Molecular Remission Using Low-Dose Immunotherapy with Minimal Toxicities for Poor Prognosis IGHV—Unmutated Chronic Lymphocytic Leukemia

Chronic lymphocytic leukemia (CLL) accounts for 10% of hematologic malignancies. CLL is a malignancy of CD5+ B cells and it is characterized by the accumulation of small, mature-appearing neoplastic lymphocytes in the blood, bone marrow, and secondary lymphoid tissues. In the present case, a middle-aged female patient with poor prognosis unmutated IGHV CLL achieved cytogenetic and molecular remission with minimal adverse events following six cycles of low dose recombinant human IL-2 (rIL-2) in combination with low dose targeted venetoclax. Personalized low dose rIL-2 in combination with either lenalidomide or venetoclax mediates natural killer stimulation and is an effective non-toxic immunotherapy administered in the outpatient setting for poor prognosis CLL.

Download Full-text

Mode of Action of the SDF-1/CXCL12 Inhibiting Spiegelmer® Nox-A12 and Its Impact On Chronic Lymphocytic Leukemia (CLL) Cell Motility and Chemosensitization

Blood ◽

10.1182/blood.v120.21.318.318 ◽

2012 ◽

Vol 120 (21) ◽

pp. 318-318

Author(s):

Dirk Zboralski ◽

Julia Hoellenriegel ◽

Christian Maasch ◽

Anna Kruschinski ◽

Jan A. Burger

Keyword(s):

Bone Marrow ◽

Chronic Lymphocytic Leukemia ◽

Stromal Cells ◽

Mode Of Action ◽

Leukemia Cell ◽

Lymphocytic Leukemia ◽

Lymphoid Tissues ◽

Cell Trafficking ◽

Dependent Manner

Abstract Abstract 318 NOX-A12 is a novel Spiegelmer®-based antagonist of SDF-1/CXCL12, a chemokine involved in the regulation of chronic lymphocytic leukemia (CLL) cell trafficking. Spiegelmers® are mirror-image oligonucleotides that are identified to specifically bind to proteins in a manner conceptually similar to antibodies. Unlike aptamers, however, Spiegelmers® are built from the non-natural L-isomer form of nucleotides which confers resistance to the action of nucleases and avoids potential immunogenicity. CXCL12 is constitutively secreted and presented by bone marrow stromal cells (BMSC) via glycosaminoglycans (GAG) and acts as a homing factor for normal and malignant hematopoietic cells to the bone marrow (BM) and secondary lymphoid tissues via CXCR4 receptors that are expressed at high levels on circulating CLL cells. The microenvironment in the BM and secondary lymphoid tissues, in particular the CXCL12-CXCR4 axis, favors survival and chemotherapy-resistance of leukemic cells. We therefore investigated the effects of NOX-A12 in an in vitro co-culture system to model the interaction of CLL cells with their microenvironment. Surprisingly we observed that NOX-A12 increased pseudoemperipolesis in vitro, i.e. spontaneous leukemia cell migration beneath BMSC. Interestingly, this NOX-A12 induced trans-migration of CLL cells was completely inhibited by the CXCR4 antagonist AMD3100, suggesting a CXCL12/CXCR4 dependent mechanism. We postulated that this observation might result from a direct effect of NOX-A12 on CXCL12 release by the stromal cells. Therefore, we investigated this hypothesis in different BMSC lines (MS-5, R15C, and TSt-4) and we found that NOX-A12 induced a significant CXCL12 release in all three tested cell lines. We asked whether this NOX-A12 dependent increase of CXCL12 of BMSCs is due to release from either intracellular or extracellular storages. Intracellular staining of CXCL12 using flow cytometry did not reveal significant changes when BMSCs were incubated with NOX-A12. Furthermore, the transcription of CXCL12 was not found to be altered after NOX-A12 incubation over a period of three days as shown by quantitative RT-PCR. Rather, CXCL12 is released from extracellular storages of BMSCs. First hints were obtained through a rapid CXCL12 release within five minutes of incubation with NOX-A12. To confirm that CXCL12 is bound to the extracellular surface (by GAGs like heparin) and is being detached by NOX-A12 we first incubated BMSCs with NOX-A12, followed by a wash step and the addition of recombinant CXCL12. Recombinant CXCL12 was bound by BMSCs that were pre-incubated with NOX-A12 but not with a non-functional control (revNOX-A12), indicating that NOX-A12 strips off CXCL12. To corroborate the findings we incubated the BMSCs with heparin which also led to the release of CXCL12 in a dose dependent manner. Of note, the EC50 of heparin regarding CXCL12 release was much higher compared to the EC50 of NOX-A12 (≈ 12 μM vs. 5 nM) revealing the high affinity of NOX-A12 to CXCL12. The competition of NOX-A12 with heparin regarding CXCL12 binding was confirmed by Biacore experiments. Based on these findings, we developed a novel adapted co-culture approach to examine the ability of NOX-A12 to chemosensitize CLL cells. In this setting, we first strip off CXCL12 from BMSCs by NOX-A12 and subsequently add CLL cells which will be either non-treated or treated with chemotherapy (fludarabine combined with bendamustine). We found that NOX-A12 slightly decreased CLL cell viability. As expected, a strong viability decrease was observed with chemotherapy, which could be even further decreased by the combination with NOX-A12, suggesting synergistic effects. In conclusion, we propose that NOX-A12's mode of action is the release of extracellular bound CXCL12 and its subsequent inhibition. Since CXCL12 induces leukemia cell trafficking and homing to tissue microenvironment and also favors leukemia cell survival, we believe that targeting CXCL12 is an attractive approach to remove the protective effects of CXCL12-secreting BMSCs in order to sensitize CLL cells for subsequent chemotherapy. Thus, NOX-A12 represents a very promising agent to significantly improve the treatment of CLL. The compound is currently being tested in a Phase IIa study in relapsed CLL patients. Disclosures: Zboralski: NOXXON Pharma AG, Berlin, Germany: Employment. Maasch:NOXXON Pharma AG: Employment. Kruschinski:NOXXON Pharma AG: Employment. Burger:NOXXON Pharma AG: Consultancy, Research Funding.

Download Full-text

Autologous and allogeneic bone marrow transplantation for poor prognosis patients with B-cell chronic lymphocytic leukemia

Blood ◽

10.1182/blood.v82.4.1366.1366 ◽

1993 ◽

Vol 82 (4) ◽

pp. 1366-1376 ◽

Cited By ~ 125

Author(s):

SN Rabinowe ◽

RJ Soiffer ◽

JG Gribben ◽

H Daley ◽

AS Freedman ◽

...

Keyword(s):

Bone Marrow ◽

Chronic Lymphocytic Leukemia ◽

B Cell ◽

Poor Prognosis ◽

Lymphocytic Leukemia ◽

High Dose ◽

Allogeneic Bone ◽

Tumor Doubling Time ◽

Cell Chronic Lymphocytic Leukemia ◽

Patients With Poor Prognosis

Abstract Twenty patients with poor prognosis B-cell chronic lymphocytic leukemia (B-CLL) underwent uniform high-dose chemoradiotherapy followed by rescue with multiple monoclonal antibody-purged autologous bone marrow (BM) (12 patients) or T-cell-depleted allogeneic BM from HLA-identical siblings (8 patients) in a pilot study to assess the feasibility of BM transplantation (BMT) in this disease. All had poor prognosis disease by either staging, BM pattern, tumor doubling time criteria, or cytogenetics. All patients achieved remission criteria (defined as < or = 2 adenopathy, absence of splenomegaly, < or = 20% of the intertrabecular space involved on BM biopsy) before BMT. Despite the use of fludarabine, a median of three treatment regimens were required to achieve BMT eligibility. After BMT, all patients achieved complete hematologic engraftment. Toxicities were not significantly different between autologous versus allogeneic BMT. Two toxic deaths were observed. Of 19 evaluable patients, 17 clinical complete clinical remissions (89%) were observed, with 2 patients (1 allogeneic and 1 autologous) exhibiting persistent BM disease. Complete clinical remissions were documented at the phenotypic and molecular level for the majority of patients in whom dual fluorescence for CD5 and CD20 (15 of 15; 100%) and Ig gene rearrangements (11 of 14; 79%) were performed. Although long-term follow-up is needed to assess any potential impact on the disease-free and overall survival of these patients, this study shows the feasibility of using high-dose chemoradiotherapy and BMT in patients with poor prognosis B-CLL.

Download Full-text

Chronic lymphocytic leukemia focus in the context of a cardiac mass in a pretreated patient: an exceptional incidental finding

Tumori Journal ◽

10.1177/0300891620909421 ◽

2020 ◽

Vol 106 (6) ◽

pp. NP29-NP32

Author(s):

Ginevra Lolli ◽

Alessandro Broccoli ◽

Vittorio Stefoni ◽

Lisa Argnani ◽

Ornella Leone ◽

...

Keyword(s):

Chronic Lymphocytic Leukemia ◽

Cardiac Tumor ◽

Cardiac Involvement ◽

Incidental Finding ◽

Hematologic Malignancies ◽

Atrial Myxoma ◽

Cardiac Mass ◽

Lymphocytic Leukemia ◽

Lymphoid Tissues ◽

Clonal Proliferation

Background: B-cell chronic lymphocytic leukemia (B-CLL) is a lymphoproliferative disorder consisting of clonal proliferation and accumulation of small, mature, CD5-positive B-lymphocytes in the blood, bone marrow, and lymphoid tissues. Among extranodal localizations, cardiac involvement is extremely rare: to our knowledge, there are no findings reported in the literature of concomitant B-CLL diagnosis in the context of atrial myxoma (so-called collision tumours) and the best strategy to treat these malignancies is unclear. Case report: We report the case of a 67-year-old woman diagnosed with B-CLL and atrial myxoma. Our patient was cardiologically symptomless and the cardiac mass was an incidental finding. The cardiac tumor appeared several years after B-CLL diagnosis. Histologic examination of the cardiac mass, removed in the suspicion of an atrial myxoma, revealed a lymphoid focus of B-CLL. The patient underwent surgery and subsequent systemic therapy for B-CLL. Conclusions: The concomitant presence of B-CLL in the context of an atrial myxoma is extremely rare. The best strategy to treat these cardiac hematologic malignancies is unclear.

Download Full-text

Autologous and allogeneic bone marrow transplantation for poor prognosis patients with B-cell chronic lymphocytic leukemia

Blood ◽

10.1182/blood.v82.4.1366.bloodjournal8241366 ◽

1993 ◽

Vol 82 (4) ◽

pp. 1366-1376 ◽

Cited By ~ 3

Author(s):

SN Rabinowe ◽

RJ Soiffer ◽

JG Gribben ◽

H Daley ◽

AS Freedman ◽

...

Keyword(s):

Bone Marrow ◽

Chronic Lymphocytic Leukemia ◽

B Cell ◽

Poor Prognosis ◽

Lymphocytic Leukemia ◽

High Dose ◽

Allogeneic Bone ◽

Tumor Doubling Time ◽

Cell Chronic Lymphocytic Leukemia ◽

Patients With Poor Prognosis

Twenty patients with poor prognosis B-cell chronic lymphocytic leukemia (B-CLL) underwent uniform high-dose chemoradiotherapy followed by rescue with multiple monoclonal antibody-purged autologous bone marrow (BM) (12 patients) or T-cell-depleted allogeneic BM from HLA-identical siblings (8 patients) in a pilot study to assess the feasibility of BM transplantation (BMT) in this disease. All had poor prognosis disease by either staging, BM pattern, tumor doubling time criteria, or cytogenetics. All patients achieved remission criteria (defined as < or = 2 adenopathy, absence of splenomegaly, < or = 20% of the intertrabecular space involved on BM biopsy) before BMT. Despite the use of fludarabine, a median of three treatment regimens were required to achieve BMT eligibility. After BMT, all patients achieved complete hematologic engraftment. Toxicities were not significantly different between autologous versus allogeneic BMT. Two toxic deaths were observed. Of 19 evaluable patients, 17 clinical complete clinical remissions (89%) were observed, with 2 patients (1 allogeneic and 1 autologous) exhibiting persistent BM disease. Complete clinical remissions were documented at the phenotypic and molecular level for the majority of patients in whom dual fluorescence for CD5 and CD20 (15 of 15; 100%) and Ig gene rearrangements (11 of 14; 79%) were performed. Although long-term follow-up is needed to assess any potential impact on the disease-free and overall survival of these patients, this study shows the feasibility of using high-dose chemoradiotherapy and BMT in patients with poor prognosis B-CLL.

Download Full-text

Three Cases of Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma (CLL/SLL) Involving Cerebrospinal Fluid (CSF)

American Journal of Clinical Pathology ◽

10.1093/ajcp/aqz121.017 ◽

2019 ◽

Vol 152 (Supplement_1) ◽

pp. S111-S112

Author(s):

Anna Shestakova ◽

Jayne Healey ◽

Sheila (Xiaohui) Zhao ◽

Sherif Rezk ◽

Jamie Nakagiri

Keyword(s):

Bone Marrow ◽

Flow Cytometry ◽

Cerebrospinal Fluid ◽

Chronic Lymphocytic Leukemia ◽

Bone Marrow Involvement ◽

Lymphocytic Leukemia ◽

Lymphoid Tissues ◽

Proliferative Index ◽

Cns Involvement ◽

Ki 67

Abstract Background Chronic lymphocytic leukemia (CLL) is a clonal disorder of B lymphocytes, characterized by proliferation of small mature lymphocytes involving the blood, bone marrow, and lymphoid tissues. CLL can rarely involve the central nervous system (CNS), either by involving brain parenchyma or cerebrospinal fluid (CSF). We present a series of three cases with clinically significant involvement of the CNS with CLL. Results During the past 2 years, our medical center managed three patients with CLL who presented with symptomatic CNS involvement, as determined by flow cytometry. The immunophenotypic profile was that of a typical CLL with light chain restricted small B cells positive for CD20 (dim) and coexpressing CD5 and CD23. In addition, two patients had brain involvement by SLL that was confirmed by brain biopsy. Notably, the brain lesions had a mildly elevated Ki-67 proliferative index (10%-30%). Bone marrow was involved in two patients, showing nodular, interstitial, and diffuse patterns. Bone marrow involvement ranged from 60% to 80% and showed very low Ki-67 proliferative index. None of the patients had features suggestive of a CLL transformation. FISH was performed on either bone marrow or CSF and demonstrated that patient 1 had Del11q(ATM) and Dell13q, patient 2 had trisomy 12, and patient 3 had del17(TP53) and IGH rearrangement. All of the patients showed persistent CSF involvement, ranging from 4 to 12 weeks, requiring aggressive treatment with intrathecal chemotherapy. At the end of treatment, all of the patients were clear of CNS involvement as judged by flow cytometry of CSF. Conclusion We report three patients who had persistent involvement of CSF. Only one patient had del17(TP53), a cytogenetic feature that is associated with high-risk CLL. It would be interesting to study clonal evolution of CLL to understand the mechanisms that underlie involvement of the CNS.

Download Full-text

Faculty Opinions recommendation of Somatic MED12 mutations are associated with poor prognosis markers in chronic lymphocytic leukemia.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.725360440.793539257 ◽

2017 ◽

Author(s):

Alistair Williams

Keyword(s):

Chronic Lymphocytic Leukemia ◽

Poor Prognosis ◽

Lymphocytic Leukemia

Download Full-text

Aberrant Expression of TLR2, TLR7, TLR9, Splicing Variants of TLR4 and MYD88 in Chronic Lymphocytic Leukemia Patients

Journal of Clinical Medicine ◽

10.3390/jcm10040867 ◽

2021 ◽

Vol 10 (4) ◽

pp. 867

Author(s):

Katarzyna Skorka ◽

Paulina Wlasiuk ◽

Agnieszka Karczmarczyk ◽

Krzysztof Giannopoulos

Keyword(s):

Bone Marrow ◽

Chronic Lymphocytic Leukemia ◽

Cytotoxic T Cells ◽

Lymphocytic Leukemia ◽

Aberrant Expression ◽

Downstream Signaling ◽

Splicing Variants ◽

High Level ◽

Time To First Treatment ◽

First Time

Functional toll-like receptors (TLRs) could modulate anti-tumor effects by activating inflammatory cytokines and the cytotoxic T-cells response. However, excessive TLR expression could promote tumor progression, since TLR-induced inflammation might stimulate cancer cells expansion into the microenvironment. Myd88 is involved in activation NF-κB through TLRs downstream signaling, hence in the current study we provided, for the first time, a complex characterization of expression of TLR2, TLR4, TLR7, TLR9, and MYD88 as well as their splicing forms in two distinct compartments of the microenvironment of chronic lymphocytic leukemia (CLL): peripheral blood and bone marrow. We found correlations between MYD88 and TLRs expressions in both compartments, indicating their relevant cooperation in CLL. The MYD88 expression was higher in CLL patients compared to healthy volunteers (HVs) (0.1780 vs. 0.128, p < 0.0001). The TLRs expression was aberrant in CLL compared to HVs. Analysis of survival curves revealed a shorter time to first treatment in the group of patients with low level of TLR4(3) expression compared to high level of TLR4(3) expression in bone marrow (13 months vs. 48 months, p = 0.0207). We suggest that TLRs expression is differentially regulated in CLL but is similarly shared between two distinct compartments of the microenvironment.

Download Full-text

A novel adoptive transfer model of chronic lymphocytic leukemia suggests a key role for T lymphocytes in the disease

Blood ◽

10.1182/blood-2010-12-324210 ◽

2011 ◽

Vol 117 (20) ◽

pp. 5463-5472 ◽

Cited By ~ 120

Author(s):

Davide Bagnara ◽

Matthew S. Kaufman ◽

Carlo Calissano ◽

Sonia Marsilio ◽

Piers E. M. Patten ◽

...

Keyword(s):

Chronic Lymphocytic Leukemia ◽

T Lymphocytes ◽

Adoptive Transfer ◽

Severe Combined Immunodeficiency ◽

Immune Surveillance ◽

Lymphocytic Leukemia ◽

Unknown Etiology ◽

Lymphoid Tissues ◽

Transfer Model

AbstractChronic lymphocytic leukemia (CLL) is an incurable adult disease of unknown etiology. Understanding the biology of CLL cells, particularly cell maturation and growth in vivo, has been impeded by lack of a reproducible adoptive transfer model. We report a simple, reproducible system in which primary CLL cells proliferate in nonobese diabetes/severe combined immunodeficiency/γcnull mice under the influence of activated CLL-derived T lymphocytes. By cotransferring autologous T lymphocytes, activated in vivo by alloantigens, the survival and growth of primary CFSE-labeled CLL cells in vivo is achieved and quantified. Using this approach, we have identified key roles for CD4+ T cells in CLL expansion, a direct link between CD38 expression by leukemic B cells and their activation, and support for CLL cells preferentially proliferating in secondary lymphoid tissues. The model should simplify analyzing kinetics of CLL cells in vivo, deciphering involvement of nonleukemic elements and nongenetic factors promoting CLL cell growth, identifying and characterizing potential leukemic stem cells, and permitting preclinical studies of novel therapeutics. Because autologous activated T lymphocytes are 2-edged swords, generating unwanted graph-versus-host and possibly autologous antitumor reactions, the model may also facilitate analyses of T-cell populations involved in immune surveillance relevant to hematopoietic transplantation and tumor cytoxicity.

Download Full-text