On the road to CLL · Del13q14.3 Trisomy 12 Fazi, Scarfò et al, Blood 2011 7/16 cases 43.8%...
Transcript of On the road to CLL · Del13q14.3 Trisomy 12 Fazi, Scarfò et al, Blood 2011 7/16 cases 43.8%...
On the road to CLL
PAOLO GHIA
Strategic Research Program on CLL - Lab of B Cell Neoplasia
Division of Experimental Oncology
Università Vita-Salute San Raffaele - Milano
IRCCS Istituto Scientifico San Raffaele - Milano
Low-count
MBL
CLL
GC
HSC CD5+ B cell
Primary event Genetic
alteration
Chronic
microenvironmental
(Antigenic?)
stimulation
Antigen
T
Th
APCs
Antigen-
primed
DC
Genetic
alteration
High-count
MBL
T cell-independent
A long path to CLL
Modified from Bertilaccio et al., Leukemia 2013
Genetic
alteration
Richter’s
Syndrome
Barrio. et al, EHA 2016 poster #194; Hernandez-Sanchez et al, EHA 2016, oral presentation #115
• Characteristic phenotype: CD5+, CD23+, CD20dim, sIgMdim
CD
5
CD
19
Kappa CD20 CD79b CD5
Kappa CD20 CD79b
CD
5
CD5
CD
19
Chronic Lymphocytic Leukemia (CLL)
0
1
2
3
4
5
6
7
8
9
10
<40 40-49 50-59 60-69 70-79 ≥80
Perc
en
tag
e (
%)
Years
Male Female
5.2% >18yy
Dagklis et al, Blood 2009
6.7% >40yy
CLL-like MBL is common among the elderly
Scarfò et al, Sem Canc Biol 2010
In individuals >40 years of age
The more you search, the more you find...
Nieto et al, Blood 2009
500.000 events
12% overall
5.000.000 events
Scarfò et al, Sem Canc Biol 2010
5.2% overall
Are we all bound to have it?
0
1
2
3
0 – 0.5 0.5 – 5.0 >5.0
Pre
va
len
ce
(%
)
B-Lymphocyte count (109/L)
High-count MBL CLL
Are all MBL equal?
Rawstron et al, NEJM 2009
Biological features of high-count MBL
0
1
2
3
0 – 1.0 0.5 – 5.0 >5.0
Pre
va
len
ce
(%
)
B-Lymphocyte count (109/L)
(General population)
Low-count MBL
CLL
1.1% per year CLL
(Clinical)
High-count MBL
Are all MBL equal?
Fazi, Scarfò et al, Blood 2011
MBL cells tend to persist with time
A
B
Fazi, Scarfò et al, Blood 2011
Median follow-up time= 34 months
MBL cells tend to remain stable with time
Low-count MBL
Normal B-cells
P=0.430
100
80
60
40
20
0 6 1 2 3 4 0 5
Perc
enta
ge a
live
Years since screening
CLL-like MBL: 5/48 oncology, 3/5 MBL Controls: 0/88 oncology referrals
CLL-like B-cells typically <0.01 x 109/L
A. Rawstron unpublished 2015
Del13q14.3
Trisomy 12
Fazi, Scarfò et al, Blood 2011
7/16 cases
43.8%
Del17p13
1/16 cases
6.3%
2/16 cases
12.5%
ID SEX AGE
Follow-up
(months)
Clone
(cells per μl)
FISH IGHV gene
IGHV
homology
1st visit
Follow-
up
VB0314 F 78 47 5,79 4,82 Del13q14.3*, Trisomy 12 IGHV4-59/-61 94,4
VB0588 F 65 39 96,73 319,10 Del13q14.3 IGHV4-59 93,5
VB1002 F 63 35 1,67 1,60 Del17p IGHV4-59/-61 97,0
VB1134 M 58 34 2,36 0,46 Del13q34 n.d. n.d.
VB1202 F 61 34 4,72 18,56 Del13q14.3 n.d. n.d.
VB1320 F 61 24 0,41 3,82 Del13q14.3-q34, Del17p n.d. n.d.
VB1377 M 68 24 3,78 2,42 Del13q34 n.d. n.d.
VB1470 F 73 23 0,94 4,02 Del13q14.3* n.d. n.d.
Low-count MBL carry identical genetic lesions
TP53 disruption is associated with poor prognosis
Wt: wildtype; OS: overall survival
Nonsense Missense Frameshift
5’ 3’
1
DNA BINDING
EX4 EX9
393 TP53
TP53 M
17p-
TP53 M /17p-
Wt
Aberration Incidence (%)1
Median OS (months)1
17p del 7 32
11q del 18 79
+12 16 114
Normal 18 111
13q del 55 133
13q deletion as sole abnormality
17p deletion
Normal Trisomy 12q 11q deletion
Months
% S
urv
ivin
g
0 12 24 36 48 60 72 84 98 108 132 156 180
100
80
40
20
0
60
Wt (n=277; median not reached)
TP53 M (n=14; 30.2 median months) 17p- (n=16; median 19.2 months)
Time (months)
Fra
ctio
n A
live
0 OS2
0 12 24 36 48 60 72 84 96 108
1.0
0.4
0.1 0.2 0.3
0.5 0.6
0.9 0.8 0.7
del13q14
del17p13 +12
del11q22-q23
OS1
1. Döhner H, et al. N Engl J Med 2000;343:1910–6; 2. Zenz T, et al. J Clin Oncol 2010;28:4473–9.
TP53 mutation and/or del(17p) predict non-response to first-line chemoimmunotherapy
O
S p
rop
ort
ion
0
0.4
0.6
0.8
1.0
0.2
0 96 90 84 78 72 66 60 54 48 42 36 30 18 12 6 24
Months
del(17p) del(11q) Trisomy 12 del(13q) Normal
FC FCR
O
S p
rop
ort
ion
0
0.4
0.6
0.8
1.0
0.2
0 96 90 84 78 72 66 60 54 48 42 36 30 18 12 6 24
Months
FC and TP53 WT FC and TP53 mut FCR and TP53 WT FCR and TP53 mut
FC, fludarabine, cyclophosphamide; FCR, FC, fludarabine, cyclophosphamide, rituximab; OS, overall survival Stilgenbauer S, et al. Blood 2014;123:3247–54
16
Fazi, Scarfò et al, Blood 2011
Del17p13 2/16 cases
12.5%
Patients 17p- may have stable disease
Best et al, Leukemia 2009
TP53 disruption is associated with poor prognosis
Aberration Incidence (%)1
Median OS (months)1
17p del 7 32
11q del 18 79
+12 16 114
Normal 18 111
13q del 55 133
13q deletion as sole abnormality
17p deletion
Normal Trisomy 12q 11q deletion
Months
% S
urv
ivin
g
0 12 24 36 48 60 72 84 98 108 132 156 180
100
80
40
20
0
60 del13q14
del17p13 +12
del11q22-q23
OS1
Dohner et al. NEJM 2000 Calin et al. PNAS 2002
Döhner, New Engl J Med 2000
Klein et al, Cancer cell, 2010
Del 13q in CLL and MBL
Cimmino, et al. (2005) PNAS
BCL2 is a target of miR-15 and miR-16
actin
BCL2
actin
Po
sit
ive c
on
tro
l
To
- - + 72h
Mcl1
Scielzo et al, Leukemia 2011, Fonte et al, Clin Can Res, 2013 Hanada M et al, Blood 1993, Kitada S et al, Blood 1998
BCL2 is overexpressed in CLL
+ 24h
Po
sit
ive c
on
tro
l
To
- - + 72h
+ 24h
actin
BCL2
CD40L
CD40L
Bcl-2
Burger, Ghia et al, Blood, 2009
Microenvironmental stimuli in CLL
Ballesteros et al, EHA 2016, poster #1037
Damle et al, 1999 Time from diagnosis
Hamblin et al, 1999
IG genes can be mutated in CLL
Herishanu Y et al. Blood 2011
BCR is activated in the LN microenvironment
BCR signalling in CLL is heterogeneous
Bad prognosis
Survival
Proliferation
Good prognosis
Zupo et al, 1996; Chen et al, 2002; Lanham et al, 2003
BCR reactivity in CLL: self and foreign antigens
Dühren-von Minden et al, Nature 2012 Hervé et al, JCI 2005, Lanemo Myhrinder et al, Blood 2008, Hoogeboom et al, JEM 2013,
Kostareli et al, Leukemia 2011; Hwang et al, PlosOne 2014; ten Hacken et al, EHA 2016, poster #195
• 30.4% of all CLL cases (2308/7596)
Agathangelidis et al, 2012 Blood
H
L
H
L HCDR3
FR2 FR3 FR1
CDR1 CDR2
IGHJ IGHV
Stereotyped receptors in CLL
Gounari et al, EHA 2016, oral presentation #116
Subset #4
Subset #2
Stereotyped subsets have a distinct clinical course
Baliakas et al. Lancet Haematology 2014 Baliakas et al. EHA 2016, poster #598
Baliakas et al. Lancet Haematology 2014
Poor clinical course is independent of cytogenetics
Subsets
Cu
mu
lati
ve
eve
nts
Strefford et al, Leukemia, 2013; Malcikova et al, BJH 2014
Subset 1 Subset 2 Subset 8
Rossi et al, Blood, 2013
Gene mutations and IG stereotypy
Genetic abnormalities
MBL overt CLL Refractory CLL/
Richter Syndrome Normal B cell
Low-count
MBL
CLL
GC
HSC CD5+ B cell
Primary event Genetic
alteration
Chronic
microenvironmental
(Antigenic?)
stimulation
Antigen
T
Th
APCs
Antigen-
primed
DC
Genetic
alteration
High-count
MBL
T cell-independent
A long path to CLL
Modified from Bertilaccio et al., Leukemia 2013
Genetic
alteration
Richter’s
Syndrome
Barrio. et al, EHA 2016 poster #194; Hernandez-Sanchez et al, EHA 2016, oral presentation #115
IRCCS Istituto Scientifico San Raffaele
Laboratory of B Cell Neoplasia
Lydia Scarfò, Alessandra Rovida, Engin Bojnik,
Costantinos Xhantopoulos, Silvia Heltai,
Pamela Ranghetti, Silvia Bonfiglio
Strategic Research Program on CLL
Lydia Scarfò, Piera Angelillo, Maria Colia, Antonella
Capasso, Virginia Sgarlato, Stefania Cresta, Eloise Scarano
Division of Experimental Oncology
CERTH, Thessaloniki
Anna Vardi, Stavroula Ntoufa,
Aliki Xochelli, Anastasia
Hadzidimitrious, Andreas
Agathangelidis, Maria Gounari,
Kostas Stamatopoulos
Karolinska Institut, Stockholm
Lesley Ann Sutton, Panayotis
Baliakas, Viktor Ljungstrom,
Richard Rosenquist