The risk factors for CLL, including the relevance of monoclonal B cell lymphocytosis

(MBL):

Chronic lymphocytic leukemia (CLL) is the most common leukemia in adults in Western
countries (Kipps et al., 2017), and while its exact cause is not fully understood, several risk
factors have been identified. Understanding these risk factors can provide insights into the
development of CLL and may help in identifying individuals who are at higher risk. Monoclonal
B cell lymphocytosis (MBL) is a precursor condition to CLL (Shanafelt et al., 2013) and is also
relevant in understanding the risk factors associated with CLL.

1. Age: CLL is primarily a disease of older adults, with the average age of diagnosis being
around 70 years old. The incidence of CLL increases with age, and it is rare in
individuals under 40 years old.

2. Genetic predisposition: Family history plays a significant role in the development of

CLL. Individuals with first-degree relatives (parents, siblings, or children) diagnosed
with CLL are at a higher risk of developing the disease themselves. Specific genetic
abnormalities, such as mutations in genes like ATM, TP53, NOTCH1, and SF3B1, have
been associated with familial CLL and may contribute to an increased risk.

3. Environmental factors: Certain environmental exposures have been linked to an

increased risk of CLL. These include exposure to certain chemicals such as benzene and
certain herbicides and pesticides. Additionally, exposure to ionizing radiation, such as
that experienced during radiation therapy for previous cancers, may increase the risk of
developing CLL.

4. Immune dysfunction: Abnormalities in the immune system have been implicated in the
development of CLL. Individuals with certain immune deficiencies or autoimmune
disorders may have an increased risk of CLL. Additionally, factors that suppress the
immune system, such as certain medications used in organ transplantation, may also
increase the risk.

5. Monoclonal B cell lymphocytosis (MBL): MBL is a precursor condition to CLL,

characterized by the presence of a small population of monoclonal B cells in the blood.
MBL is often detected incidentally during routine blood tests and does not typically cause
symptoms. While most individuals with MBL do not progress to CLL, some do over
time. The risk of progression to CLL is higher in individuals with certain types of MBL,
such as those with a higher absolute lymphocyte count or an abnormal
immunophenotype. Therefore, MBL is considered a significant risk factor for CLL, and
individuals with MBL should be monitored regularly for signs of disease progression.

Leaving aside the immunophenotype, the amount of circulating monoclonal B cells is the main
diagnostic criterion used to differentiate MBL from CLL. There are two different subtypes of

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MBL that have been identified: low-count MBL (LC-MBL), also known as "general" population
MBL, and high-count MBL (HC-MBL), also known as "clinical" MBL, with 0.5-4.99× 10^9
clonal B cells/L (Kipps et al., 2017). It should be mentioned that the majority of people with
MBL have normal absolute B cell counts, with less than 10% of all B cells being clonal B cells
(Shanafelt et al., 2013).

Growing older causes a progressive increase in the incidence of MBL; in fact, MBL is almost
never seen in those under 40, but it can be found in over 20% of those over 70 and up to 75% of
patients over 90 (Kipps et al., 2017). A familial history of solid or haematological malignancies
has also been linked to MBL, suggesting that age is not the only factor strongly associated with
the condition. In fact, 17% of first-degree relatives from families with at least two cases of CLL
who did not have a personal history of lymphoproliferative disorders were found to have MBL,
with some cases occurring at a young age (less than 40 years old) (Shanafelt et al., 2013). Gender
is another factor associated with MBL prevalence since, like CLL, males are far more likely than
females to develop MBL (Kipps et al., 2017).

At least in certain cases, immunodeficiency and infection exposure may also predispose to the
development of MBL, particularly when paired with advanced age and male gender. One notable
instance is the elevated occurrence of MBL in individuals infected with the hepatitis C virus
(HCV) (Kipps et al., 2017). However, it was discovered that those who had received an influenza
or pneumococcal vaccination had a noticeably lower incidence of MBL (Shanafelt et al., 2013).

Understanding these risk factors can help identify individuals who may benefit from closer
monitoring or early intervention strategies to detect CLL at an early stage when treatment may
be more effective. Additionally, identifying individuals with MBL allows for closer monitoring
and early intervention if progression to CLL occurs.

Importance of flow cytometry in the diagnosis of CLL:

Flow cytometry plays a crucial role in the diagnosis and characterization of chronic lymphocytic
leukemia (CLL). Here's why it's so important:

1. Identification of Abnormal Cell Populations: Flow cytometry allows for the analysis of
multiple characteristics of individual cells in a heterogeneous population (Rawstron et al.,
2008). In CLL, flow cytometry helps identify abnormal B-cell populations that express
characteristic markers such as CD5, CD19, CD20 (typically dim), and CD23 (Rawstron et
al., 2008). CLL cells typically have a distinctive immunophenotypic profile, which aids in
distinguishing them from normal B cells and other lymphoid malignancies.
2. Quantification of Abnormal Cell Numbers: Flow cytometry provides quantitative data on
the proportion of abnormal cells present in the sample (Rawstron et al., 2008). In CLL, this
is particularly important because the disease is characterized by the accumulation of
monoclonal B cells in the blood and bone marrow (Rawstron et al., 2008). By quantifying
the percentage of abnormal B cells, flow cytometry helps confirm the diagnosis and assess
disease burden.

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3. Detection of Minimal Residual Disease (MRD): Flow cytometry is sensitive enough to
detect minimal residual disease (MRD), which refers to the presence of residual cancer cells
in the body after treatment (Shanafelt et al., 2013). Assessing MRD levels after treatment
can help predict relapse and guide treatment decisions. In CLL, flow cytometry is used to
monitor MRD levels in the blood and bone marrow to evaluate treatment response and
disease progression.
4. Prognostic Marker Analysis: Flow cytometry can be used to assess additional markers
that have prognostic significance in CLL (Shanafelt et al., 2013). For example, the
expression levels of certain surface antigens, such as CD38 and ZAP-70, are associated with
disease progression and overall survival (Shanafelt et al., 2013). Flow cytometry allows for
the simultaneous analysis of these markers alongside the standard CLL panel, providing
valuable prognostic information that can guide treatment decisions.
5. Monitoring Disease Progression and Response to Treatment: Flow cytometry is used
serially to monitor disease progression and response to treatment in CLL patients (Rawstron
et al., 2008). Changes in the proportion of abnormal B cells and other immunophenotypic
characteristics can indicate disease progression or response to therapy. Regular monitoring
with flow cytometry helps clinicians adjust treatment strategies as needed to optimize
patient outcomes.

Importance of disease prognostication in CLL:

Prognostication in chronic lymphocytic leukemia (CLL) is crucial for several reasons:

1. Treatment Selection: Prognostic markers help guide treatment decisions in CLL. Certain
markers may indicate whether a patient is likely to have an aggressive or indolent disease
course, influencing the choice of therapy. Tailoring treatment based on prognostic factors
can improve outcomes and minimize unnecessary toxicity.

2. Risk Stratification: Prognostic markers allow for risk stratification of CLL patients,
categorizing them into different risk groups based on their likelihood of disease
progression and overall survival. This information helps clinicians identify patients who
may benefit from more intensive monitoring or early intervention strategies.

3. Clinical Trial Enrollment: Prognostic markers are often used to stratify patients
enrolled in clinical trials, ensuring that patients with similar risk profiles are grouped
together. This helps researchers evaluate treatment efficacy more accurately and may lead
to the development of targeted therapies for specific risk groups.

4. Patient Counseling: Prognostic information empowers patients and their families to

make informed decisions about their treatment and care. Understanding their prognosis
allows patients to plan for the future and optimize their quality of life.

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The relevance of FISH:

Fluorescence in situ hybridization (FISH) is a molecular cytogenetic technique used to detect

specific chromosomal abnormalities in CLL. It is particularly relevant in prognostication because
certain cytogenetic abnormalities are associated with different disease outcomes:

1. Del 13q: Patients with del 13q as the sole abnormality or in combination with other
abnormalities generally have a favorable prognosis and may have a more indolent disease
course.

2. Del 11q: Deletion of the long arm of chromosome 11 (del 11q) is associated with a
poorer prognosis and shorter time to disease progression. Patients with del 11q may
require more aggressive treatment approaches.

3. Del 17p: Deletion of the short arm of chromosome 17 (del 17p) is associated with a very
poor prognosis and resistance to standard CLL treatments. Patients with del 17p often
have a shorter overall survival and may require alternative therapeutic strategies, such as
novel targeted agents.

4. Trisomy 12: Trisomy 12 is associated with an intermediate prognosis in CLL, with

outcomes falling between those associated with del 13q and del 11q/del 17p.

In the case presented, the patient's FISH studies revealed the presence of del 13q and del 17p
abnormalities (Rossi et al., 2011). Additionally, molecular studies indicated an unmutated IGVH
gene status (U-CLL), which is also associated with a poorer prognosis (Rossi et al., 2011). These
findings suggest a high-risk disease profile for the patient. Despite being asymptomatic at
diagnosis, the patient's clinical symptoms and Binet stage B indicate a more advanced disease
stage.

Considering the patient's high-risk cytogenetic abnormalities and clinical stage, prognosis may
be less favorable, and the patient may require close monitoring and potentially more aggressive
treatment approache (Rossi et al., 2011s. However, the response to treatment with ibrutinib is
encouraging, as evidenced by the gradual reduction in lymphocytosis. Regular monitoring of
disease progression and response to therapy will be essential in managing the patient's CLL.

The role of small molecule inhibitors compared to “traditional” therapies (e.g. fludarabine,
cyclophosphamide and rituximab) in the treatment of CLL:

Small molecule inhibitors, such as ibrutinib, have emerged as promising treatments for chronic
lymphocytic leukemia (CLL) and offer distinct advantages compared to traditional therapies like
fludarabine, cyclophosphamide, and rituximab (FCR).

1. Mechanism of Action: Small molecule inhibitors target specific pathways or proteins

involved in the survival and proliferation of CLL cells. Ibrutinib, for example, is a

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 Bruton's tyrosine kinase (BTK) inhibitor that blocks B-cell receptor (BCR) signaling,
thereby inhibiting CLL cell proliferation and promoting cell death. In contrast, traditional
therapies like FCR work by inducing DNA damage or targeting CD20-positive B cells.

2. Efficacy: Small molecule inhibitors have shown impressive efficacy in CLL, including
high overall response rates and durable remissions. Clinical trials have demonstrated that
ibrutinib achieves superior progression-free survival (PFS) and overall survival (OS)
compared to traditional chemoimmunotherapy regimens like FCR, particularly in patients
with high-risk disease features or relapsed/refractory CLL.

3. Safety Profile: Small molecule inhibitors generally have a more favorable safety profile
compared to traditional chemotherapy. While traditional therapies are associated with
myelosuppression, increased risk of infections, and long-term toxicities, small molecule
inhibitors like ibrutinib typically cause fewer hematologic toxicities and are better
tolerated by elderly or frail patients.

4. Convenience: Small molecule inhibitors are administered orally, allowing for convenient
outpatient treatment compared to traditional intravenous chemotherapy regimens. This
reduces the need for hospital visits and minimizes treatment-related disruptions to
patients' daily lives.

In the case described, the patient was diagnosed with CLL with unfavorable prognostic
indicators, including unmutated IGVH gene status (U-CLL) and chromosomal abnormalities (del
13q and del 17p). Additionally, the patient presented with clinical symptoms indicating Binet
stage B CLL, suggesting a need for treatment.

Given the high-risk features and symptomatic disease, the rationale for prescribing ibrutinib in
this case is multifaceted:

1. Targeted Therapy: Ibrutinib, as a BTK inhibitor, targets the BCR signaling pathway,
which is essential for the survival and proliferation of CLL cells. By inhibiting BTK,
ibrutinib disrupts this pathway, leading to apoptosis of CLL cells and reducing disease
burden.

2. Improved Efficacy: Clinical studies have demonstrated the efficacy of ibrutinib in CLL,
particularly in patients with high-risk disease features such as U-CLL and del 17p.
Ibrutinib has been shown to achieve high overall response rates and durable remissions,
even in patients with relapsed/refractory CLL.

3. Tolerability: Ibrutinib has a favorable safety profile compared to traditional

chemotherapy, making it suitable for elderly patients or those with comorbidities. The
oral administration of ibrutinib also offers convenience and flexibility in treatment
delivery.

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 4. Long-Term Disease Control: Ibrutinib has demonstrated prolonged progression-free
survival and overall survival compared to traditional therapies, making it an attractive
option for patients requiring long-term disease control.

brutinib represents a targeted therapy with significant clinical benefits for patients with CLL,
especially those with high-risk disease features like the patient in this case (Byrd et al., 2013). Its
efficacy, tolerability, and convenience make it a preferred treatment option in the management of
CLL, particularly in the era of personalized medicine.

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