vaccine (PCV13) has been recommended in the United States and some EU countries for pneumococcal infection prevention in patients with CLL (besides the long-standing standard, 23-valent pneumococcal polysaccharide vaccine, PPV23). The aim of this study was to compare the immune response to PCV13 in 24 previously untreated CLL patients and healthy subjects.

Methods

Both groups were evaluated for: the levels of specific pneumococcal antibodies, the levels of IgG and IgG subclasses and selected peripheral blood lymphocyte subpopulations including the frequency of plasmablasts before and after immunization.

Results

Adequate response to vaccination, defined as an at least two-fold increase in specific pneumococcal antibody titers versus pre-vaccination baseline titers, was found in 58.3% of CLL patients and 100% of healthy subjects. Both the CLL group and the control group demonstrated a statistically significant increase in the IgG2 subclass levels following vaccination (P = 0.0301). After vaccination, the frequency of plasmablasts was significantly lower (P<0.0001) in CLL patients in comparison to that in controls. Patients who responded to vaccination had lower clinical stage of CLL as well as higher total IgG, and IgG2 subclass levels. No significant vaccine-related side effects were observed.

Conclusions

PCV13 vaccination in CLL patients is safe and induces an effective immune response in a considerable proportion of patients. To achieve an optimal vaccination response, the administration of PCV13 is recommended as soon as possible following CLL diagnosis.     

The Spectrum of Kidney Pathology in B-Cell Chronic Lymphocytic Leukemia / Small Lymphocytic Lymphoma: A 25-Year Multicenter Experience

Background

Chronic lymphocytic leukemia and small lymphocytic lymphoma are 2 different presentations of the most common B-cell neoplasm in western countries (CLL/SLL). In this disease, kidney involvement is usually silent, and is rarely reported in the literature. This study provides a clinicopathological analysis of all-cause kidney disease in CLL/SLL patients.

Methods

Fifteen CLL/SLL patients with kidney biopsy were identified retrospectively. Demographic, clinical, pathological and laboratory data were assessed at biopsy, and during follow-up.

Results

At biopsy 11 patients presented impaired renal function, 7 patients nephrotic syndrome, 6 patients dysproteinemia, and 3 patients cryoglobulinemia. Kidney pathology revealed CLL/SLL-specific monoclonal infiltrate in 10 biopsies, glomerulopathy in 9 biopsies (5 membranoproliferative glomerulonephritis, 2 minimal change disease, 1 glomerulonephritis with organized microtubular monoclonal immunoglobulin deposits, 1 AHL amyloidosis). Five patients presented interstitial granulomas attributed to CLL/SLL. After treatment of the hematological disease, improvement of renal function was observed in 7/11 patients, and remission of nephrotic syndrome in 5/7 patients. During follow-up, aggravation of the kidney disease systematically occurred in the absence of favorable response to hematological treatment.

Conclusions

A broad spectrum of kidney diseases is associated with CLL/SLL. In this setting, kidney biopsy can provide important information for diagnosis and therapeutic guidance.     

Clinical and Biological Relevance of Genomic Heterogeneity in Chronic Lymphocytic Leukemia

Background

Chronic lymphocytic leukemia (CLL) is typically regarded as an indolent B-cell malignancy. However, there is wide variability with regards to need for therapy, time to progressive disease, and treatment response. This clinical variability is due, in part, to biological heterogeneity between individual patients’ leukemias. While much has been learned about this biological variation using genomic approaches, it is unclear whether such efforts have sufficiently evaluated biological and clinical heterogeneity in CLL.

Methods

To study the extent of genomic variability in CLL and the biological and clinical attributes of genomic classification in CLL, we evaluated 893 unique CLL samples from fifteen publicly available gene expression profiling datasets. We used unsupervised approaches to divide the data into subgroups, evaluated the biological pathways and genetic aberrations that were associated with the subgroups, and compared prognostic and clinical outcome data between the subgroups.

Results

Using an unsupervised approach, we determined that approximately 600 CLL samples are needed to define the spectrum of diversity in CLL genomic expression. We identified seven genomically-defined CLL subgroups that have distinct biological properties, are associated with specific chromosomal deletions and amplifications, and have marked differences in molecular prognostic markers and clinical outcomes.

Conclusions

Our results indicate that investigations focusing on small numbers of patient samples likely provide a biased outlook on CLL biology. These findings may have important implications in identifying patients who should be treated with specific targeted therapies, which could have efficacy against CLL cells that rely on specific biological pathways.     

A phase I/II trial of oxidized autologous tumor vaccines during the “watch and wait” phase of chronic lymphocytic leukemia

Based on their activity in patients with advanced stage chronic lymphocytic leukemia (CLL), a phase I/II study was designed to evaluate the feasibility, safety, and efficacy of autologous vaccines made from oxidized tumor cells in patients with earlier stage CLL, and to determine an optimal schedule of injections. Eighteen patients (at risk for disease progression and with white blood cell counts between 15 and 100×10⁶ cells/ml) were injected intramuscularly with 10 ml of oxidized autologous blood (composed mainly of CLL cells) either 12 times over 6 weeks (group 1), 12 times over 16 days (group 2), or 4 times over 6 weeks (group 3). Fourteen out of eighteen patients had Rai stage 0–II disease, while 4/18 had stage III–IV disease but did not require conventional treatment. Partial clinical responses, associated with enhanced anti-tumor T cell activity in vitro, were observed in 5/18 patients of whom three were in group 2. Stable disease was observed in six patients while disease progression appeared not to be affected in the remaining patients. Toxicity was minimal. Vaccination with oxidized autologous tumor cells appears worthy of further investigation and may be a potential alternative to a watch and wait strategy for selected CLL patients.     

Dysregulated angiogenesis in B-chronic lymphocytic leukemia: Morphologic, immunohistochemical, and flow cytometric evidence

Background

The extent of enhanced bone marrow angiogenesis in chronic lymphocytic leukemia (CLL) and relationship to proangiogenic factors and prognostic indicators is largely unexplored.

Methods

To further investigate the role of angiogenesis in CLL by evaluating the topography and extent of angiogenesis in a group of CLL bone marrow biopsies, to study the expression of pro and antiangiogenic vascular factors in CLL cells to more precisely document the cell types producing these factors, and to evaluate the role, if any, of localized hypoxia in upregulation of angiogenesis in CLL We used immunohistochemistry (IHC) (n = 21 pts) with antibodies to CD3 and CD20, proangiogenic (VEGF, HIF-1a) and antiangiogenic (TSP-1) factors, and VEGF receptors -1 and -2 to examine pattern/extent of CLL marrow involvement, microvessel density (MVD), and angiogenic characteristics; flow cytometry (FC) was performed on 21 additional cases for VEGF and TSP-1.

Results

CLL patients had higher MVD (23.8 vs 14.6, p~0.0002) compared to controls (n = 10). MVD was highest at the periphery of focal infiltrates, was not enhanced in proliferation centers, and was increased irrespective of the presence or absence of cytogenetic/immunophenotypic markers of aggressivity. By IHC, CLL cells were VEGF(+), HIF-1a (+), TSP-1(-), VEGFR-1(+), and VEGFR-2(+). By FC, CLL cells were 1.4–2.0-fold brighter for VEGF than T cells and were TSP-1(-).

Conclusion

CLL demonstrates enhanced angiogenesis, with increased MVD, upregulated VEGF and downregulated TSP-1. Upregulation of HIF-1a in all CLL cases suggests localized tissue hypoxia as an important stimulant of microvessel proliferation. The presence of VEGF receptors on CLL cells implies an autocrine effect for VEGF. Differences in MVD did not correlate with traditional genetic/immunophenotypic markers of aggressiveness.     

Kinetics of excision repair of UV-induced DNA damage, measured using the comet assay

The kinetics of UV- (254 nm) irradiation-induced DNA single-strand breaks (SSBs), generated during the excision repair of UV-induced DNA damage, in leukemic lymphocytes and in normal blood mononuclear cells (MNCs) were studied using the alkaline comet assay. The cells were isolated by density gradient centrifugation from peripheral blood of patients with chronic lymphocytic leukemia (CLL) and from healthy study subjects. The cytotoxicity of UV irradiation was determined in vitro in peripheral blood mononuclear lymphocytes from 36 CLL patients and from eight healthy donors using the incorporation of radioactive leucine in 4-day cultures. A remarkable difference in excision repair capability was observed between normal and leukemic lymphocytes. In contrast to normal lymphocytes, there was always a subpopulation of CLL cells that did not complete the repair of UV-induced DNA damage during the 24-h repair period. Furthermore, differences were also recorded between UV-sensitive and UV-resistant CLL cases. The differences in DNA migration between the maximum increase (59-77 microm) and that at 24 h after irradiation (21-66 microm) was statistically significant in two of three patients exhibiting UV-resistance. Correspondingly, only in one of three patients exhibiting UV-sensitivity was the difference in DNA migration statistically significant (maximum increase: 44-107 microm, vs. 24 h after: 42-100 microm). Our results confirm an abnormal pattern of the CLL cell response to UV irradiation. Furthermore, we identified defective processing of UV-induced DNA damage in CLL versus normal lymphocytes, particularly in UV-sensitive cases.     

Teniposide is not effective in chronic lymphocytic leukemia

Teniposide has been evaluated in a phase II clinical trial in chronic lymphocytic leukemia (CLL). Among 16 consecutive patients with CLL entered in the study and treated with Teniposide, 100 mg/m2 weekly, no objective response was observed. Toxicity was generally mild and mainly hematologic. Teniposide at this dosage and schedule is an inactive drug in CLL.     

Cellules grumelées: old terminology revisited. Regarding the cytologic diagnosis of chronic lymphocytic leukemia and well-differentiated lymphocytic lymphoma in pleural effusions

Distinguishing chronic lymphocytic leukemia (CLL) or well-differentiated lymphocytic lymphoma (WDLL) from a benign chronic inflammatory process involving the serous cavities is often a difficult task for the cytopathologist faced with a lymphocyte-rich effusion fluid. Spriggs and Boddington decribed characteristic heavy chromatin clumping (cellules grumelées) of the lymphocytic nuclei in effusions as diagnostic of chronic lymphocytic leukemia. A study of 23 cases of lymphocyte-rich pleural effusions in our laboratory showed that, while this cytomorphologic feature is a function of cytopreparatory technique and fixation, it was observed only in cases of CLL or WDLL and not in benign inflammatory processes.     

Genetic features of B-cell chronic lymphocytic leukemia

The genetic features of B-cell chronic lymphocytic leukemia (CLL) are currently being reassessed by molecular cytogenetic techniques such as fluorescence in situ hybridization (FISH). Conventional cytogenetic studies by chromosome banding are difficult in CLL mainly because of the low in vitro mitotic activity of the tumor cells, which leads to poor quantity and quality of metaphase spreads. Molecular genetic analyses are limited because candidate genes are known for only a few chromosomal aberrations that are observed in CLL. FISH was found to be a powerful tool for the genetic analysis of CLL as it overcomes both the low mitotic activity of the CLL cells and the lack of suitable candidate genes for analysis. Using FISH, the detection of chromosomal aberrations can be performed at the single cell level in both dividing and non-dividing cells, thus circumventing the need of metaphase preparations from tumor cells. Probes for the detection of trisomies, deletions and translocation breakpoints can be applied to the regions of interest with the growing number of clones available from genome-wide libraries. Using the interphase cytogenetic FISH approach with a disease specific set of probes, chromosome aberrations can be found in more than 80% of CLL cases. The most frequently observed abnormalities are losses of chromosomal material, with deletions in band 13q14 being the most common, followed by deletions in 11q22-q23, deletions in 17p13 and deletions in 6q21. The most common gains of chromosomal material are trisomies 12q, 8q and 3q. Translocation breakpoints, in particular involving the immunoglobulin heavy chain locus at 14q32, which are frequently observed in other types of non-Hodgkin's lymphoma, are rare events in CLL. Genes affected by common chromosome aberrations in CLL appear to be p53 in cases with 17p deletion and ataxia telangiectasia mutated (ATM), which is mutated in a subset of cases with 11q22-q23 aberrations. However, for the other frequently affected genomic regions, the search for candidate genes is ongoing. In parallel, the accurate evaluation of the incidence of chromosome aberrations in CLL by FISH allows the correlation of genetic abnormalities with clinical disease manifestations and outcome. In particular, 17p abnormalities and deletions in 11q22-q23 have already been shown to be among the most important independent prognostic factors identifying subgroups of patients with rapid disease progression and short survival. In addition, deletion 17p has been associated with resistance to treatment with purine analogs. Therefore, genetic abnormalities may allow a risk assessment for individual patients at the time of diagnosis, thus giving the opportunity for a risk-adapted management.     

Gefitinib targets ZAP-70-expressing chronic lymphocytic leukemia cells and inhibits B-cell receptor signaling

Chronic lymphocytic leukemia (CLL) can be divided into groups based on biomarkers of poor prognosis. The expression of the tyrosine kinase ZAP-70 (member of the Syk tyrosine kinase family) in CLL cells is associated with shorter overall survival in CLL patients. Currently, there is a lack of targeted therapies for patients with ZAP-70 expression in CLL cells. The tyrosine kinase inhibitor gefitinib has been shown to be effective at induce apoptosis in acute myeloid leukemia through inhibition of Syk. In this study, we sought to test the efficacy of gefitinib in primary human ZAP-70+ CLL cells. We demonstrate that gefitinib preferentially induces cell death in ZAP-70-expressing CLL cells with a median IC₅₀ of 4.5 μM. In addition, gefitinib decreases the viability of ZAP-70+ Jurkat T leukemia cells but fails to affect T cells from CLL patients. Western blot analysis shows gefitinib reduces both basal and B-cell receptor (BCR)-stimulated phosphorylation of Syk/ZAP-70, ERK, and Akt in ZAP-70+ CLL cells. Moreover, gefitinib inhibits the pro-survival response from BCR stimulation and decreases pro-survival proteins such as Mcl-1. Finally, ZAP-70 expression sensitizes Raji cells to gefitinib treatment. These results demonstrate that gefitinib specifically targets ZAP-70+ CLL cells and inhibits the BCR cell survival pathway leading to apoptosis. This represents the likelihood of tyrosine kinase inhibitors being effective targeted treatments for ZAP-70+ CLL cells.The clinical course of chronic lymphocytic leukemia (CLL) is highly variable, and although some patients are treated at diagnosis, others may not require therapy for years.¹ Biomarkers can help stratify these patients into indolent and aggressive disease categories. The aggressiveness of CLL is dependent on whether the leukemia cells have (60% of CLL population) or lack (40% of CLL population) mutations of the immunoglobulin variable region of the heavy chain (IgV_H). Thus, patients with early-stage disease have a median survival of 8 years if they have unmutated IgV_H (Un-IgV_H) and 24 years if they have mutated IgV_H (Mu-IgV_H) disease.² A surrogate marker for IgV_H mutational status is the expression of zeta-chain-associated protein 70 (ZAP-70); IgV_H mutated CLL cells are frequently ZAP-70 negative, whereas IgV_H unmutated cells are more typically ZAP-70 positive.³ ZAP-70 staining in CLL is not an all-or-nothing phenomenon, and to maximize the correlation with IgV_H mutational status, a ZAP-70-positive case is defined as ≥20% of the CLL cells staining for ZAP-70. Like IgV_H status, overexpression of ZAP-70 in CLL cells is associated with aggressive disease; time to treatment is 2.6 years for ZAP-70+ patients compared with 8 years for ZAP-70− patients independent of Rai stage.³ Thus, ZAP-70 is a rationale target for therapy in CLL.Although the clinical relevance of ZAP-70 in CLL is well known, its molecular function is less understood. ZAP-70 is a member of the Syk family of protein tyrosine kinases and is normally involved in signal transduction of the T-cell receptor in T cells. ZAP-70 overexpression in malignant B cells, such as CLL cells, enhances the B-cell receptor (BCR) pathway. This pathway is a key mechanism for cell survival in CLL.^4,5 Upon activation of the BCR, tyrosine kinase Lyn phosphorylates and activates Syk, leading to activation of downstream signaling pathways and upregulation of anti-apoptotic proteins, such as Mcl-1. CLL cells with both Un-IgV_H and high ZAP-70 expression show increased activation of proteins downstream of the BCR such as Akt, mitogen-activated protein kinase (MAPK), and NF-κB.^4,6,7 This suggests that alterations in the BCR signaling pathway through increased expression of the tyrosine kinase ZAP-70 are important in CLL disease progression.Gefitinib is a tyrosine kinase inhibitor known for targeting the epidermal growth factor receptor (EGFR) and is used in the treatment of non-small-cell lung cancer and other cancers of epithelial origin.⁸ The drug is well tolerated, with rash and diarrhea being the only dose-limiting toxicities. Importantly to leukemias, it is not myelosuppressive.⁹ Apart from its effects on EGFR activity, gefitinib has shown activity against >20 other kinase targets, including Lyn and Syk.^10,11 Gefitinib has been shown activity in acute myeloid leukemia (AML), myelodysplastic syndrome (MDS), and acute lymphocytic leukemia (ALL), inducing both differentiation and cell death in vitro.¹² These effects are associated with inhibition of Syk phosphorylation. Thus, although gefitinib is used to treat lung cancer by inhibiting EGFR, it has potential utility in the treatment of CLL patients with high expression of Syk family members that include ZAP-70.In this study we show that gefitinib selectively induces apoptosis in ZAP-70-expressing CLL cells, both when unstimulated and BCR activated. These effects are associated in both cases with a reduction in overall tyrosine phosphorylation and specific decreases in Lyn/Lck, Syk/ZAP-70, ERK1/2, and Akt phosphorylation. These changes produce a decreased expression of Mcl-1 and blocked anti-apoptotic signaling. Forced overexpression of ZAP-70 by lentiviral infection in the Raji B-cell line increases the sensitivity of the cells to gefitinib-induced apoptosis. However, normal T cells from CLL patients, which also express ZAP-70, are not affected by gefitinib. These results suggest that tyrosine kinase inhibitors such as gefitinib are a viable treatment option for ZAP-70+ CLL patients.     

Ribonuclease deficiency in lymphocytes of patients with chronic lymphocytic leukemia (CLL)

Ribonuclease (RNase) activity in the lymphocytes of 20 chronic lymphocytic leukemia (CLL) patients and 10 normal subjects was studied. It was found that in the lymphocytes of the control subjects the RNase activity could be detected in the pH range 4.5 to 8.6, inclusive. The RNase activity versus pH profile of normal lymphocytes consists of an acid RNase peak at pH 6.5 and alkaline RNase peak at pH 7.8. When treated with pCMB an inhibitor-bound RNase activity was revealed. The peak of this activity lay between pH 6.7 to 7.0. Liberating the inhibitor-bound RNase activity changed the RNase activity-pH profile, yielding one peak curve with a maximum at pH 7.0. RNase activity in CLL lymphocytes was remarkably lower than that in normal lymphocytes. The acid RNase in 80% of the CLL patients was lower by a factor of ten. Likewise, a many fold decrease in alkaline RNase activity (in some cases down to the zero level) was observed in CLL lymphocytes. However, in 70% of CLL patients, a level of the inhibitor-bound RNase activity was similar to that found in normal lymphocytes. In 20% of the studied CLL patients, a remarkable decrease in both free alkaline and inhibitor-bound RNase activity was observed. When poly-C was used as a substrate for determining RNase activity, a decrease to approximately 15% in CLL lymphocytes was observed, when poly-U was used instead of poly-C, a decrease to 65% was found only as compared with normal lymphocytes. This may suggest that CLL lymphocytes are deficient in a poly-C specific RNase which displays its activity within a neutral and alkaline pH range.     

Telomerase Contributes to Fludarabine Resistance in Primary Human Leukemic Lymphocytes

We report that Imetelstat, a telomerase inhibitor that binds to the RNA component of telomerase (hTR), can sensitize primary CLL lymphocytes to fludarabine in vitro. This effect was observed in lymphocytes from clinically resistant cases and with cytogenetic abnormalities associated with bad prognosis. Imetelstat mediated-sensitization to fludarabine was not associated with telomerase activity, but with the basal expression of Ku80. Since both Imetelstat and Ku80 bind hTR, we assessed 1) if Ku80 and Imetelstat alter each other''s binding to hTR in vitro and 2) the effect of an oligonucleotide complementary to the Ku binding site in hTR (Ku oligo) on the survival of primary CLL lymphocytes exposed to fludarabine. We show that Imetelstat interferes with the binding of Ku70/80 (Ku) to hTR and that the Ku oligo can sensitize CLL lymphocytes to FLU. Our results suggest that Ku binding to hTR may contribute to fludarabine resistance in CLL lmphocytes. This is the first report highlighting the potentially broad effectiveness of Imetelstat in CLL, and the potential biological and clinical implications of a functional interaction between Ku and hTR in primary human cancer cells.     

Expanded CD8+ T cells of murine and human CLL are driven into a senescent KLRG1+ effector memory phenotype

Altered numbers and functions of T cells have previously been demonstrated in chronic lymphocytic leukemia (CLL) patients. However, dynamics and specific T-cell subset alterations have not been studied in great detail. Therefore, we studied CLL blood lymphocyte subsets of individual patients in a longitudinal manner. Dynamic expansions of blood CD4 ⁺ and CD8 ⁺ T-cell numbers were consistently associated with a progressively increasing CLL leukemic compartment. Interestingly, the T-cell subset expansion over time was more pronounced in CD38 ⁺ CLL. Additionally, we performed gene expression profiling of CD3 ⁺ T cells of CLL patients and normal donors. Using gene set enrichment analysis, we found significant enrichment of genes with higher expression in CLL T cells within CD8⁺ effector memory and terminal effector T-cell gene signatures. In agreement with these data, we observed a marked expansion of phenotypic CD8 ⁺ effector memory T cells in CLL by flow cytometry. Moreover, we observed that increments of CD8 ⁺ effector memory T cells in human CLL and also mouse CLL (Eμ-TCL1 model) were due to an expansion of the inhibitory killer cell lectin-like receptor G1 (KLRG1) expressing cellular subset. Furthermore, higher plasma levels of the natural KLRG1 ligand E-cadherin were detected in CLL patients compared to normal donor controls. The predominance of KLRG1⁺ expression within CD8⁺ T cells in conjunction with increased systemic soluble E-cadherin might significantly contribute to CLL immune dysfunction and might additionally represent an important component of the CLL microenvironment.