The n e w e ng l a n d j o u r na l
Review Article
From the Department of Leukemia, Uni-
versity of Texas M.D. Anderson Cancer
Center, Houston. Address reprint requests
to Dr. Burger at the Department of Leu-
kemia, Unit 428, University of Texas M.D.
Anderson Cancer Center, Houston, TX
77030, or at ­jaburger@​­mdanderson​.­org.
N Engl J Med 2020;383:460-73.
DOI: 10.1056/NEJMra1908213
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460
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of m e dic i n e
Dan L. Longo, M.D., Editor
Treatment of Chronic Lymphocytic
Leukemia
Jan A. Burger, M.D., Ph.D.​​
C
hronic lymphocytic leukemia (CLL) cells proliferate in second-
ary lymphoid organs (lymph nodes and spleen), where B-cell receptor sig-
naling promotes the expansion of the monoclonal B lymphocytes. B-cell
receptor signaling is the target of kinase inhibitors, which have transformed CLL
therapy during the past decade. Bruton’s tyrosine kinase (BTK) and isoform-selec-
tive phosphatidylinositol 3-kinase (PI3K) inhibitors disrupt B-cell receptor signal-
ing and other circuits between CLL cells and the tissue microenvironment. BCL2
(B-cell lymphoma 2), an antiapoptotic molecule strongly expressed in CLL cells,
has emerged as another important therapeutic target. The transition from chemo-
therapy-based regimens to new, molecularly targeted agents is based on a series
of clinical trials, most of them published in the Journal,1-10 showing a survival
benefit from BTK inhibitors (ibrutinib and acalabrutinib) and the BCL2 antagonist
venetoclax, as compared with older CLL therapies (chemotherapeutic agents,5 anti-
CD20 antibodies,2,3,11 or combinations of these agents7-10,12-14). These benefits are
profound in patients with high-risk CLL and are less pronounced in those with
low-risk CLL. However, the new treatment approaches also come with challenges
(i.e., the emergence of drug resistance, serious side effects, and high costs). Com-
bination therapies to achieve deeper remissions, allowing for fixed-duration or
intermittent treatment, will help to optimize the use of the new targeted drugs.
B ackground
CLL is the most common leukemia in adults in Western countries, with a male
predominance and an average age at diagnosis of 72 years. The disease is charac-
terized by an accumulation of monoclonal, mature, CD5+ B cells in the periph-
eral blood, bone marrow, and secondary lymphoid organs. CLL is 10 to 20 times
as common in Western countries as in Asia, suggesting that genetic factors, envi-
ronmental factors, or both influence susceptibility to the disease. Often, CLL is
diagnosed after a workup for incidental lymphocytosis. The presentation and
clinical course are highly variable, ranging from asymptomatic, indolent disease
that may never require therapy (in approximately 30% of patients) to active disease
that can lead to progressive lymphocytosis, cytopenias (anemia and thrombocyto-
penia), lymphadenopathy, hepatosplenomegaly, B symptoms (i.e., weight loss, night
sweats, and fever), fatigue, recurrent infections, or autoimmune complications.
Autoimmune complications — in most cases, autoimmune thrombocytopenia or
hemolytic anemia — can occur without other signs of CLL progression and with-
out reflecting an alteration in the natural history of the disease or the prognosis
and should be treated primarily with glucocorticoids.
The guidelines of the International Workshop on Chronic Lymphocytic Leuke-
mia (iwCLL) provide unified disease staging and guidance for the clinical manage-
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The New England Journal of Medicine
 Treatment of Chronic Lymphocytic Leukemia

Table 1. Response Rates and Survival with Chemoimmunotherapy or Novel Agents for the Treatment of Chronic
Lymphocytic Leukemia (CLL).*

Overall Response Progression-free

Treatment Disease State (Complete Remission) Survival Overall Survival

% (%)
FCR Previously untreated CLL 20
90 (44) Median, 56.8 mo Median, 12.7 yr
BR Previously untreated CLL21 96 (31) Median, 41.7 mo 92% at 3 yr
Chlorambucil plus Previously untreated CLL 22
77.3 (22.3) Median, 29.2 mo NA
obinutuzumab
Ibrutinib Relapsed or refractory CLL19 89 (10) Median, 52 mo 55% at 7 yr
Ibrutinib Previously untreated CLL5,18 92 (30) 70% at 5 yr 83% at 5 yr
Acalabrutinib Relapsed or refractory CLL4,23 94 62% at 45 mo >90% at 16 mo
Acalabrutinib Previously untreated CLL14 86 (1) 82% at 30 mo 94% at 30 mo
Acalabrutinib plus Previously untreated CLL14 94 (13) 90% at 30 mo 95% at 30 mo
obinutuzumab
Venetoclax Relapsed or refractory CLL6 79 (20) Median, 25 mo 84% at 24 mo
Venetoclax plus Relapsed or refractory CLL 7
93.3 (26.8) 84.9% at 24 mo 92% at 24 mo
rituximab
Venetoclax plus Previously untreated CLL10 84.7 (49.5) 88.2% at 24 mo 91.8% at 24 mo
obinutuzumab

* More detailed data, including side effects, and additional data from other key CLL clinical trials are provided in Tables
S1, S2, and S3 in the Supplementary Appendix, available with the full text of this article at NEJM.org. BR denotes
bendamustine and rituximab, FCR fludarabine, cyclophosphamide, and rituximab, and NA not available.

ment of CLL.15 Patients with early-stage (low-
risk) CLL (lymphocytosis alone; Rai stage 0, Binet
stage A) have an estimated median life expec-
tancy of approximately 13 years16,17 and normally
are not treated. Patients with intermediate-stage
CLL (lymphocytosis with lymphadenopathy, hep-
atosplenomegaly, or both; Rai stage I or II, Binet
stage B) have an estimated median life expec-
tancy of 8 years and can be treated if they have
signs of disease activity. Patients with advanced-
stage (high-risk) CLL (lymphocytosis with lymph-
adenopathy, hepatosplenomegaly, or both, as well
as marrow infiltration–related anemia, throm-
bocytopenia, or both; Rai stage III or IV, Binet
stage C) should always be treated; these patients
formerly had an estimated median life expec-
tancy of only 2 years, according to data derived
from the period when alkylating agents consti-
tuted the primary treatment of CLL. However,
survival has improved substantially with the
more recent, widespread use of the novel agents.
For example, 83% of patients with CLL remain
alive 5 years after starting frontline ibrutinib
therapy,18 and 55% of patients with relapsed or
refractory CLL remain alive 7 years after starting
ibrutinib salvage therapy19 (Table 1).
The diagnosis of CLL is based on the presence
of lymphocytosis (>5000 lymphocytes per cubic
millimeter) with a typical immune phenotype on
flow cytometry. Bone marrow testing and radio-
logic studies generally are not required for the
initial workup or follow-up. Prognostic markers
include cytogenetic abnormalities such as del(13q),
del(17p), trisomy 12, and del(11q),24 as well as
the mutation status of immunoglobulin heavy-
chain variable (IGHV) genes of the B-cell recep-
tor.25,26 Patients with one or more high-risk
markers — del(17p), del(11q), or unmutated IGHV
— characteristically have a shorter time to initial
treatment and shorter remissions after chemo-
therapy-based treatment than patients with the
following markers for low-risk CLL: del(13q),
trisomy 12, or mutated IGHV. To estimate the
risk of progression and time to initial treatment
in individual patients with early-stage disease, the
International Prognostic Index for Chronic Lym-
phocytic Leukemia (CLL-IPI) can be used, which
categorizes risk (low, intermediate, high, or very
high) on the basis of weighted individual risk
factors (status with respect to 17p deletion and
TP53 mutation, IGHV mutation status, serum β2-
microglobulin level [<3.5 mg per liter or ≥3.5 mg

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 The n e w e ng l a n d j o u r na l of m e dic i n e

per liter], age, and clinical stage).27 The median
time to initial therapy is 7 years for patients
with low or intermediate risk, according to the
CLL-IPI (accounting for approximately 75% of
patients with CLL), as compared with 2 years for
patients with a high or very high risk (approxi-
mately 25% of patients).
When CLL was last reviewed in the Journal,28
the importance of the B-cell receptor for patho-
genesis and prognostication, along with the role
of the tissue microenvironment, was highlighted,
but agents for targeting these pathways were
lacking. Since then, kinase inhibitors blocking
B-cell receptor signaling and the BCL2 antago-
nist venetoclax have been introduced and are
fundamentally changing the CLL treatment land-
scape.
B- Cel l R ecep t or Signa l ing
a nd the Patho gene sis of CL L
Secondary lymphoid organs are the primary site
for CLL cell proliferation,29 which has been
shown directly in patients with CLL by labeling
proliferating CLL cells with deuterated (“heavy”)
water.30 In lymph nodes, CLL cells form charac-
teristic proliferation centers that mimic normal
B-cell follicles (“pseudofollicles”) (Figs. 1 and 2).
Here, CLL cells engage in cellular and molecular
interactions that resemble those of normal B
cells expanding in germinal centers during adap-
tive immune responses.31 CLL cells interact with
T cells32 and monocyte-derived macrophages
(so-called nurselike cells), resulting in CLL-cell
activation with a B-cell receptor and nuclear fac-

A B

C D

Figure 1. Chronic Lymphocytic Leukemia (CLL) Cells Proliferating in the Lymph-Node Microenvironment.
Panels A, B, and C show sections from CLL-affected lymph nodes at progressively higher magnifications (hematoxy-
lin and eosin). Round areas of activated and proliferating CLL cells, termed pseudofollicles (also called proliferation
centers), are surrounded by sheets of darker, resting lymphocytes. Pseudofollicles are a hallmark of CLL histopathol-
ogy. In Panel D, Ki-67 staining highlights proliferating CLL cells (brown) within the proliferation centers.

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 Treatment of Chronic Lymphocytic Leukemia

tor κΒ (ΝF-κΒ) gene signature.29 This signature
is recapitulated when CLL cells are cultured in
vitro with nurselike cells,33 suggesting that mac-
rophages are important for triggering B-cell re-
ceptor signaling in CLL.
The precise mechanism underlying the activa-
tion of B-cell receptor signaling in CLL remains
controversial. Activating pathway mutations,
similar to those in diffuse large B-cell lympho-
ma, are not found in untreated CLL, although
mutations in PLCG2 (the gene encoding phospho-
lipase C gamma 2) can emerge when resistance
to BTK inhibitors develops.34 Therefore, B-cell
receptor activation in CLL is normally antigen-
dependent, resulting from B-cell receptor en-
gagement with antigens in lymph nodes and the
spleen. For example, B-cell receptors can bind
various autoantigens, including calreticulin, cyto-

A B
Resting Nurselike cell
Lymph CLL cell
node

Nurselike cell
Other
CLL cell

BTK
reticular cell BCR BCR
CXCL12
CXCR4
CXCL13 Proliferating
PROLIFERATION CENTER CLL cell BCR
CXCR5
SYK
CCL3
and CCL4 BTKi
PI3K PI3Ki
CCR1 CD40 ligand
CCR4
CLL T cell
CCR5 T cell

C Anti-CD20

CD20

BCL2 antagonist

Figure 2. B-Cell Receptor (BCR) Signaling in the Proliferation of CLL Cells.

Interactions between CLL cells and the tissue microenvironment (i.e., nonmalignant cells), such as macrophages
(also referred to as nurselike cells), T cells, and reticular stromal cells result in activation and proliferation of the
CLL cells (Panel A). BCR signaling in CLL cells is activated in secondary lymphatic organs by soluble or cell-surface
antigens, which can be autoantigens (e.g., calreticulin on nurselike cells) (Panel B). Homotypic interactions between
BCR molecules (right upper corner) result in autonomous BCR signaling. BCR activation causes downstream signal-
ing through spleen tyrosine kinase (SYK), Bruton’s tyrosine kinase (BTK), and phosphatidylinositol 3-kinase (PI3K),
which are the targets of the BTK inhibitors (BTKi) ibrutinib and acalabrutinib and the PI3K inhibitors (PI3Ki) idelalis-
ib and duvelisib. SYK, BTK, and PI3K also transmit signaling from chemokine receptors, such as CXCR4 and CXCR5,
which regulate tissue homing and retention of CLL cells. In response to BCR signaling, CLL cells secrete the che-
moattractants CCL3 and CCL4, which attract T cells for cognate interactions, as seen in CLL proliferation centers.
This loop is also effectively inhibited by the kinase inhibitors (BTKi and PI3Ki). T cells, in turn, promote CLL-cell pro-
liferation through CD40–CD40 ligand interactions. CLL cells constitutively express high levels of the antiapoptotic
protein BCL2, which is localized in the outer membrane of mitochondria (Panel C). BCL2 is targeted by the BCL2
antagonist venetoclax, a BH2 mimetic, resulting in CLL-cell apoptosis. The surface antigen CD20 is the target of
antibodies (rituximab, ofatumumab, and obinutuzumab), which are commonly administered in combination with
chemotherapy or targeted therapies. CCR denotes C-C chemokine receptor, and CXCL C-X-C motif chemokine ligand.

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 The n e w e ng l a n d j o u r na l of m e dic i n e

skeletal nonmuscle myosin heavy chain IIA, vi-
mentin, IgG, DNA, or apoptotic cells. Microbial
antigens, such as lipopolysaccharides, or β-(1,6)-
glucan, a fungal antigen, can also activate CLL
B-cell receptors and, in turn, promote CLL pro-
liferation.35 In addition, B-cell receptor activation
in CLL can occur when two CLL B-cell receptors
engage each other,36 resulting in autonomous
signaling (Fig. 2B). Signaling downstream of the
B-cell receptor activates kinases (LYN, spleen tyro-
sine kinase [SYK], BTK, and PI3K) (Fig. 3). Among
these kinases, BTK has emerged as the most
successful therapeutic target. Downstream sig-
naling through extracellular signal-regulated ki-
nase (ERK) and NF-κB results in transcriptional
activation. An example is activation of the T-cell
chemoattractants CCL3 and CCL4, which are
secreted at high concentrations by B-cell recep-
tor–activated CLL cells and function as plasma
biomarkers in patients with CLL treated with
kinase inhibitors that target BTK38 or PI3K.39
IGH V Mu tat ion S tat us a nd
S ter eo t y ped B- Cel l R ecep t or s
The mutation status of IGHV genes influences
the natural history of CLL. IGHV mutation analy-
sis distinguishes patients whose CLL cells ex-
press mutated IGHV with 2% or greater deviation
from the IGHV germline sequence (who gener-
ally have indolent disease) from patients with
unmutated CLL with less than 2% deviation25,26
(who present with more active and treatment-
resistant disease). These differences in clinical
behavior have been linked to differences in B-cell
receptor responsiveness. Unmutated CLL clones

BCR
Antigen
Chemokine
Integrins receptors
(e.g., CXCR4) CD19
β α CD79
CD20 BTKi PI3Ki
A B CCL3
CCL4
CELL MEMBRANE
LYN SYK BTK PI3K

PLCG2 Mutations in
BTKi-resistant CLL
Ca2+
PKC
ERK
NF-κB

Transcription

CYTOPLASM NUCLEUS

Figure 3. BCR Signaling, Chemokine Receptors, and Adhesion Molecules.

Antigen binding to the BCR results in the formation of clusters of surface molecules, which include the BCR, CD19,
CD20, CXCR4, and LYN. BCR signals are transmitted through the BCR complex–associated molecules CD79A and
CD79B, resulting in activation of immunoreceptor tyrosine-based activation motif (ITAM) residues on the cytoplas-
mic tails of CD79A and CD79B. This, in turn, activates SYK, BTK, PI3K, and phospholipase C gamma 2 (PLCG2). BTK
and PLCG2 mutations are often found in BTKi-resistant CLL. Further responses downstream include calcium mobili-
zation, activation of protein kinase C (PKC), and the extracellular signal-regulated kinase (ERK)–mitogen-activated
protein kinase (MAPK) and nuclear factor κB (NF-κB) pathways. This signaling response promotes activation of
transcription in the nucleus and favors CLL-cell survival and proliferation. Through IgM signaling–induced down-
regulation of the transcriptional repressor BCL6,37 the T-cell chemoattractants CCL3 and CCL4 are induced and be-
come secreted by CLL cells. SYK, BTK, and PI3K, the targets of the kinase inhibitors, also transmit signals from
chemokine receptors and adhesion molecules (integrins), which regulate CLL-cell migration and homing to the sec-
ondary lymphatic organs. Conversely, kinase inhibitors targeting these molecules disrupt the function of chemokine
receptors and integrins, resulting in defective homing and the mobilization of CLL cells from secondary lymphatic
organs to the peripheral blood, causing redistribution lymphocytosis.

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 Treatment of Chronic Lymphocytic Leukemia
respond to various autoantigens, triggering ro-
bust B-cell receptor signaling, whereas mutated
CLL cells display more selective binding to re-
stricted antigens and less active B-cell receptor
signaling. Consequently, mutated CLL clones re-
main stable or expand at a slower rate than clones
from patients with unmutated CLL. Patients with
unmutated IGHV also used to have a worse prog-
nosis — due to shorter remissions and shorter
survival after chemotherapy-based treatments
— than patients with mutated IGHV.25,26 The
negative prognostic effect of unmutated IGHV is
overcome when patients are treated with the
new targeted agents. Long-term follow-up of pa-
tients receiving ibrutinib as frontline therapy
showed that the survival of patients with unmu-
tated CLL was excellent and similar to the sur-
vival of those with mutated IGHV.18
The discovery of virtually identical (stereo-
typed) B-cell receptor sequences in unrelated
patients with CLL solidified the concept that
common antigens drive the development and
progression of CLL. Approximately 30% of pa-
tients can be grouped into CLL subgroups on the
basis of shared immunoglobulin sequence mo-
tifs,40 with distinct clinical behavior and func-
tional differences in terms of B-cell receptor
activation.41
Aggressive CLL is not universally associated
with unmutated IGHV, and IGHV sequencing may
not always be available. Testing CLL cells for
expression of CD38 and the zeta chain–associ-
ated protein kinase 70 (ZAP-70) with the use of
flow cytometry provides valuable additional in-
formation. Positivity for CD3825 or ZAP-7042,43 can
function as a surrogate marker for IGHV muta-
tion status (i.e., positivity for CD38 or ZAP-70
often — but not always — is associated with
unmutated IGHV and indicates an unfavorable
prognosis).
T r e atmen t A pproache s
Chemoimmunotherapy
Before the introduction of the new agents, CLL
therapy was based mostly on chemotherapy
comprising alkylating agents (chlorambucil, cyclo-
phosphamide, and bendamustine), nucleoside ana-
logues (fludarabine, pentostatin, and cladribine),
and glucocorticoids. Younger, fit patients typi-
cally received more intensive therapy, whereas
elderly patients with coexisting conditions were
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treated with lower-intensity regimens (Fig. 4).
The addition of anti-CD20 antibodies to chemo-
therapy resulted in prolonged survival with both
low-intensity regimens22,44 and higher-intensity
regimens,20 and chemoimmunotherapy therefore
became standard therapy before the advent of
the new agents (Table 1). The combination of
fludarabine, cyclophosphamide, and rituximab
(FCR)20,45 was commonly used for younger, fit
patients; bendamustine combined with rituximab
(BR)21,46 was commonly used for elderly patients;
and chlorambucil with anti-CD20 antibodies was
used for elderly patients with coexisting condi-
tions.22,44 However, a series of randomized tri-
als2,5,7-10,12 showed better survival with the new
agents (kinase inhibitors and venetoclax), leading
to a decline in the use of chemoimmunotherapy.
FCR was the first regimen to induce complete
remissions in a large proportion of patients45
and to improve overall survival (median progres-
sion-free survival, 56.8 months)20,47 (Table 1).
Long-term analyses revealed that low-risk pa-
tients often have durable remissions after treat-
ment with FCR,48 whereas higher-risk patients
typically have shorter remissions.47 The shortest
remissions are associated with del(17p) (5-year
progression-free survival, 15.3%), followed by
del(11q) (5-year progression-free survival, 31.4%)
and unmutated CLL (5-year progression-free
survival, 33.1%).47 Achievement of undetectable
minimal residual disease (MRD) (defined as <1 CLL
cell per 10,000 cells in the blood or marrow)
after treatment with FCR is also a strong predic-
tor of progression-free survival, which may prompt
earlier treatment discontinuation and can attenu-
ate the negative prognostic effect of unmutated
IGHV genes.48 FCR treatment is associated with a
plateau in the progression-free survival curve for
patients with CLL and mutated IGHV genes
(progression-free survival at 12.8 years, 53.9%).48
Promising modifications of the FCR regimen
incorporate new agents (ibrutinib49 and obinutuz­
umab, an anti-CD20 antibody used instead of
rituximab50), reduce the number of fludarabine
and cyclophosphamide cycles, or both.50,51
BR, another widely used regimen, is less effec-
tive but also less myelosuppressive than FCR.21
When BR was compared with a new agent (ibru-
tinib8 or venetoclax7), BR-treated patients had
significantly shorter progression-free survival.
Similarly, randomized trials comparing the new
agents with chlorambucil plus anti-CD20 anti-
465
 The n e w e ng l a n d j o u r na l of m e dic i n e

Glucocorticoids Fludarabine Chemoimmunotherapy

and alkylating plus cyclophos- with FCR induces
agents introduced phamide high CR rates
bendamustine

Nucleoside Progression-free survival

analogs benefit from anti-CD20
(fludarabine) mAb obinutuzumab plus
introduced chlorambucil vs. rituximab
plus chlorambucil or
FCR regimen
Rai and Binet chlorambucil alone
improves overall
staging
survival

1950 1960 1970 1980 1990 2000 2005 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
SYK inhibitor Progression-free
fostamatinib survival benefit
active in CLL from venetoclax
plus rituximab
vs. BR in RR CLL

Better progression-
BTK inhibitor ibrutinib active free survival with
in refractory, high-risk CLL ibrutinib with or
without rituximab
vs. BR in untreated
PI3Kδ inhibitor idelalisib active
CLL
in refractory, high-risk CLL

Progression-free survival and overall survival benefit from
ibrutinib vs. chlorambucil in untreated CLL
BCL2 antagonist venetoclax and
second generation BTKi acalabrutinib
active in refractory, high-risk CLL
Progression-free survival and
overall survival benefit from
ibrutinib plus rituximab
vs. FCR in untreated CLL
Venetoclax plus ibrutinib
induces high rates
of CR in untreated CLL

Progression-free benefit from

venetoclax plus obinutuzumab
vs. chlorambucil plus
obinutuzumab in untreated CLL

Figure 4. Milestones in Clinical CLL Research.

Shown in yellow above the time line are traditional chemotherapy-based approaches to treatment. Systemic therapy with alkylating
agents and glucocorticoids for patients with CLL was introduced in the 1950s, and alkylators, especially chlorambucil, given alone or
with glucocorticoids, remained widely used, even though they did not improve survival or result in deep remissions. Nucleoside ana-
logues became effective combination partners for alkylators in the 1990s, and with the addition of rituximab in the early 2000s, the con-
cept of chemoimmunotherapy was established. Fludarabine, cyclophosphamide, and rituximab (FCR) became the first therapeutic regi-
men to provide a survival benefit. Shown in green below the time line are targeted therapies. Since 2010, kinase inhibitors targeting BTK
and PI3K isoforms, the BCL2 antagonist venetoclax, and newer CD20 antibodies, such as obinutuzumab, have been approved. In ran-
domized trials, BTK inhibitors and venetoclax improve survival, as compared with chemotherapy-based regimens. CR denotes complete
remission, BR bendamustine plus rituximab, mAb monoclonal antibody, and RR refractory or relapsed.

bodies showed significantly longer progression- Early clinical testing revealed a characteristic
free survival with the BTK inhibitors12,14 or with pattern of response to the kinase inhibitors.1,2,52
venetoclax plus obinutuzumab.10 First, as compared with patients who have other
B-cell cancers, patients with CLL have the high-
Kinase Inhibitors est response rates and the most durable remis-
For the treatment of CLL, kinase inhibitors that sions. Second, kinase inhibitors typically mobilize
target the B-cell receptor signaling kinases SYK, CLL cells to move from the tissues to the periph-
BTK, and PI3K isoforms are normally adminis- eral blood, causing rapid shrinkage of enlarged
tered daily as oral agents until toxicity or CLL lymph nodes, along with a transient increase in
progression precludes further administration. peripheral-blood CLL cell counts (“redistribution

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 Treatment of Chronic Lymphocytic Leukemia
lymphocytosis”). Third, in contrast to chemoim-
munotherapy, kinase inhibitors generally are not
myelosuppressive and work well in patients with
high-risk and chemotherapy-refractory CLL.
BTK Inhibitors
Ibrutinib is the first-in-class BTK inhibitor, which
forms a covalent bond to cysteine 481 in BTK. A
nonreceptor tyrosine kinase, BTK plays a central
role in B-cell receptor signaling and B-cell devel-
opment. BTK was named after Dr. Ogden Bruton,
a pediatrician, who first described a hereditary
immunodeficiency syndrome, X-linked agam-
maglobulinemia, in the 1950s.53 Patients with
X-linked agammaglobulinemia lack blood B cells
and immunoglobulins as a result of functional
null BTK mutations.54
After triggering B-cell receptors, BTK is acti-
vated by upstream kinases (LYN and SYK). BTK
also transmits signals from chemokine receptors
and adhesion molecules (integrins),55,56 which
organize B-cell migration and homing to the
lymphatic tissues (Fig. 4). Functional inhibition
of these homing receptors is the basis for redis-
tribution lymphocytosis,38,57 which causes the
white-cell count to increase by a factor of 2 to
3 or more during the first weeks of therapy in
most patients with CLL. This lymphocytosis,
which is asymptomatic, typically resolves during
the first months of therapy (although it can per-
sist for more than 12 months) and is not a sign
of resistance or a suboptimal response.58 On the
basis of the estimated tissue leukemia-cell burden
and correlations with redistribution lymphocy-
tosis, approximately a quarter of tissue CLL cells
are mobilized to the peripheral blood when
ibrutinib treatment is started.59 Conversely, a
majority of tissue CLL cells undergo cell death
without redistribution to the blood and normal­
ly without signs of tumor lysis. Serial measure-
ments of leukemia-cell proliferation and death
rates after deuterium labeling in patients with
CLL showed abrogation of cell proliferation and
a robust increase in cell death once ibrutinib
therapy was started.60
The first trial of ibrutinib in patients with
relapsed or refractory CLL and a small cohort of
previously untreated patients1 showed high re-
sponse rates, mostly partial responses,1 and very
durable responses in patients without previous
treatment (7-year progression-free survival, 83%),
whereas patients with relapsed or refractory CLL
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had shorter remissions (7-year progression-free
survival, 34%).19 Common toxic effects were di-
arrhea, myalgia, arthralgia, and bruising,1 which
normally did not require treatment interruptions
or adjustments. Minor bleeding and bruising are
common with BTK inhibitors and are due to
inhibition of BTK-mediated platelet adhesion.
Infectious complications occur most frequently
at the beginning of ibrutinib therapy and decline
over time.61
The RESONATE trial showed a major survival
benefit with ibrutinib as compared with the anti-
CD20 antibody ofatumumab, leading to Food and
Drug Administration (FDA) approval of ibrutinib
in 2014 for relapsed or refractory CLL.3 The ef-
ficacy and safety of ibrutinib as frontline therapy
was established in the RESONATE-2 trial, which
showed significantly prolonged progression-free
survival (70% at 5 years)18 and overall survival
with ibrutinib as compared with chlorambucil.5
Response rates and improvements in hemoglo-
bin levels and platelet counts were greater with
ibrutinib. Arterial hypertension and atrial fibril-
lation were documented as additional side ef-
fects.5 The Alliance A041202 trial showed longer
progression-free survival with ibrutinib, alone or
in combination with rituximab, than with BR in
previously untreated patients with CLL.8 The ad-
dition of rituximab to ibrutinib, as compared
with ibrutinib alone, did not prolong progres-
sion-free survival in this trial8 or in another ran-
domized trial.62 The iLLUMINATE trial, which
compared ibrutinib plus obinutuzumab with
chlorambucil plus obinutuzumab,12 also showed
markedly longer progression-free survival in the
ibrutinib group. Finally, the National Clinical
Trials Network E1912 trial showed improved
progression-free and overall survival with ibruti-
nib plus rituximab as compared with FCR.9
Acalabrutinib, a second-generation, covalent
BTK inhibitor, has higher BTK selectivity than
ibrutinib; for example, acalabrutinib does not
inhibit epidermal growth factor receptor (EGFR),
interleukin-2–inducible T-cell kinase (ITK), or
TEC, which are tyrosine kinases that are at least
partially inhibited by ibrutinib. A phase 1–2 study
showed high response rates among patients with
relapsed or refractory CLL.4 The side effects of
acalabrutinib, including headache, diarrhea, up-
per respiratory tract infection, fatigue, nausea,
arthralgia, hypertension, and atrial fibrillation,
are similar to those of ibrutinib (except for aca-
467
 The n e w e ng l a n d j o u r na l
labrutinib-related headaches), but their frequen-
cy may be lower as a result of higher selectivity
for BTK.
Acalabrutinib received FDA approval for the
treatment of CLL (frontline treatment and
treatment of relapsed CLL) on the basis of two
randomized trials, ELEVATE-TN and ASCEND.
ELEVATE-TN, which evaluated acalabrutinib, with
or without obinutuzumab, as compared with
obinutuzumab plus chlorambucil, showed sig-
nificantly longer progression-free survival in the
acalabrutinib groups.14 The ASCEND trial, which
compared acalabrutinib with idelalisib (a PI3K
inhibitor) plus rituximab or BR,13 also showed
superior progression-free survival in the acala-
brutinib group. Adverse events of interest with
acalabrutinib in the ASCEND trial (median fol-
low-up, 16.1 months) were atrial fibrillation (in
5% of patients), bleeding (in 26%), grade 3 or
higher infections (in 15%), and secondary can-
cers (in 14%). In the ELEVATE-TN trial (median
follow-up, 28 months), adverse events associated
with acalabrutinib included atrial fibrillation (in
3% of patients in the acalabrutinib-alone group
and 4% in the acalabrutinib–obinutuzumab
group), grade 3 or higher bleeding (in 2% of
patients in both groups), and grade 3 or higher
hypertension (in 3% of patients in the acalabru-
tinib-alone group and 2% in the acalabrutinib–
obinutuzumab group). An ongoing randomized
trial will ultimately determine whether acalabru-
tinib differs significantly from ibrutinib with
respect to the side effect profile or efficacy.
Zanubrutinib, another covalent BTK inhibi-
tor, is also more BTK-selective than ibrutinib is.
On the basis of encouraging phase 1–2 data,63
CLL registration trials are ongoing.
Cardiac Arrhythmias, Fungal Infections,
and Bleeding with BTK Inhibitors
Several randomized studies showed an increased
incidence of atrial fibrillation in ibrutinib-treat-
ed patients.5,64 In a pooled analysis of ibrutinib-
treated patients, the incidence of atrial fibrilla-
tion was 6.5% after 16.6 months, as compared
with 1.6% for comparator therapy, and increased
to 10.4% after 36 months.64 Most patients with
atrial fibrillation received medical management,
including anticoagulant therapy, and did not need
to permanently discontinue ibrutinib. There have
also been rare reports of ventricular arrhythmias
and sudden death from cardiac causes in patients
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of m e dic i n e
treated with ibrutinib.65 Venetoclax can be con-
sidered as an alternative for patients at risk for
cardiac arrhythmias.
Fungal infections, especially aspergillus in-
fection, are another safety concern with ibruti-
nib. The incidence of aspergillus infection as-
sociated with ibrutinib therapy is lower among
patients with CLL than among patients with
central nervous system lymphoma. Predominant
sites of infection are the lungs and central ner-
vous system, and an early onset after the start of
ibrutinib therapy is characteristic.66 General anti-
fungal prophylaxis is not warranted in patients
with CLL, but particular attention to the risk of
fungal infection, especially during the first
months of therapy, is recommended for high-
risk patients (i.e., patients receiving concomitant
glucocorticoid therapy, those who have received
multiple lines of prior therapy, and those with
diabetes or liver disease).
Patients with CLL already have an increased
risk of bleeding complications, as compared
with healthy age-matched people, and treatment
with ibrutinib and other BTK inhibitors increas-
es the frequency of low-grade bleeding, especially
bruising. The bleeding is due to inhibition of
BTK-dependent platelet aggregation. An integrat-
ed analysis of 15 ibrutinib trials revealed that
the rate of low-grade bleeding was higher with
ibrutinib than with the comparator (35% vs. 15%).
Major hemorrhage was also more common with
ibrutinib than with the comparator (occurring in
4.4% of patients vs. 2.8%), but after adjustment
for the longer duration of therapy with ibrutinib,
the incidence of major hemorrhage was similar
(3.2 and 3.1 events per 1000 person-months,
respectively).67 In view of these effects, BTK in-
hibitors should be withheld perioperatively, and
patients receiving anticoagulant therapy should
be monitored for signs of bleeding.
PI3K Inhibitors
Idelalisib, an oral reversible inhibitor of PI3Kδ,
inhibits the signaling of the B-cell receptor and
CLL homing receptors.68 Like the BTK inhibi-
tors, idelalisib causes redistribution lymphocyto-
sis,39 which is shortened by the addition of anti-
CD20 antibodies, such as rituximab. In a
randomized phase 3 trial, idelalisib plus ritux-
imab significantly prolonged the rate of progres-
sion-free survival (93% at 24 weeks; median
survival, 20.3 months69) and overall survival, as
 Treatment of Chronic Lymphocytic Leukemia
compared with placebo plus rituximab.2 Because
of autoimmune side effects (hepatitis, colitis, and
pneumonitis), infectious side effects (pneumo-
cystis pneumonia and cytomegalovirus infection),
and lower efficacy than the BTK inhibitors,13
idelalisib is not the first-choice kinase inhibitor
for CLL therapy, but it is a valuable alternative
for patients in whom BTK inhibitors are associ-
ated with unacceptable side effects.
Duvelisib is a dual PI3K inhibitor that targets
PI3Kδ and PI3Kγ. In the DUO trial, duvelisib was
compared with ofatumumab.11 Longer progres-
sion-free survival (13.3 months vs. 9.9 months)
and higher response rates supported the FDA ap-
proval of duvelisib for relapsed or refractory CLL.
BCL2 Antagonist
Venetoclax is an orally administered, potent se-
lective inhibitor of BCL2.70,71 BCL2 is located in
the outer mitochondrial membrane, where it
inhibits proapoptotic proteins and supports cell
survival. BCL2 overexpression in CLL has been
linked to the deletion of miR-15a and miR-16-1,
two microRNAs located at chromosome 13q14.3.72
During the early development of venetoclax,
cases of severe tumor lysis syndrome occurred.
Therefore, slower dose escalation, with weekly
dose ramp-up and strict monitoring for the tu-
mor lysis syndrome, was implemented, with
proven safety in subsequent patients.6,7,10
The phase 1 trial of venetoclax in patients with
relapsed or refractory CLL showed high response
rates across all subgroups of patients with CLL
and a median progression-free survival of 25
months.6 Besides the tumor lysis syndrome, neu-
tropenia (but not thrombocytopenia) was a com-
mon side effect. In the MURANO trial, fixed-
duration therapy with venetoclax, given for 24
cycles (28 days per cycle) and combined with
rituximab during the first 6 cycles, significantly
improved survival, as compared with BR (2-year
progression-free survival rate, 84.9% vs. 36.3%).7
The CLL14 trial of the German CLL Study Group
also showed a major survival benefit with fixed-
duration venetoclax, given for 12 cycles and
combined with obinutuzumab during cycles 1
through 6, as compared with chlorambucil plus
obinutuzumab in elderly, previously untreated
patients with CLL (2-year progression-free sur-
vival rate, 88.2% vs. 64.1%).10 On the basis of the
CLL14 and MURANO data, venetoclax in combi-
nation with anti-CD20 antibodies received FDA
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approval as frontline treatment and treatment
of relapsed CLL. The durability of responses in
venetoclax-treated patients is associated with the
depth of remission; patients with a complete
response and remissions with undetectable MRD
have the longest remissions, whereas patients
with incomplete remissions, bulky disease, prior
therapy with a BTK inhibitor, or more than three
prior lines of therapy have shorter remissions.73
Venetoclax is an attractive alternative if BTK
inhibitors have unacceptable side effects or if
limited-duration therapy is preferred. In addition,
venetoclax is active in CLL that has developed
resistance to kinase inhibitors (ibrutinib or idelal-
isib), with an overall response in 65% of patients
and a median progression-free survival of 24.7
months.74 Given the unrestricted approval of
ibrutinib, acalabrutinib, and venetoclax for CLL
therapy in the United States, sequencing of these
agents is becoming an important topic. Cross-
trial comparisons are problematic, given the dif-
ferent regimens (long-term continuous adminis-
tration vs. time-limited administration), but so
far, no major differences in survival have been
noted between ibrutinib and venetoclax as front-
line treatment for CLL.
In a phase 2 study, ibrutinib was administered
in combination with venetoclax for 24 months.75
After 12 months, an impressive 88% of patients
had a complete response, and 61% had undetect-
able MRD. However, unlike patients treated with
chemoimmunotherapy76 or venetoclax,73 for whom
the depth of remission closely correlates with
the duration of the treatment response, patients
treated with a BTK inhibitor have an excellent
outcome without necessarily having a deep re-
mission,58 provided they can receive long-term
treatment that is associated with acceptable side
effects. The appeal of combination therapy in
which BTK inhibitors are administered with
venetoclax, anti-CD20 antibodies, or both is the
potential for treatment of limited duration.
Long-term follow-up of the combined-treatment
trials and randomized trials will determine
whether deeper remissions achieved by combin-
ing BTK inhibitors with other agents translate
into any survival benefit, as compared with BTK
inhibitor monotherapy administered indefinitely.
The anticipated randomized CLL17 trial of the
German CLL Study Group, comparing ibrutinib
as the standard of care with venetoclax plus
obinutuzumab or venetoclax plus ibrutinib, is
469
 The n e w e ng l a n d j o u r na l
expected to address this important question.
Given the shorter follow-up with venetoclax and
lack of prospective data about salvage therapy
for patients with venetoclax-resistant CLL, BTK
inhibitors normally are used before venetoclax
in most patients treated outside of clinical trials.
Resistance to the Novel Agents
Primary resistance to BTK inhibitors is highly
unusual in CLL. Redistribution lymphocytosis,
an expected on-target effect during the first
months of therapy, should not be confused with
disease progression. In patients who truly have
disease progression soon after the initiation of
kinase inhibitor therapy, Richter’s transforma-
tion (histologic progression to diffuse large B-cell
lymphoma), which normally occurs in less than
5% of patients with CLL, or alternative diagnoses
need to be considered. Secondary resistance (i.e.,
treatment failure after an initial response to a
BTK inhibitor) can be due to Richter’s transfor-
mation, which characteristically occurs early dur-
ing the first year of therapy,77,78 presumably from
progression of preexisting high-grade clones. CLL
progression during treatment with ibrutinib char-
acteristically occurs later in high-risk patients.1,79
Resistance to BTK inhibitors is often associ-
ated with BTK mutations at the ibrutinib binding
site (C481S), activating mutations in PLCG2, or
both.34,78,80 BTK mutations reduce the binding of
kinase inhibitors and therefore their efficacy,
whereas PLCG2 mutations result in BTK-indepen-
dent pathway activation.34 Moreover, del(8p) and
additional driver mutations have been described
in ibrutinib-resistant CLL.81 In a few selected
cases tested with droplet-microfluidic technology
and growth kinetic analyses, ibrutinib-resistant
subclones were already detectable at low levels in
pretreatment samples,81 suggesting that BTK
inhibitor therapy can cause clonal selection and
expansion. It has been proposed that kinase in-
hibitor therapy causes genomic instability through
up-regulation of activation-induced cytidine de-
aminase (AID), which could pave the way for
drug resistance or other cancers, on the basis of
data from mouse models and human B-cell
lines.82 Fortunately, AID up-regulation by idelal-
isib or ibrutinib could not be reproduced in
primary CLL cells (i.e., serial CLL cell samples
from ibrutinib-treated patients) or in CLL cells
induced in vitro to express AID by CD40 ligand
plus interleukin-4 stimulation. Under these more
physiologic conditions, ibrutinib down-regulat-
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of m e dic i n e
ed rather than up-regulated AID,83 which is more
consistent with the antiproliferative activity of
the kinase inhibitors.
Venetoclax resistance can be manifested as
recurrent CLL or, less frequently, as transforma-
tion to diffuse large B-cell lymphoma (Richter’s
transformation) and has been linked to BCL2
mutations (G101V) that reduce the binding of
venetoclax to BCL2, often with additional BCL2
mutations,84 emergence of clones with a complex
karyotype, mutations in BTG1 (the B-cell trans-
location gene) and aberrations of CDKN2A or
CDKN2B (the cyclin-dependent kinase genes,
which are more common with Richter’s trans-
formation), and overexpression of the prosur-
vival proteins BCL-XL and MCL1.85 Prospective
data on the management of venetoclax-resistant
CLL are needed. Although resistance is a common
reason for the failure of venetoclax treatment in
patients with relapsed CLL,73 ibrutinib therapy,
especially when used in early lines of treatment,
is more likely to fail because of adverse toxic
effects.77,86
Cellular Therapy
Although the use of BTK inhibitors and veneto-
clax has significantly improved survival, patients
with high-risk CLL continue to be at risk for
progressive disease due to the development of
resistance. Therefore, allogeneic hematopoietic
stem-cell transplantation should be considered
in selected younger patients with high-risk dis-
ease — those with del(17p), TP53 mutations, or
both and a complex karyotype — especially if
they have previously received chemoimmunother-
apy and subsequently had a relapse.6,10,61 The tim-
ing of transplantation has substantially changed
with the introduction of the new agents. Given
the high response rates with the new agents and
the significant transplantation-related morbidity
and mortality,87 patients generally receive a BTK
inhibitor, venetoclax, or both before they are
considered to be candidates for hematopoietic
stem-cell transplantation. In high-risk patients,
remissions with ibrutinib can be durable when it
is given as frontline therapy, but remissions are
generally shorter after prior exposure to chemo-
therapy. For example, the estimated 5-year pro-
gression-free survival rate among patients with
CLL and del(17p) or TP53 mutations was 74%
when ibrutinib was used as frontline therapy but
only 19% when it was used for the treatment of
relapsed CLL.88
 Treatment of Chronic Lymphocytic Leukemia

Clinical progress with autologous CD19 chi- acalabrutinib) induce durable remissions in the
meric antigen receptor (CAR) T-cell therapy in majority of patients, which are, however, mostly
CLL has been decelerated because of low re- partial. Hence, long-term treatment is required
sponse rates and short remissions.89 Recently, a when a BTK inhibitor is used as a single agent,
trial of CD19-targeting CAR T cells (at a 1:1 ratio
a plan that can be complicated by toxic effects
of CD4 and CD8 cells), together with ibrutinib, and the emergence of resistance. The BCL2 an-
in patients with ibrutinib-refractory CLL showed tagonist venetoclax, a more recent addition to
more promising results.90 This approach was more the therapeutic armamentarium, is typically given
active, inducing remissions with undetectable for a limited time, together with anti-CD20 anti-
MRD in the marrow in 61%, with a 12-month bodies, to induce deep remissions, but resistant
progression-free survival rate of 59% and an clones can emerge and clinical relapses occur,
overall survival rate of 86% among patients with especially in high-risk patients. The use of che-
undetectable MRD; it also had a better side-­ moimmunotherapy is steadily declining, given
effects profile, with less severe cytokine releasethe better side-effect profiles and improved sur-
syndrome. HLA-mismatched, CD19-directed CAR– vival with the novel agents. An exception is the
natural killer cells derived from cord blood may small group of younger, fit patients with low-
become another option for cellular therapy, given risk CLL (i.e., mutated IGHV), who often stay in
promising early safety and efficacy results.91 Be-remission for more than 10 years after treatment
cause approximately half of the patients with CLL with the FCR regimen. For such patients, FCR
who undergo allogeneic hematopoietic stem-cell treatment remains an alternative to the newer
transplantation have long-term remissions and agents. Clearly, the new agents have already im-
survival,87 allogeneic transplantation remains theproved the prognosis and quality of life for many
standard cellular therapy approach at this time. patients with CLL, especially those with high-
risk CLL. The challenge for this new decade is
to capitalize on the early success of the novel
C onclusions
agents with regimens that reduce the duration of
Basic and translational research underscored the drug exposure and the associated risks of toxic
importance of the B-cell receptor,28 the CLL mi- effects and resistance, as well as treatment costs.
croenvironment,92 and antiapoptotic proteins70 in Dr. Burger reports receiving grant support and advisory board
fees from Pharmacyclics, grant support, advisory board fees, and
the biology of CLL, and we now can look back at lecture fees from Gilead, advisory board fees from AstraZeneca,
a decade of transformative clinical research in and lecture fees and travel support from Janssen. No other poten-
CLL, with approval of drugs that target these key tial conflict of interest relevant to this article was reported.
Disclosure forms provided by the author are available with the
disease pathways. Within a short time, the BTK full text of this article at NEJM.org.
and PI3K inhibitors and venetoclax overturned I thank M.D. Anderson’s Moon Shot Program in CLL, the CLL
CLL treatment and replaced chemotherapy-based Global Research Foundation, Dr. Andreas Rosenwald for pro-
viding photomicrographs of lymph nodes in patients with CLL,
treatments for most patients who have this leu- and my family and colleagues for all their encouragement and
kemia. The BTK inhibitors (i.e., ibrutinib and support.

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