Percentage of Smudge Cells on Blood Smear Predicts Prognosis in Chronic Lymphocytic Leukemia: A Multicenter Study.

Abstract Background: Smudge cells are ruptured CLL cells seen on blood smears of CLL patients. For over a century, smudge cells were thought to represent an artifact of slide preparation. We recently showed that smudge cell formation was inversely proportional to leukemic B cell vimentin content. Vimentin is a cytoskeletal protein critical for lymphocyte rigidity and migration; high vimentin content is related to poor prognosis in CLL. Concordantly, in an initial small cohort of patients from a single institution, we found that patients with a low (<30%) percentage of smudge cells on a blood smear have a shorter time to treatment (Mayo Clin Proc.2007;82:449–53). In the current study, we evaluated the impact of smudge cell percentage on prognosis of patients with CLL seen at member institutions of the CLL Research Consortium (CRC). Methods: Archived blood smears from untreated patients with CLL were evaluated for smudge levels. All blood smears were prepared manually in a standard fashion from blood obtained by CRC Tissue Core and stained with WrightGiemsa stain. Smudge cells were defined as broken cells with no intact cytoplasm and a disrupted nuclear membrane. A total of 200 lymphocytes and smudge cells were counted on each slide and the results were expressed as the percent smudge cells. The association between the percentage of smudge cells, prognostic factors (IgVH status, CD38, ZAP-70 and FISH) and time to initial therapy (TTT) was examined. Results: We calculated smudge cell percentage on blood smears obtained prior to treatment for 337 CLL patients. The median smudge cell percentage was 32 (range 2–95%). The percentage of smudge cells was lower in CD38 positive patients (mean 33% vs. 38% in CD38 negative patients, p=0.04). No difference in smudge cell percentage was observed based on IgVH gene mutation status or Zap70 expression. Smudge cell percentage as a continuous variable was associated with prolonged TTT, exponential coefficient 0.98, p=0.04. Using our previously published cutoff of 30% to stratify patients in low and high risk categories, the estimated median time to first therapy of patients with smudge cell percentage ≤30% (n=178) was 7.8 years versus not reached in patients in patients with > 30% (n=159) of smudge cells, p=0.0036, (Figure 1). Ten years from diagnosis, 62% of patients with ≤30% of smudge cells versus 39% of patients with >30% of smudge cells required therapy. In multivariate analysis, the low percentage of smudge cells (≤30%) was an independent predictor of the shortened time to treatment (HR 1.86, 95%CI 1.09–3.16, p=0.02). Conclusion: This multicenter study confirms our initial finding that the percentage of smudge cells on a blood smear is an independent predictor of clinical outcome in patients with CLL. The estimation of smudge cell percentage on routine blood smear provides a simple and inexpensive prognostic test available to nearly all patients with a diagnosis of CLL worldwide. It also allows reanalysis and risk stratification of previously completed trials provided that blood smears have been archived. Further studies of the role of the cytoskeleton in CLL biology are warranted and ongoing in our laboratory. Figure Figure

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Percentage of Smudge Cells on Routine Blood Smear Predicts Survival in Chronic Lymphocytic Leukemia

Journal of Clinical Oncology ◽

10.1200/jco.2008.17.0795 ◽

2009 ◽

Vol 27 (11) ◽

pp. 1844-1849 ◽

Cited By ~ 45

Author(s):

Grzegorz S. Nowakowski ◽

James D. Hoyer ◽

Tait D. Shanafelt ◽

Clive S. Zent ◽

Timothy G. Call ◽

...

Keyword(s):

Overall Survival ◽

Chronic Lymphocytic Leukemia ◽

Blood Smear ◽

Early Stage ◽

Continuous Variable ◽

Lymphocytic Leukemia ◽

Intact Cells ◽

Cell Percentage ◽

Blood Smears ◽

The Relationship

PurposeSmudge cells are ruptured chronic lymphocytic leukemia (CLL) cells appearing on the blood smears of CLL patients. Our recent findings suggest that the number of smudge cells may have important biologic correlations rather than being only an artifact of slide preparation. In this study, we evaluated whether the smudge cell percentage on a blood smear predicted survival of CLL patients.Patients and MethodsWe calculated smudge cell percentages (ratio of smudged to intact cells plus smudged lymphocytes) on archived blood smears from a cohort of previously untreated patients with predominantly early-stage CLL enrolled onto a prospective observational study. The relationship between percentage of smudge cells, patient survival, and other prognostic factors was explored.ResultsBetween 1994 and 2002, 108 patients were enrolled onto the study and had archived blood smears available for review; 80% of patients had Rai stage 0 or I disease. The median smudge cell percentage was 28% (range, 1% to 75%). The percentage of smudge cells was lower in CD38+versus CD38–patients (P = .019) and in Zap70-positive versus Zap70-negative patients (P = .028). Smudge cell percentage as a continuous variable was associated with prolonged survival (P = .042). The 10-year survival rate was 50% for patients with 30% or less smudge cells compared with 80% for patients with more than 30% of smudge cells (P = .015). In multivariate analysis, the percentage of smudge cells was an independent predictor of overall survival.ConclusionPercentage of smudge cells on blood smear is readily available and an independent factor predicting overall survival in CLL.

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Prognostic and predictive significance of smudge cell percentage on routine blood smear in chronic lymphocytic leukemia patients: A single center study from northern India.

Journal of Clinical Oncology ◽

10.1200/jco.2012.30.15_suppl.6593 ◽

2012 ◽

Vol 30 (15_suppl) ◽

pp. 6593-6593

Author(s):

Ajay Gogia ◽

Vinod Raina ◽

Atul Sharma ◽

Lalit Kumar ◽

Ritu Gupta ◽

...

Keyword(s):

Chronic Lymphocytic Leukemia ◽

Lymphocyte Count ◽

Blood Smear ◽

Lymphocytic Leukemia ◽

Stage Ii ◽

Stage Iii ◽

Routine Blood ◽

Cell Percentage ◽

Blood Smears

6593 Background: Smudge cells are ruptured lymphocytes seen on routine blood smears of chronic lymphocytic leukemia (CLL) patients. We evaluated prognostic and predictive significance of smudge cells percentage on a blood smear in CLL patients. Methods: We calculated smudge cell percentages (ratio of smudged to intact cells plus smudged lymphocyte) on archived blood smears of 185 untreated CLL patients registered at I.R.C.H, AIIMS, New Delhi over a period of 11 years. Results: There were 135 males and 50 females. The median age was 60 years (28-89). Median absolute lymphocyte count was 42 X109/L. Clinical Rai stage distribution was: stage 0 - 10%, stage I - 15%, stage II - 40%, stage III -15 % and stage IV - 20%. The median smudge cells percentage was 27% (4% to 76%). There was no correlation of proportion of smudge cells with age, sex, lymphocyte count, organomegaly, ZAP 70 + or CD 38 + CLL patients, but there was significant correlation with stage of disease. Median smudge cell percentage in stage 0 & I -33% (12-76), stage II- 31% (12-61) and stage III&IV-21% (4-51) [ p=<0.001]. One third of early stage (0, I &II) patients required treatment during follow up, at the end of 5 years of follow up 55% required treatment with smudge cell < 30%, against 24% patients requiring treatment with smudge cells > 30% [p=0.01]. The percentage of smudge cells as a continuous variable correlated with OS [HR 0.96, p< 0.001]. The 5-year survival rate was 51% for patients with 30% or less smudge cells compared with 81% for patients with more than 30% of smudge cells. Thirty percent of patients died during follow up. Median OS was 5 years with median follow up period of 3.9 years. Smudge cells percentage (<30% vs. >30%) had significant association with OS [HR 0.47, 95%CI (0.32-0.71), p=0.001)]. Conclusions: Simple and inexpensive detection of smudge cells on blood smears on routine diagnostic test useful in predicting progression free and OS in CLL patients and may be beneficial in countries with limited recourses.

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The prognostic value of smudge cells (Gumprecht shadows) in chronic lymphocytic leukaemia

Orvosi Hetilap ◽

10.1556/oh.2012.29477 ◽

2012 ◽

Vol 153 (44) ◽

pp. 1732-1737 ◽

Cited By ~ 1

Author(s):

László Szerafin ◽

János Jakó ◽

Ferenc Riskó ◽

Zsuzsanna Hevessy

Keyword(s):

Chronic Lymphocytic Leukaemia ◽

Prognostic Value ◽

Blood Smear ◽

Lymphocytic Leukaemia ◽

Annexin V ◽

Inverse Correlation ◽

Treated Group ◽

Time To Treatment ◽

Cell Percentage

Introduction: Smudge cells (Gumprecht shadows) are chronic lymphocytic leukaemic cells ruptured during peripherial blood smear preparation. It has been demonstrated to be linked to reduced expression of the cytoskeletal protein vimentin and its inverse correlation with the clinical outcome of the disease. Aims: Investigation of the percentage of smudge cells, CD38-, ZAP-70-positive cells and the time to treatment in patients with chronic lymphocytic leukaemia. Methods: Authors investigated the percentage of smudge cells, CD38- and ZAP-70-positive cells in the peripheral blood of 50 patients with chronic lymphocytic leukaemia and their correlation with the time to treatment. Results: 21 patients required treatment in the follow-up period. Their median smudge cell percentage was 9.9%, while it was 26.8% in the non-treated group. The cut-off value of smudge cell positivity was set to 20%. 59.3% of the patients with less than cut-off had to be treated in the follow-up time compared to 21.7% of patients with more smudge cells. These findings were similar to the prognostic value of CD38 and ZAP-70. The necessity of treatment increased to 75–77.8% with the combination of investigated markers. The time to treatment was 19 months when smudge cells were less than 20%, but above 20% it was 36.15 months. In case of low smudge cell percentage and CD38 positivity the time to treatment was 14.14 months and in case of high smudge cell percentage and CD38 negativity it was 32.92 months. In discordant cases the time to treatment was 18.43 months. The authors also present a case report that demonstrates the relationship between the percentage of smudge cells and apoptotic cells with annexin V and 7-AAD staining. Conclusions: Estimation of smudge cells on a blood smear could be a simple and cheap prognostic test in chronic lymphocytic leukaemia with sensitivity similar to CD38 and ZAP-70 estimation. Combination of these tests raised the sensitivity of their prognostic value. Orv. Hetil., 2012, 153, 1732–1737.

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Percentage of Smudge Cells Predicting Prognosis In Chronic Lymphocytic Leukemia

Blood ◽

10.1182/blood.v116.21.4624.4624 ◽

2010 ◽

Vol 116 (21) ◽

pp. 4624-4624

Author(s):

Ravikumar Paluri ◽

Supriya Koya ◽

Randall S. Davis ◽

Fun Jun Li ◽

Alan B Cantor ◽

...

Keyword(s):

Image Analysis ◽

Chronic Lymphocytic Leukemia ◽

Lymphocytic Leukemia ◽

Cell Counting ◽

Lower Percentage ◽

Categorical Variables ◽

Clinical Parameters ◽

Computerized Image Analysis ◽

Cell Percentage ◽

Blood Smears

Abstract Abstract 4624 Background: Identifying prognostic markers is important for clinical and pathological course of chronic lymphocytic leukemia. Percentage of smudge cells in CLL patients has recently been reported as a novel prognostic factor. We present here the preliminary results of the retrospective cohort study of 90 patients diagnosed with CLL at a major referral center in the state of Alabama between 1997 and 2009. Methods: Smudge cell percentage (ratio of smudge cells to combined smudge cells and intact cells) was calculated by microscopic evaluation of archived Wright-Giemsa stained blood smears. A total of 200 cell differential was counted for inter-observer consistency. For the first time, the concordance between observers was assessed by quantization of morphological parameters of lymphocytes using computerized image analysis. Medical records of above mentioned patients were reviewed for molecular, genetic and clinical parameters including CD38, ZAP 70 expression, immunocytopenias and response to first treatment. Primary endpoint of this analysis was time to initiation of chemotherapy for first treatment (TIFT). It was calculated from date of first diagnosis until first dose of chemotherapy. Untreated patients in the follow up were censored. Kaplan Meier survival analysis and log rank test were used for statistical analysis. Prognostic factors for TIFT were analyzed with Cox's proportional hazards regression. Wilcoxon rank sum test and Fishers exact test were used to evaluate differences between groups for continuous and categorical variables, respectively. We had more than 90% Power to detect an association between smudge cell percentage and TIFT. Results: Of the 160 treatment naïve CLL patients enrolled for the study, 90 had archived blood smears available for evaluation. Patient characteristics include Rai stage 0 or 1 disease (87%), CD 38+ (30%), Zap 70 + (35%), 13q Del + (26%). Percentage of smudge cells ranged from 2 to 90 % (median 34%). Patients with CD38+ and ZAP 70+ on flow cytometry had lower percentage of smudge cell than those with negative markers and are trending towards significance (p=0.08). Our cohort included 16% of African American population and had no significant difference in TIFT when compared to Caucasians. In univariate analysis smudge cell percentage (stratified as less than or more than 30) was significantly associated with TIFT (p=0.04). Rai stages 0, 1 and 2 were significantly associated with longer TIFT than stage 3 and 4 (p= 0.01). Genetic parameters- deletion 13 q and 11q were associated with significantly greater TIFT (p= 0.008 and P=0.001 respectively). Patients who developed immunocytopenias during the course of study had shorter TIFT (p=0.01). We performed Step wise multivariate Cox regression analysis and identified del11q (HR=0.02, p=0.001) and Rai stage (HR=0.008, p <0.0001) as independent predictors of TIFT. Patients with longer TIFT had better response to treatment when compared to shorter TIFT (68% vs 32%, p=0.05). Contrary to our expectation, we found that, in multivariate analysis, we found smudge cell percentage is not significantly associated with TIFT (p= 0.75). Conclusion: Time for initiation of first treatment is significantly shorter in CLL patients with del11q and del13q and those who develop immunocytopenias. Smudge cell percentage did not significantly predict TIFT in this single center study. We speculate this could be due to subjective decision on initiation of chemotherapy by physicians, based on several other clinical parameters and co-morbidities. Larger studies are needed that concurrently assess any confounders between smudge cell percentage and TIFT. Alternatively, computerized image analysis is superior to observer measurements and can be considered for accuracy and reproducibility of cytological evaluation. It can ascertain the objectivity of concordance in differential cell counting in similar studies. Disclosures: No relevant conflicts of interest to declare.

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Proteomic Analysis of Chronic Lymphocytic Leukemia Cells Identifies Vimentin as a Novel Prognostic Factor for Aggressive Disease.

Blood ◽

10.1182/blood.v106.11.707.707 ◽

2005 ◽

Vol 106 (11) ◽

pp. 707-707 ◽

Cited By ~ 3

Author(s):

Grzegorz S. Nowakowski ◽

Yean K. Lee ◽

Nancy D. Bone ◽

William G. Morice ◽

David Barnidge ◽

...

Keyword(s):

Flow Cytometry ◽

Prognostic Significance ◽

Surrogate Marker ◽

Continuous Variable ◽

Lymphocytic Leukemia ◽

Intermediate Filament Protein ◽

M Cells ◽

Vimentin Expression ◽

Mutation Status ◽

Time To Treatment

Abstract The IgVH mutation status is an independent predictor of time to treatment and survival in CLL. However, the biological basis of this difference is unknown. Clinical use of the IgVH mutation status as a prognostic marker is limited due to the technical difficulties of assessing this feature. As such, we probed for differences in protein expression by CLL cells with unmutated (UM) vs mutated (M) IgVH using phage peptide display libraries (PDPL). Methods: PDPL consists of phages engineered to express random peptides (7-mer) on the coat protein. From approximately 2x1011 phages displaying all possible permutations of 7-mer peptide, we selected phages binding to UM cells by incubation with 106 UM cells and elution of bound phages. Then, from numerous phages initially binding to UM cells, we subtracted phages binding to M cells by multiple incubations with M cells (106). Thus, the phages that bound only to UM cells were selected. The procedure was repeated multiple times to increase selection specificity. The peptide sequences displayed by selected phages were evaluated. We identified phage targets on UM cells by immunoprecipitation (IP) of CLL protein with specific phage and by sequencing of precipitated protein. The expression of target protein in CLL cells was confirmed by immunobloting and flow cytometry. Results: Sequencing of phages from the 3rd round of selection (UM v. M) revealed several peptides, with the most predominant being FPSAHFL. IP identified the cellular target for FPSAHFL as vimentin, an intermediate filament protein involved in cell motility and activation. The level of vimentin expressed by CLL cells varied between patient samples (n=15). UM CLL cases were found to express higher levels of vimentin (the mean MFI was 1002; SD 381), than cases of M CLL (mean MFI 547; SD 109), p=0.0128. To evaluate the prognostic significance of vimentin, we assessed vimentin expression by flow cytometry in a separate subgroup of 40 CLL patients. Archived cell samples collected between 6/2000 – 6/2001 were used. The median follow up was 81 months (40–233). Vimentin expression (MFI) as a continuous variable was a risk factor for a shortened time to treatment (TTT) with a proportional hazard ratio of 4.152 (95% CI 1.33–15.220, p=0.0317). Using MFI closest to the median (and rounded to 2 decimal places) as a cutoff, we stratified patients in high (n=21) and low (n=19) vimentin expression groups. The median times to treatment (TTT) in patients with high vs low level expression of vimentin were 2.8 and 12.9 years respectively, p=0.0025 (Fig.). Conclusion: Using novel proteomic technology, we found that CLL cells with unmutated IgVH expressed higher levels of vimentin than CLL cells with mutated IgVH. A high-level of vimentin expression defined by flow cytometry appears to be associated with high-risk disease. Validation of these findings could allow for the vimentin level to be used as a surrogate marker for expression of unmutated IgVH in CLL. Figure Figure

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Using Smudge Cells Percentage on Routine Blood Smear in Chronic Lymphoytic Leukemia As Prognostic Factor: Senegalese Experience

Blood ◽

10.1182/blood.v126.23.5273.5273 ◽

2015 ◽

Vol 126 (23) ◽

pp. 5273-5273 ◽

Cited By ~ 2

Author(s):

Abibatou Sall ◽

Awa Oumar Touré ◽

Fatimata Bintou Sall ◽

Abdoulaye Sène ◽

Cedric Aumont ◽

...

Keyword(s):

Flow Cytometry ◽

Lymphocyte Count ◽

Blood Smear ◽

Prognostic Markers ◽

Survival Times ◽

Cytogenetic Abnormalities ◽

Cell Percentage ◽

Blood Smears ◽

Trisomy 12 ◽

Binet Stage

Abstract Introduction/ Background : Chronic lymphocytic leukemia (CLL) is a heterogeneous disease which can present as an aggressive and life threatening leukemia or as an indolent form that will not require treatment for decades. This heterogeneity has important consequences which will impact on clinical approaches, treatment strategies, and survival times from diagnosis. Prognostic markers such as expression of specific proteins in or on CLL cells (ie, CD38, 70-kD ζ-associated protein or CD49d), cytogenetic abnormalities (del 13q, del 11q, del 17p and trisomy 12) quantified by FISH and immunoglobulin heavy chain (IgVH) gene mutation have all been very useful. Futhermore, patients with early-stage disease, with biologically aggressive disease and shorter survival times can be distiguished. However, these prognostic tests are expensive and require considerable technical expertise and equipment and thus are not available to many patients with CLL living in developing countries. Therefore less expensive prognostic markers are needed. In this study, we evaluated the prognostic significance of smudge cells percentage on a blood smear in CLL patients. Patients and Methods : In this prospective study, 42 untreated patients with CLL have participated after signing a consent form. Patients were seen at our center between July 2011 and May 2015. Patients were diagnosed on the basis of an absolute lymphocyte count greater than 5.109/L and a demonstration of monoclonality using flow cytometry (panel comprising CD19, CD5, CD22, CD23, FMC7, and surface Ig). Staging was done according to the Binet staging system. CD38 surface expression was determined by flow cytometry in all patients. The cytogenetic abnormalities : del 13q, del 11q, del 17p and trisomy 12, were performed by FISH and available for 25 patients.Smudge cells were defined as broken cells with no intact cytoplasm and a disrupted nuclear membrane (Figure 1). The smudge cell percentage is estimated by counting 200 lymphocytes and/or smudge cells; the smudge cell number is then divided by total number of cells counted (smudge cells + intact lymphocytes) and multiplied by 100. Each slide was evaluated by 2 hematologists and the blood smears were prepared using a manual wedge method. Categorical variables were analyzed using the χ2 test or Fisher exact test (p<0.05). The statistical analysis was performed using STATA version 13. Results : The mean age was 63 years ranging from 48 to 85. There were 31 males and 11 females (sex ratio=2.81). At the time of diagnosis 81% of the patients were classified as having advanced Binet stages B or C. The median lymphocyte count was 189.9 109/L (ranges, 5.2 - 887 109/L). The prognostic marker CD38 was positive in 28 patients, while 11 patients had 13q del, 7 patients Trisomy 12, 3 del 11d and 3 del 17p. The median smudge cell percentage was 20.1% (range, 4 - 80%) and 30 patients had a percentage less than 30. We found no correlation of proportion of smudge cells with age (p=0.19) and sex (p=0.76). However there was a significant correlation with the Binet stage (p=0.0002), the CD38 expression (p=0.04) and a negative correlation with the lymphocyte count (p=0,01) (r= -0,38). Conclusion: A low percentage of smudge cells (less than 30%) is associated with high lymphocyte count, advanced Binet stage (B or C) and positive CD38. Simple, accessible and inexpensive, the percentage of smudge cells on a routine blood smear could be a prognostic test available to all patients with CLL especially those in countries with limited resources. Figure 1. Blood smears of patients with CLL. A, B, C : presence of smudge cells (arrows). D : blood smear without smudge cells. Figure 1. Blood smears of patients with CLL. A, B, C : presence of smudge cells (arrows). D : blood smear without smudge cells. Disclosures No relevant conflicts of interest to declare.

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Prognostic and Predictive Significance of Smudge Cell Percentage on Routine Blood Smear in Chronic Lymphocytic Leukemia

Clinical Lymphoma Myeloma & Leukemia ◽

10.1016/j.clml.2014.02.007 ◽

2014 ◽

Vol 14 (6) ◽

pp. 514-517 ◽

Cited By ~ 8

Author(s):

Ajay Gogia ◽

Vinod Raina ◽

Ritu Gupta ◽

Smeeta Gajendra ◽

Lalit Kumar ◽

...

Keyword(s):

Chronic Lymphocytic Leukemia ◽

Blood Smear ◽

Lymphocytic Leukemia ◽

Routine Blood ◽

Cell Percentage

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CLLU1 Gene Expression Level As a Prognostic Parameter in Patients with Chronic Lymphocytic Leukemia

Blood ◽

10.1182/blood.v118.21.4603.4603 ◽

2011 ◽

Vol 118 (21) ◽

pp. 4603-4603

Author(s):

Mustafa Sevinc ◽

Ahmet Emre Eskazan ◽

Aydin Karabulut ◽

Suzin Catal Tatonyan ◽

Emine Gulturk ◽

...

Keyword(s):

B Cells ◽

Chronic Lymphocytic Leukemia ◽

Clinical Course ◽

Lymphocytic Leukemia ◽

Expression Level ◽

Time To Treatment ◽

Prognostic Parameter ◽

Β2 Microglobulin ◽

Staging Systems ◽

The Impact

Abstract Abstract 4603 Background Chronic lymphocytic leukemia (CLL) is the most frequent leukemia in the Western world with an annual incidence of 5/100,000. The clinical course of the disease is highly variable; while some CLL patients experience a stable clinical course that will never affect their morbidity or mortality, some of them will eventually progress and require chemotherapy. In addition to the traditional prognostic markers (e.g. Rai and Binet staging systems), more recently, mutational status of the variable regions of the immunoglobulin heavy chains (IgVH), chromosomal aberrations, CD38 expression and Zeta-chain-associated protein kinase 70 (ZAP-70) expression are used to better determine the prognosis in CLL patients. A novel CLL-specific gene, CLL Up-regulated gene 1 (CLLU1) that uniquely overexpressed in CLL patients, was recently demonstrated. It has been shown that CLLU1 mRNA expression levels in CLL patients predict time to initiation of therapy as well as overall survival (OS), and CLLU1 is highly up-regulated in poor-risk groups. The aim of this study is to investigate the relationship between CLLU1 levels and well known prognostic parameters and, to determine the importance of CLLU1 gene on prognosis and clinical course in our CLL patients. Methods 116 (46 female, 70 male) CLL patients who consecutively visited our outpatient clinic between May 2009 and March 2010 were enrolled in the study. Median age was 60 years (range, 30–87 years). Blood samples were drawn from the patients for CLLU1 determination, and CLLU1 levels were determined by RT-PCR method. CLLU1 expression level was counted both in CLL patients and healthy B cells as the difference between CLLU1 and abl (taken as an house keeping gene) gene. Then, they are transformed as folds which is the ratio between CLLU1 level in CLL patients and that in healthy B cells. Patients with CLLU1 expression exceeding the CLLU1 expression of normal (CD19+) B-cells were taken as positive. Each patient was followed for at least one year for survival data. For the statistical analysis, student’s t-test, Mann-Whitney U test and Pearson correlation were used. p<0.05 was considered as statistical significant. The study was approved by the local research ethics committee, and written informed consent was obtained from the patients. Results There was no relationship between CLLU1 levels and, sex, age, modified RAI and BINET stages, lymphocyte counts and LDH levels at the time of diagnosis. Patients with nodular bone marrow infiltration had lower CLLU1 levels than patients with non-nodular infiltration (57.6 vs 498). Patients with high β2 microglobulin levels had higher CLLU1 levels than the ones with low β2 microglobulin levels (356.7 vs 13.6, p<0.05). ZAP-70 positive patients had higher CLLU1 levels than ZAP-70 negative patients (217.2 vs 10.2, p=0.007) (Figure 1). Among the patients with CD38 levels studied (n=53) CLLU1 levels were higher in patients with CD38 levels above the median value than patients with CD38 levels below the median value (438.4 vs 42.2). CLLU1 levels were higher in cases who needed treatment than cases without treatment. Patients with a shorter time to treatment had higher CLLU1 levels than patients with a longer time to treatment (p=0.028) (Figure 2). Conclusion With a limited number of patients we could demonstrate that CLLU1 levels correlated with β2 microglobulin levels and ZAP-70. Although there were similar findings also with CD38 levels; the association was not statistically significant due to the limited number of cases. Time to treatment was shorter in patients with CLLU1 levels above the median value than patients with CLLU1 levels below the median value. CLLU1 is a promising and specific new prognostic parameter in patients with CLL, and further studies in larger series are needed to define the impact of CLLU1 in the prognosis and clinical course of CLL patients. Disclosure This study was supported by Istanbul University Research Fund. Disclosures: No relevant conflicts of interest to declare.

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The impact of increasing karyotypic complexity and evolution on survival in CLL patients treated with ibrutinib.

Blood ◽

10.1182/blood.2020010536 ◽

2021 ◽

Author(s):

Adam S Kittai ◽

Cecelia R Miller ◽

Daniel Goldstein ◽

Ying Huang ◽

Lynne V. Abruzzo ◽

...

Keyword(s):

Overall Survival ◽

Clonal Evolution ◽

Single Agent ◽

Multivariable Analysis ◽

Progression Free Survival ◽

Continuous Variable ◽

Lymphocytic Leukemia ◽

Karyotypic Analysis ◽

Cytogenetic Abnormalities ◽

The Impact

Complex karyotype defined as ≥3 cytogenetic abnormalities is prognostic of survival in patients treated with ibrutinib or venetoclax in relapsed/refractory (RR) chronic lymphocytic leukemia (CLL). Recent studies re-evaluating this dichotomous variable have shown that higher numbers of cytogenetic abnormalities (i.e. ≥5) have a worse overall survival in patients treated with chemoimmunotherapy. We sought to determine if increasing karyotypic complexity, treated as a continuous variable, was prognostic of survival for patients treated with ibrutinib for CLL. We conducted a retrospective analysis of all patients with CLL treated with single-agent ibrutinib or in combination with an anti-CD20 antibody at our institution. We included 456 patients with both treatment-naïve (TN) and RR disease. Median number of prior therapies was 2 (range 0-13), 30% of patients had del(17p), and 75% were IGHV unmutated. 50% had ≥3 cytogenetic abnormalities including 30% with ≥5. In a multivariable analysis, increasing karyotypic complexity was an independent predictor of shorter progression-free survival (HR 1.07 (95% CI 1.04-1.10), p<0.0001) and overall survival (HR 1.09 (95% CI 1.05-1.12), p<0.0001). Furthermore, we found that presence of clonal evolution determined by cytogenetic analysis at progression was prognostic of subsequent survival (p=0.02). This solidifies karyotypic complexity as an important prognostic factor for CLL patients treated with ibrutinib. Further research should consider sequential karyotypic analysis as a determination of risk of progression and death in patients with CLL.

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