w w w . r b h h . o r g
Revista
Brasileira
de
Hematologia
e
Hemoterapia
Brazilian
Journal
of
Hematology
and
Hemotherapy
Special
article
Diagnosis
and
treatment
of
chronic
lymphocytic
leukemia:
recommendations
from
the
Brazilian
Group
of
Chronic
Lymphocytic
Leukemia
Celso
Arrais
Rodrigues
a,b,∗,
Matheus
Vescovi
Gonc¸alves
a,c,
Maura
Rosane
Valério
Ikoma
d,
Irene
Lorand-Metze
e,
André
Domingues
Pereira
b,
Danielle
Leão
Cordeiro
de
Farias
f,
Maria
de
Lourdes
Lopes
Ferrari
Chauffaille
a,c,
Rony
Schaffel
g,
Eduardo
Flávio
Oliveira
Ribeiro
h,
Talita
Silveira
da
Rocha
i,j,
Valeria
Buccheri
k,
Yuri
Vasconcelos
l,
Vera
Lúcia
de
Piratininga
Figueiredo
m,
Carlos
Sérgio
Chiattone
j,n,
Mihoko
Yamamoto
a,
on
behalf
of
the
Brazilian
Group
of
Chronic
Lymphocytic
Leukemia.
aUniversidadeFederaldeSãoPaulo(UNIFESP),SãoPaulo,SP,Brazil
bHospitalSírioLibanês,SãoPaulo,SP,Brazil
cFleuryMedicinaeSaúde,SãoPaulo,SP,Brazil
dHospitalAmaralCarvalho,Jaú,SP,Brazil
eUniversidadeEstadualdeCampinas(UNICAMP),SãoPaulo,SP,Brazil
fUniversidadeFederaldeGoiás(UFG),Goiânia,GO,Brazil
gUniversidadeFederaldoRiodeJaneiro(UFRJ),RiodeJaneiro,RJ,Brazil
hHospitalSantaLúcia,Brasília,DF,Brazil
iA.CCamargoCancerCenter,SãoPaulo,SP,Brazil
jSantaCasadeMisericórdiadeSãoPaulo,SãoPaulo,SP,Brazil
kInstitutodoCâncerdoEstadodeSãoPaulo(ICESP),SãoPaulo,SP,Brazil
lInstitutoGoianodeOncologiaeHematologia(INGOH),Goiânia,GO,Brazil
mInstitutodeAssistênciaMédicaaoServidorPúblicoEstadual(IAMSPE),SãoPaulo,SP,Brazil
nHospitalSamaritano,SãoPaulo,SP,Brazil
a
r
t
i
c
l
e
i
n
f
o
Articlehistory:
Received19July2016 Accepted19July2016
Availableonline20August2016
Keywords:
Chroniclymphocyticleukemia
a
b
s
t
r
a
c
t
Chronic lymphocytic leukemiais characterized by clonal proliferation andprogressive accumulationofB-celllymphocytesthattypicallyexpressCD19+,CD5+andCD23+.The lym-phocytesusuallyinfiltratethebonemarrow,peripheralblood,lymphnodes,andspleen.The diagnosisisestablishedbyimmunophenotypingcirculatingB-lymphocytes,andprognosis isdefinedbytwostagingsystems(RaiandBinet)establishedbyphysicalexaminationand bloodcounts,aswellasbyseveralbiologicalandgeneticmarkers.Inthisupdate,wepresent therecommendationsfromtheBrazilianGroupofChronicLymphocyticLeukemiaforthe
∗ Correspondingauthorat:UniversidadeFederaldeSãoPaulo(UNIFESP),RuaDoutorDiogodeFaria,824,VilaClementino,04037-002São
Paulo,SP,Brazil.
E-mailaddress:celsoarrais@gmail.com(C.A.Rodrigues).
http://dx.doi.org/10.1016/j.bjhh.2016.07.004
Immunophenotyping Cytogenetics Staging Prognosis
diagnosisandtreatmentofchroniclymphocyticleukemia.Thefollowingrecommendations arebasedonanextensiveliteraturereviewwiththeaimofcontributingtomoreuniform patientcareinBrazilandpossiblyinothercountrieswithasimilarsocial–economicprofile. ©2016Associac¸ ˜aoBrasileiradeHematologia,HemoterapiaeTerapiaCelular.Published byElsevierEditoraLtda.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
Chroniclymphocyticleukemia(CLL)isthemostcommontype ofleukemiainadultsandaccountsforapproximately30%of allleukemiasinthispopulationgroup.Theannualincidence ofCLLintheUnitedStatesisapproximately4.6cases/100,000 personsperyear.Themedianageatdiagnosisis71years,and over95%ofpatientsareolderthan50years.1CLLisless fre-quentinindividualswithAsianandMiddleEasternancestry.2 Itisslightlymorecommoninmales,witha1.25:1male:female ratio.3
TheetiologyofCLLisstillunknown.Geneticand environ-mentalfactorsmayhaveanimportantrole.Thelowfrequency ofCLL inindividualswithEasternethnicity andthehigher incidenceinfamily members(5–10%)than othermature B-cellneoplasmsreflectthepotentialimportanceofagenetic factor.4CLL usedtobeconsidered adiseaseofnaïveB-cell lymphocyteshoweverrecentstudiessuggestthereisa post-germinalcenterorigin.5
Theclinicalpresentation atdiagnosisis extremely vari-able.Approximately60%ofpatientsare asymptomatic,and the disease may besuspected aftera routineblood count. Whensymptomatic,patientspresentwithvaguesymptoms offatigueorweakness.6
Patientsusuallyhaveagoodperformancestatusat diag-nosis.Lymphadenopathymaybeobservedinapproximately 80% ofcasesoftenwithcervical and axillary lymphnodes bilaterallyandsymmetricallybeingaffected.Splenomegalyis usuallymildtomoderateandisobservedinapproximately 50%ofcases;hepatomegalyislessfrequent.7,8Althoughrare atdiagnosis,asthe diseaseprogresses patientscanhaveB symptoms, whichare defined asunintentionalweight loss of 10% or more within six month, fever above 38◦C for
twoormoreweekswithoutotherevidenceofinfection,and night sweats for more than a month without evidence of infection.
Anemia and thrombocytopenia may be observed in 15–30% of patients. They generally result from bone mar-row infiltration, although they can also be related to an autoimmune phenomenon [autoimmune hemolytic ane-mia(AIHA), immunethrombocytopenia (ITP),and immune neutropenia].7,8 Lymphocytosis is always present, but the absolutenumberoflymphocytesisextremelyvariable.Ina recent analysis by the Brazilian CLL Registry (unpublished data),themedianhemoglobinlevelwas13g/dL,plateletcount was180×109/L,whitebloodcellcountwas35×109/L(range:
7–900×109/L),andlymphocytecountwas27×109/L(range:
5.4–891.0×109/L)among1612BrazilianpatientswithCLL.
RichterSyndrome,whichisdefinedasthetransformation ofCLL into anaggressivelymphoma (most commonly dif-fuselargeB-celllymphoma)occursin5–10%ofallcases.The
syndromemaybesuspectediftherearesignsofaggressive disease,suchasimpairmentofperformancestatus,presence ofBsymptoms,andrapidincreaseinthesizeoflymphnodes.1 Infections are common complications of CLL due to the deficiency of both the cellular and humoral immune system. Tcells,naturalkillercells,neutrophils, and mono-cytes/macrophages may be significantly compromised.9,10 Furthermore, hypogammaglobulinemia isnot rare and can becomemoreintenseafterCLL treatment.11 Although pre-ventiveuseofintravenousimmunoglobuliniscontroversial,it maybenecessaryiftherearesevererecurrentinfections.12,13 Bacterial infections are common even prior to the treat-ment of CLL. The most common agents are Streptococcus pneumoniae,Staphylococcusaureus,andHaemophilusinfluenzae. Responsetoimmunizationisvariable,andvaccinationshould becarriedoutearlyinthediseasetoobtainthebestresults. Livevirusvaccinesshouldbeavoided.14Viralinfectionscan also occur,and specialattention should bepaid toherpes zosterreactivation.Fungalinfectionsoropportunistic bacte-ria,however,are rareinuntreatedCLL.Theintroductionof immunosuppressivedrugssignificantlyincreasestheriskfor cytomegalovirusinfections,aswellasPneumocystisjiroveci, Lis-teriamonocytogenes,andfungalinfections.14
Secondarymalignancies,suchasskinandlungcancer,are morecommoninCLLpatientsthaninthegeneralpopulation, whichmaybeduetoimmunodeficiency.20
Diagnosis
CLL is defined by the presence of at least 5×109/L
CD5+/CD23+ monoclonalBlymphocytes inperipheralblood
(PB)formorethanthreemonths,21with immunophenotyp-ing ofPB being sufficient fordiagnosis. Small lymphocytic lymphoma is distinguishable only by its non-leukemic appearanceandrequiresthepresenceoflymphadenopathy and/orsplenomegalyandaclonalBlymphocytecount(CLL immunophenotype)thatdoesnotexceed5×109/LinthePB.22
CLL-typemonoclonalBlymphocytosis(MBL)isdefinedby thepresenceoffewerthan5×109/LB-cellswiththeCLL
phe-notypeinthePBintheabsenceoflymphadenopathy,spleen or hepatic enlargement, cytopenias, and disease-related symptoms.23 In the 2016 revision of the WHO classifica-tionoflymphoidneoplasms,adistinctionbetweenlow-count (<0.5×109/L)and high-countMBL(>0.5×109/L)was
recom-mended because low-count MBL has a low probability of progressingto CLL,whilehigh-count MBL may progressat arateof1–2%peryear.24,25 TheincidenceofMBLamonga healthypopulationmayvarydependingonthesensitivityof thediagnosticmethodbutcanreachupto12%.26
Morphologicalevaluationofabloodsmearshouldshow smallmaturelymphocyteswithanarrowcytoplasm,adense nucleuswithpartiallyaggregatedchromatin,andtheabsence ofvisiblenucleoli.Thepercentageofprolymphocytesinblood lymphocytesmaybe<55%.Ahigherpercentagewouldfavor thediagnosisofprolymphocyticleukemia.Gumprecht shad-owsarefrequentlyfoundonCLLPBslides.22
CLLlymphocytesexhibitacharacteristicprofileofCD19+,
CD5+,CD23+,CD20+low,CD200+,CD22+low/negative,CD79b+
low/negative,CD43+low,sIg+orsIg+low,sIgM+low,CD11c+
low/negative,FMC7negative,CD10negative,andCD103 neg-ative.
Matutesetal.27proposedascoringsystemforthe diagno-sisofCLL(modifiedin1997)28basedontheevaluationoffive parameters:CD5+(1point),CD23+(1point),FMC7negative(1
point),weakintensityofkappa/lambdachains(1point),and weakornegativeCD22/CD79b(1point).TheCLLscoreranges between5(typicalCLLcases)and3(lesstypicalCLLcases). Scoresof0–2excludethediagnosisofCLL.
ClassicallaboratorymarkersforadverseprognosesofCLL are CD38,29 CD49d,30 and ZAP-70.31 Thecut-off values for CD49dandCD38areatleast30%,whilethecut-offforZAP-70 is not clear and technically controversial.32 The expres-sionsofsomemarkers, suchasCD305 (LAIR-1),CCR6,and CXCR5arealsoassociatedwithsomehigh-riskchromosomal abnormalities.33
RecommendationsoftheBrazilianGroupofCLLgroupfor diagnosis
1) Complete blood count and differential white blood cell count;
2) Morphologicalevaluationofabloodsmear;
3) PB immunophenotyping: atleast a 4-color panelof the fluorochromesFITC,PE,PerCPorPerCPCy5.5,andAPC per-formedaccordingtotheconsensusoftheBrazilianGroup of Flow Cytometry (GBCFLUX) for Chronic Lymphopro-liferativeDisorders(in press).Thispanelshouldinclude onescreeningtube(CD8/Lambda,CD56/Kappa,CD19/CD4, CD3) and two diagnostic tubes, including CD45, CD20, CD19,CD5, CD79b, CD23, CD19, and CD200.The Brazil-ianGroupofCLLalsorecommendstwoadditionaltubes forprognosticand minimal residualdisease (MRD) pur-poses,includingCD38,CD305,CD19,CD49d,CD81,CD43, CD19,andsIgM.ZAP-70isconsideredanoptional progno-sticmarker.
Panels using six, eight, or more colors should use the samemarkersinappropriatecombinations.TheEuroflow group34 designed an 8-color panel of monoclonal anti-bodies(MoAbs)toimprovediagnosisandtodifferentiate CLLfromotherBcelllymphoproliferativedisorders.They includedallMoAbsproposedbyMatuteswiththe excep-tion of FMC7 and CD22, and they incorporated other markers such as CD43, CD81, CD38, CD20, and CD200. CD200isparticularly useful fordifferentiatingCLL from mantlecelllymphoma.
4) BonemarrowbiopsyandaspirationareNOTrecommended for routine CLL diagnosis. This procedure may be per-formedinpatientswho willparticipateinclinical trials and/orpatientswithpersistentcytopeniasaftertreatment todifferentiateleukemicinfiltrationfromtherapy-related toxicity.Thebonemarrowsmearshouldbecharacterized bythepresenceofCLLcells,thepercentageofwhichis typ-icallyabove30%.Infiltrationinabonemarrowbiopsymay haveanodular,interstitial,ordiffusegrowthpattern. 5) Imaging techniques, such as ultrasound, computed
tomography, magneticresonance imaging, and positron emissiontomography-CT(PET-CT)scanning,areNOT rec-ommendedforroutineCLLdiagnosisorstaging.
Prognosis
Twoclinicalstagingsystems(RaiandBinet)wereintroduced inthe1970sandarestillwidelyused.Theyareeasytoapply intheclinicalpractice,basedonlyonclinicaldata,andtake into accountlymphnode,spleen,andliverinvolvement,as wellasthepresenceofcytopenias(anemiaand thrombocy-topenia)(Table1).Somepatientsinthelow-riskgroup(0–1Rai andBinetA)may,however,exhibitrapiddiseaseprogression, whileothersremaininastablediseaseconditionformany years.7,8Otherprognosticfactorshavebeenresearchedinan attempttopredictdiseaseevolutionbytakingintoaccount other clinicaland biologicalprognosticfactors.Unfavorable prognosticfactorsincludemalegender,aninitialwhiteblood cellcountabove35×109/L,lymphocytedoublingtime(LDT)
Table1–Clinicalstagingandsurvival.110
BINETstagingsystem
Stage Risk Characteristics %ofcases
A Low <threeenlargednodesiteswithoutanemiaorthrombocytopenia 63
B Intermediate ≥threeenlargednodesiteswithoutanemiaorthrombocytopenia 30
C High Presenceofanemiaand/orthrombocytopeniaa 7
RAIstagingsystem
Stage Risk Characteristics
0 Low Lymphocytosis
I Intermediate Lymphocytosis+nodeenlargement
II Intermediate Lymphocytosis+palpablespleenand/orliver
III High Lymphocytosis+anemiab
IV High Lymphocytosis+thrombocytopeniab
a Anemia:Hb<10g/dL;thrombocytopenia:<100×109/L. b Anemia:Hb<11g/dL;thrombocytopenia:<100×109/L.
moresensitivethan clinical stagingfordeterminingtumor burdenandpredictingdiseaseprogression.
Immunoglobulin heavy chain variable region (IGHV) mutation status has an important role in CLL progno-sis. Mutated IGHV is related toan indolent clinical course and a ‘non-mutated’ state with a moreaggressive disease progression.39,40However,determiningIGHVmutationstatus involvesexpensiveandlabor-intensivemoleculartechniques, whichhaslimiteditsuseinclinicalpractice.
Chromosomal abnormalities have an important role in establishingCLLprognosis.Wheneverpossible,aG-banding karyotypeshouldbeperformedbecausepatientswith com-plexaberrationsoftenpresentunfavorableoutcomes.Given thedifficultyinobtainingabnormalmetaphases,fluorescence
insituhybridization(FISH)ismoreefficientforfindingmajor geneticabnormalitiesinCLL.UsingFISH,cytogeneticchanges havebeenfoundin80%ofcases41;trisomy12wasreportedin 10–20%ofcases,deletionof13q[del(13q14.1)]wasreported inapproximately 55% ofcases, deletion of11q [del(11q22-23)] was reported in 10–25%of cases, and deletion of 17p [del(17p)](P53locus)wasreportedin5–10%ofcases.42While del(13q14.1)isrelatedtoamorefavorableprognosis,the asso-ciationbetweentrisomy12andprognosisisstillnotclearly defined,32anddel(11q22-23)associatedwithbulkydiseaseis relatedtoamoreunfavorableoutcome. Chemoimmunother-apywithpurineanalogsseemstoovercomethedel(11q22-23) prognosticeffect.41,43
Inapproximately7%ofcases,del(17p)isfoundat diagno-sis.Itisacytogenetic aberrationassociatedwiththeworst CLLprognosisandhasledclinicianstochangetheirfirst-line treatment.41However,notallpatientswithdel(17p13)require therapyatthetimeofdiagnosis.Onlyapproximately50%of treatment-naïveCLLpatientswithdel(17p13)developed pro-gressivediseasethatrequiredtherapywithin12–18months, whiletheotherhalfhadarelativelystablediseaseextending outto70monthsoffollow-up.44
Using Sanger sequencing, several studies reported that monoallelicmutationsinTP53areassociatedwithpoor prog-nosis in CLL and resistance to standard therapy.45,46 TP53 disruption (either by mutation or deletion) is present in
approximately15%ofpatients,andsomehaveboththeTP53
mutationanddel(17p13),asdetectedbyFISH.Somehaveno
TP53mutationbuthavedel(17p13)basedonFISHanalysis,and some(3–5%)havetheTP53mutationbutnodel(17p13)based onFISH.Importantly,thesepatientshadashortOSthatwas comparabletothe OSofpatientswith del(17p13)based on interphaseFISH.46–48Lessthan10%ofpatientspresentwith aTP53mutationatdiagnosis,whilethemutationispresent inupto50%ofcasesinpretreatedcohorts,includingcasesof Richter’stransformation.49
Clone size according to FISH isalso extremely relevant toCLL.Asrecentlyshown,patientswith≤20%17pdeletion
nucleihadalongermediantimetofirsttreatment(TTFT)and befferoverallsurvival(OS)fromthedateofthefirstFISHstudy (44monthsand11years,respectively)andweremorelikelyto haveanIGHVmutation.50
Despitethelackofdisease-definingmolecularalterations in CLL, somerecurrent somatic gene mutations, including mutationsinTP53,ATM,NOTCH1,SF3B1,BIRC3genes,and oth-ers,havebeendescribedasimportantprognosticmarkersand arepotentialtherapeutictargets.However,onlyTP53hasbeen consistentlydescribedasaclearhigh-riskmarkeroftherapy refractorinessand earlyrelapsetodate,andpatients could benefitfromdifferenttreatmentapproaches.25
More recently, the German CLL Study Group proposed the CLL International Prognostic Index IPI (CLL-IPI), which combines the most important genetic risk factors (IGHV, del(17p)/TP53mutations)withclinicalstage,age,andbeta-2 microglobulinlevel.51
RecommendationsoftheBrazilianGroupofCLLfor prognosisstratification
Therecommendationsaretoinvestigatethedel(17p13) detec-tionwithFISHandtestfortheTP53mutationbeforeinitiating first-linetreatment.Wheneverpossible,testingforthemost frequentgeneticaberrations,suchasdel(13q),del(11q),+12,
investigatedbyFISHbeforeinitiatinganewtreatmentbecause theremaybeclonalselectionafterthefirsttreatmentthatmay requireachangeinthetreatmentparadigm.
Overviewofminimalresidualdisease
Minimalresidualdisease(MRD)evaluationafterthreeandsix cyclesoftherapyregimens andthreemonthsaftertheend oftreatmentseemstobeanimportantoutcomepredictorfor CLLtreatment,andithasbeenincreasinglyusedin conjunc-tionwiththemoretraditionalendpointsofprogression-free survival(PFS)andOS.52,53
MRD is also an important predictor of outcome after hematopoietic stem cell transplantation (HSCT). MRD-negativestatus12monthsafterHSCThasahighprognostic significance.54However,thistimepointmustbevalidatedin prospectiveclinicaltrials.
Both immunoglobulin heavy chain (IgH)-PCR and flow cytometry can be used to asses MRD. In the European ResearchInitiativeon CLL (ERIC)study, theflow cytometry approachwasidentifiedandvalidatedtobereliablein clin-ical trials and the clinical practice. The use of the MoAb CD19/CD5/kappa/lambdacombinationmaybeimportantfor identifyingcasesthatdonotrequire extensiveanalysisfor MRDdetection.ThesecasesmusthaveaCD19+cellpercentage
>9%oftotalleukocytes,aCD19+:ratio<0.04:1or>61:1,and
incaseswithsufficientCD5+Bcellsforenumeration,>82%ofB
cellsco-expressingaCD19+CD5+:ratioof<0.05:1or>32:1or
>54%ofCD19+CD5+cellslackingsurfaceimmunoglobulin.55 The initial ERIC recommendations were based on a 4-color panel of monoclonal antibodies (FITC/PE/PerCP/APC): CD20/CD38/CD19/CD5; CD81/CD22/CD19/CD5 and CD79b/CD43/CD19/CD5, with a component specification independentofinstrumentandreagentsatthe0.01%(10−4)
level.55
In an effort to quantify CLL cells at a level of 0.001% (10−5), another ERIC assay was proposed with six
mark-ers (FITC/PE/PerC5.5/PE-Cy7/APC/APC-H7): CD3/CD38/CD5/ CD19/CD79b/CD20andCD81/CD22/CD5/CD19/CD43/CD20).
Interestingly,thisapproachcorrelatedwellwiththe4-color panel,withgood linearity evenat0.001% (10−5) sensitivity.
Recently,theERICprojectvalidatedareliableapproachto eval-uate MRD inCLL toa level of 10−5 using an8-color tube,
withacomponent specification independentofequipment andreagents.Theyidentifiedmarkersthathaveasubstantial impactontheabilitytodetectMRDandcomposeda6-color corepanel (i.e.CD19, CD20,CD5, CD43,CD79b, and CD81), incorporatingCD200orCD23tosimplifythediagnosis,oralso testingalternativeCLLMRDmarkerssuchasCD160orROR1, whichwasshowntobeaveryusefulmarkertodiscriminate normalBcellsfromCLLcells.56
Raponietal.57proposedan8-colorpanelforassessingCLL MRD, including CD81FITC/CD38PE/CD20PerCP/CD43PECy7/ CD5/APC/CD45APC-cy7/CD19V450/CD3 V500, which has showngoodcorrelationwiththe4-colorERICapproachand withASOIgHreal-timePCR(RQ-PCR),butitwastestedinonly afewpatientsandhasnotbeenvalidatedbyothercenters. Althoughtreatmentprotocolsbasedonanti-CD20monoclonal
antibodiesinducelossofCD20expression,theydonotaffect theperformanceofflowcytometryMRDassays.58,59
RecommendationsoftheBrazilianGroupofCLLforMDR evaluation
TimepointsforMRDassessment:therecommendationsare toperformMRDevaluationonlyinthecontextoftranslational research and clinical trials and usuallytoinvestigate MRD threemonthsaftercompletionoftherapyregimensintended toeradicateleukemicclones.
Sample:eitherPBorbonemarrowcanbeusedforMRD assessment.However,thereisahigherprobabilityforBMtobe MRDpositivethanPB,althoughtheassociatedclinical signif-icanceisstillunknown.Hemodilutionandsamplecellularity mustbeevaluatedandtakenintoaccount.Sensitivitymaybe lowerinhypocellularsamples.
Acquisition: the number ofacquired events in the flow cytometermustbeatleast500,000totaleventstoachievea sensitivityof10−4withatleast20CD19+/CD5+eventsneeded
tocharacterizethepopulationbeinganalyzed.
Panel ofmonoclonalantibodies:therecommendationof theBrazilianGroupofCLLforMRDassessmentistouseERIC 4-or6-colorprotocolsbasedontheirhighreproducibility.
Treatment
WithabetterunderstandingofCLL biology,therehasbeen steady progress in treatment in recent years. Several new drugs have been approved with different mechanisms of action.
Forboththeindicationoftreatmentandevaluationof ther-apy, the International Workshopon CLL (iwCLL) guidelines shouldbeused.22,42
Althoughitcannotbepursuedasatreatmentgoaldueto alackofdata,theimportanceofMRDassessmentisgrowing andiscorrelatedwithimprovedPFSand,potentially,OS.54,60
Indicationsfortreatment
Todate,thereisnoevidenceofaclinicalbenefitintreatingCLL atdiagnosis61andtreatmentshouldbeinitiatedonlyifthereis aclearindicationaccordingtoiwCLLcriteria.22Itisimportant toclarifythatalltreatmentindicationsshouldbecautiously judgedasCLL-related.Treatmentshouldbeinitiatedonlyafter othercauseshavebeenexcluded,suchasinfectiousdiseases orotherneoplasticdiseases.
Thetreatmentindicationsareasfollows:
1. Bone marrow failure manifested bythe developmentof anemiaand/orthrombocytopenia;
2. Massivesplenomegaly(atleast6cmbelowtheleftcostal margin)thatisprogressiveorsymptomatic;
3. Massivelymphnode(atleast10cminlongestdiameter)or aprogressiveorsymptomaticlymphnode;
oftwo weeksover anobservationperiodof2–3 months (thisparametershouldnotbeusediftheinitiallymphocyte countislessthan30×109/L).Inaddition,factors
contribut-ingtolymphocytosisorlymphadenopathyotherthanCLL (e.g.,infections)shouldbeexcluded.
5. Autoimmune disease(anemiaand/orthrombocytopenia) with poor responseto corticosteroidsor other standard treatments.
6. Constitutionalsymptoms,whicharedefinedasanyofthe following:unintentionalweightlossof10%ormoreinthe pastsixmonths,significantfatigue[i.e.,Eastern Cooper-ative OncologyGroup (ECOG) of 2or worse; inability to workorperformusualactivities],feverhigherthan38.0◦C
fortwoormoreweekswithoutevidenceofinfection,and nightsweatsformorethanonemonthwithoutevidence ofinfection.
Definitionofapatient’sfitness
To select the best treatment foreach patient, it is impor-tant to evaluate not only disease stage and cytogenetic risk but also the patient’s physical condition and comor-bidities. A comorbidity scale can be used to classify patients as ‘Go-Go’, ‘Slow-Go’, and ‘No-Go’.42 One exam-ple of sucha scale is the ‘cumulative illness rating scale’ (CIRS).62 In clinical trials, patients with a CIRS score ≤6 andanormalestimatedglomerularfiltrationrate(creatinine clearance>70mL/min/1.73m2) are considered ‘fit’ for more
intensivetreatments.
Chlorambucil
Monotherapywithalkylatingagents,includingchlorambucil, hasbeenthetreatmentofchoiceformanyyears61,andthis therapycanstillbeanoption,particularlyforelderlyandunfit patientsforwhom current standardtreatments arenot an option.Theadvantagesofchlorambucilincludeitslowcost, lowtoxicity,andconvenienceofbeinganoraltreatment.The maindisadvantage isthe verylow, ifany,rateofcomplete responseandtheriskofsideeffectswithlong-termuse,such asmyelodysplasia.Currently,theuseofchlorambucilaloneis avoidedwheneveramonoclonalantibodyisavailable.42
Purineanalogs
Purineanalogsarestilloneofthemostimportantdrugsin the treatment of fit patients, and fludarabine is the most studieddrug.Responserateswithfludarabinemonotherapy rangeindifferentstudiesfrom63to73%withapproximately 7–40%ofcaseshavingacompleteresponse,correspondingtoa responsethatissuperiortothatachievedwithchlorambucil.63 Long-termmonitoringrevealedabetterOSforfludarabine,64 althoughagreaterOSdoesnotseemtobeevidentinolder patients.65Fludarabinemonotherapywasalsonoless effec-tivethanmoreintensiveregimensassociatedwithalkylating agents.66,67
Combinations of purine analogs and alkylating agents havesynergisticcytotoxicityinCLLbecauseboth chemother-apies have different mechanisms of action and different toxicity profiles. The combination of fludarabine with
cyclophosphamide(FC)isthemoststudiedtherapyandyields betteroverallresponse(74–94%)andcompleteremissionrates (23–38%)thanotherregimensinthepre-rituximaberawithout increasingtheriskofinfectiondespiteahigherincidenceof neutropenia.68–70 Otherpurineanalogshavealsobeen stud-ied,buttherewasnosignificantbenefitoverfludarabine.71
Monoclonalantibodies:anti-CD20
Inrecentdecades,theadditionofmonoclonalantibodieshas changedthetreatment ofall lymphoproliferativedisorders, includingCLL,aftertheintroductionofrituximabintreatment protocols.
In CLL, rituximab is less active as a single agent than in other lymphoproliferative disorders, which is probably because ofthe low densityof CD20inthe cell membrane. Therefore,higherdosesofthismonoclonalantibodyare rec-ommendedforCLL.72,73 Thecombinationofrituximabwith fludarabine and cyclophosphamide (FCR) has a synergistic effectandefficacythathasbeenconfirmedinseveralphase IIstudiesandretrospectiveanalyses.InthelargestphaseII study,FCRresultedinanoverallresponserateof95%, com-pleteremissionrateof72%,OSatsixyearsof77%,andmedium PFSof80months.74 TheseresultsledtheGermangroupto conducttheCLL8studythatdemonstratedthesuperiorityof FCRcomparedwithFC,withbetterresponseratesand bet-terPFSratesaswellasnoincreaseintoxicityorinfectionrisk. Subgroupanalysisshowedbenefitsforallcytogeneticrisk fac-tors,exceptforindividualswithdel17p.43Thesamebeneficial resultsassociatedwithFCwerealsoobtainedwith second-line treatment.75 These resultsmadethe FCR combination the treatment ofchoice for fit patients with CLL. Because CLLoccursatahighfrequencyinolderpatients,anFCR-Lite schemehasbeendesignedinanattempttoreducetoxicity whilemaintainingefficacy.Inthis combination,fludarabine dosagesarereducedto20mg/m2,cyclophosphamidedosages
arereducedto150mg/m2onDays2–4incycle1andonDays
1–3incycles2–5,andthedosagesareincreasedforrituximab (375mg/m2onday1ofcycle1and500mg/m2onday14of
thefirstcycleandonDays1and14inallsubsequentcycles). Afterthesixcycleswerecompleted,rituximabwasgivenasa maintenancetherapyat500mg/m2onceeverythreemonths
untilrelapse.76
Ofatumumabisanothermonoclonalantibodythattargets aspecificepitopewithincreasedaffinitytoCD20andalsowith stronger complement-dependentcytotoxicity(CDC), aswell as antibody-dependent cellular cytotoxicity (ADCC).77 This drugwasapprovedinEuropeandintheUnitedStatesasa monotherapyforrelapsedor refractorypatients.Italsohas reasonableresponseratesinhigh-riskindividuals,including thosewhoarerefractorytofludarabineandalemtuzumabor refractorytofludarabineandhavebulkydisease,withoverall responseratesof58%and47%,respectively.78Inthefirst-line treatment,thecombinationwithchlorambucilin treatment-naïveunfitelderlypatientsyieldedanexcellentresponserate of82%witha12%completeresponserate.79
CDC with higher direct cell death induction.80 The CLL11 study showed thatthe combination ofobinutuzumab with chlorambucilyieldeda responserateof78.4% and a20.7% complete response rate,with 19.5% MRDnegativity inCLL patientsnoteligibleforfludarabine-basedtreatment.Itwas farsuperiortochlorambucilaloneandyieldedbetterresponse ratesthanthecombinationofrituximabandchlorambucil.81 Obinutuzumab-relatedinfusionreactionsoccurinnearly65% ofcasesinthefirstcycle(21%grade3or4),whichleadsto discontinuationin7%ofpatients.Therateofinfusion reac-tionsdropsto3%inthesecondcycleandtolessthan1%in subsequentcycles.
Bendamustine
Morerecently,bendamustine,analkylatingagentwithpurine analogproperties,wascomparedwithchlorambucilina mul-ticenter,randomizedtrialandyieldedabetterresponserate of68%witha 31%complete responserate andPFSof21.6 months.TherewasnodifferenceinOS.82
Promisingresultswereobtainedfromthecombinationof bendamustinewithrituximab(BR)inrelapsedCLLpatients at a dose of70mg/m2 of bendamustine on Days 1 and 2
and375mg/m2 ofrituximabonDay1ofthe firstcycleand
500mg/m2inthesubsequentcycles,foratotalofsixcycles
every 28 days.83 When usedas first-line treatment,the BR scheme with a higher dose of 90mg/m2 of bendamustine
yieldeda97%responserateandcompleteremissionrateof 31%.ACLL10studydemonstratedcomparableresultstoFCR intermsofresponserates butwith fewercomplete remis-sions.Thisdifferencewasnotconfirmedinthesub-analysisof patientsolderthan65yearsorwhohadmorecomorbidities.84 Unfortunately,bendamustineisnotavailableinBrazilyetand isnotapprovedforuse.
Alemtuzumab
Alemtuzumabisahumanizedmonoclonalantibodyagainst the CD52 antigen with proven activity in CLL. In patients with advanced-stage disease, alemtuzumab monotherapy yieldedresponseratesof30–50%,withamedianPFSof9–15 months after second-line treatment with fludarabine.85–87 Alemtuzumabalsohasproveneffectivenessforbothdel11q anddel17p.88Inarandomizedstudy,alemtuzumabshowed a higher response rate and better PFS in treatment-naïve patientsthanchlorambucil.89Thesynergisticactivityof alem-tuzumabwithfludarabinewaseffectiveandsafeinaphaseII study,witharesponserateof83% andcompleteremission ratewithnegativeMRDof53%.90InaphaseIIIstudy, alem-tuzumab incombination withFCwas moretoxicthan the FCRregimen.91InaphaseIIstudy,acombinationtreatment ofalemtuzumabwithFCRdemonstratedexcellentresponse ratesof92%,with70%ofallindividualsachievingcomplete remissionand57%ofdel17pindividualsachievingcomplete remission. This scheme can be an alternative bridge ther-apy to achieve remission before transplantation in del17p patients.92InamulticenterphaseIIstudy,thecombinationof 30mgalemtuzumabthreetimesaweekwith1.0g/m2
methyl-prednisolone(MP)forfiveconsecutivedaysevery4weeksin
TP53-deletedCLLresultedinanoverallresponserateof85%
andacompleteresponserateof36%.Theriskofinfectionwas age-related and seemed onlymarginallyhigher inyounger patientsthantheinfectionriskassociatedwithFCR.93
Alemtuzumab is no longer approved for use in Brazil forCLL and ismarketed onlyforits indicationinmultiple sclerosis.However,alemtuzumabisavailableforpatientswith CLLthroughacompassionate-useprogram.
Lenalidomide
Lenalidomideisamedicationwithimmunomodulatoryand antiangiogenic effects. It has reasonable response rates in relapsed patients94,95 and has some activity in del17p patients.96PhaseIItrialsdemonstratedgoodsynergismwith rituximab.97 Anassociationbetweenrituximaband fludara-bineisalsofeasible,althoughaphaseIstudyyieldedominous results,withanexcessofsideeffects,myelosuppressionand tumorflares.98
Unfortunately,lenalidomideisnotavailableinBrazilyet andisnotapprovedforuse.
AgentstargetingB-cellreceptorsignaling
A newtherapeuticdrug classhasshownpromisingresults whenusedinconjunctionwithtargetedtherapyinCLL.The most prominent agent in this class seems to be the Bru-ton’s tyrosinekinase inhibitoribrutinib.Phase Iand phase II studieshave shownasurprisingresponsein relapsedor refractory patients, including high-risk groups(e.g., del17p patientsorpatientswhorelapsedwithin24monthsof pre-vious treatment).PFS and OS at26 monthswere 71% and 83%,respectively,and57%and70%inpatientswithdel17p, respectively.99 Thephase III RESONATEstudy included 391 relapsed or refractorypatients, including 33% withdel17p. IbrutinibshowedbetterPFSandOSresultsthanofatumumab. The excellent responserates were maintainedin high-risk patientswithdel17paswellasinpatientsrefractorytopurine analogs. Thismedication is considered the best choicefor second-line treatmentinelderlypatientsandpatientswith comorbidities.100Thepresenceoflymphocytosisiscommon inibrutinibpatients,withpeaklymphocytosisusually occur-ringfourweeksafterthebeginningoftreatment,but80%of patients havehad resolution oratleast a50% decrease in theirlymphocyte count.Thisdeclinewasfasterinpatients withunmutatedIgHV.99Ibrutinibtreatmentusedasfirst-line treatment was tested in the RESONATE-2 study in elderly patientsandwascomparedwithchlorambucil,yielding excel-lentresults.Therewasa86%overallresponserate,andOSwas estimatedat24monthstobe98%.101 Combinationtherapy with rituximab102 and ofatumumab103 hasbeen performed inrelapsedpatientswithpromisingresults,eveninhigh-risk groups.Thebestapproachforusingthesenovelmodalitiesis stillamatterofdebate.Ibrutinibewasrecentlyapprovedin Brazil,onlyforrelapsed/refractoryCLLpatients.
Another important medication is an inhibitor of the class I phosphatidylinositol 3-kinase (PI3K) p110 ␦ isoform
patients105andinarelapsecontext.106InaphaseIIstudywith idelalisibasa first-linetreatment inelderlypatients, com-binationtreatmentshowedexcellentresults,withanoverall responserateof96.0%andacompleteresponserateof14.1%, aswellasPFSandOSratesat36monthsof92.9%and90%, respectively.Theresponsewasmaintainedinpatientswith del17p.Thepresenceofdiarrheaorcolitisgrade3or4can limittheuseofthismedication,mainlybecausetheincidence ofsideeffectswasmorecommonaftermultiplemonthsof treatment.105IdelalisibisnotavailableinBrazilyetandisnot approvedforuse.
Bcl-2inhibitors
Other new therapeutic classes include Bcl-2 inhibitors. A phase I study with Venetoclax (ABT-199) showed excellent results,withanoverallresponserateof79%anda20% com-pleteresponserate,including5%negativityforMRDandaPFS rateat15monthsof66%.High-riskdel17ppatientshad sim-ilarresults,butwithlesssustainedPFS.107Venetoclaxisnot availableinBrazilyetandisnotapprovedforuse.
Allogeneichematopoieticstemcelltransplantation
AllogeneicHSCTiseffectiveinCLLasshownbythe10-year completeremissionrateof69%andOSof55%inacohortof 49consecutivepatientswith20yearsoffollowup.108 How-ever,thenon-relapsemortalityisstillintherangeof20%in mostseries.109Animportantfindingisthatprognosticfactors thatnegativelyinfluencetheoutcomeofCLLunder chemoim-munotherapy, such as unmutated IGHV gene, unfavorable geneticabnormalities,andpurineanalog refractoriness, do notadverselyaffectPFSorOSafterHSCT.109Currently,HSCT isstill the only curative option for appropriatecandidates (young,fitpatientswithanadequatedonor).Asthereisno directcomparisonbetweentransplantandthenovelagents (ibrutinib,idelalisib,or venotoclax),moredataisneededto determinewhichpatientsshouldstillbeconsideredforHSCT, andwhichshouldbeconsideredforprolongedtreatmentwith oneofthesenovelagents.
Treatment recommendations are shown schematically below.Patientsclassifiedas‘Go-Go’shouldreceive combina-tiontherapywithFCR(preferable)orBR(especiallyforpatients olderthan65years).
‘Slow-Go’patientsshouldreceivechlorambucilin combi-nationwithananti-CD20antibody:rituximab,ofatumumab, orobinutuzumab(preferable).Alternativeschemesincludea fludarabine-containingregimenata reduceddose, such as FCR-lite,or acombinationofbendamustineandrituximab. Thetreatmentgoalistocontrolsymptoms.
Inpatientswithsymptomaticdiseaseanddel17porTP53
mutations,thetherapyofchoiceisakinaseinhibitor,which ispreferablyibrutinib.However,idelalisibinassociationwith rituximab or the bcl-2 inhibitor venetoclax are acceptable alternativesifavailable.Alemtuzumabaloneorin combina-tionwithMPalsohasgoodactivityandcanbeused.Allogeneic HSCTshouldbeconsideredinallpatientsingoodclinical con-ditionandifamatcheddonorisavailable.
Thefirsttreatmentcanberepeatedifthetimetorelapse has extended past 24 months in patients who received chemoimmunotherapy.
In patients with refractory CLL or early relapse (<24 months) andinpatientswithdel17p,thetreatmentshould bechanged.
Thetherapyofchoiceisibrutinib.Alemtuzumab(aloneor incombinationwithMP),idelalisibplusrituximab(for slow-gopatients),andvenetoclax(onlyinthepresenceofdel17por
TP53mutations)areacceptablealternatives,ifavailable. Allo-geneicHSCTshouldbeconsideredtheonlycurativeoption forallpatientsingoodclinicalconditionifamatcheddonor isavailable.
RecommendationsoftheBrazilianGroupofCLLforfirst andsecond-linetreatment
1) First-linetreatment: a) ‘Go-go’patients:
- Firstchoice:fludarabine,cyclophosphamide,and rit-uximab(FCR)
• Alternativeoptions:bendamustineandrituximab
(BR)
- Del(17p) orTP53: ibrutinibandconsider allogeneic HSCT
• Alternativeoptions:idelalisibplusrituximab,
vene-toclax, alemtuzumabwith or without high-dose methylprednisolone, rituximab with or without high-dosemethylprednisolone
b) ‘Slow-go’patients:
- Firstchoice:anti-CD20antibody(obinutuzumab, ofa-tumumab,orrituximab)pluschlorambucil
• Alternativeoptions:FCR-lite,BR.
- Del(17p)orTP53:ibrutinib
• Alternative options: idelalisib plus rituximab,
venetoclax, alemtuzumabhigh-dose methylpred-nisolone, rituximab with or without high-dose methylprednisolone
2) Relapsedfirst-linetreatment:
a) Progress after 24 months: repeat first-line treatment (addananti-CD20antibodyifnotusedinthefirst-line treatment)
b) Progresswithin24months: - ‘Go-go’patients:ibrutinib
• Alternative options: alemtuzumabwith or
with-outmethylprednisolone,rituximabwithorwithout high-dose methylprednisolone, allogeneic HCST, bendamustineplusrituximab
- ‘Slow-go’patients:ibrutinib
• Alternative options: idelalisib plus rituximab,
alemtuzumab with or without methylpred-nisolone, rituximab with or without high-dose methylprednisolonebendamustineplusrituximab, FCR-lite
Conflicts
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