Primer: Chronic Lymphocytic Leukaemia

PRIMER
Chronic lymphocytic leukaemia

Thomas J. Kipps1, Freda K. Stevenson2, Catherine J. Wu3, Carlo M. Croce4,
Graham Packham2, William G. Wierda5, Susan O’Brien6, John Gribben7 and Kanti Rai8
Abstract | Chronic lymphocytic leukaemia (CLL) is a malignancy of CD5+ B cells that is characterized by
the accumulation of small, mature-appearing lymphocytes in the blood, marrow and lymphoid tissues.
Signalling via surface immunoglobulin, which constitutes the major part of the B cell receptor,
and several genetic alterations play a part in CLL pathogenesis, in addition to interactions between
CLL cells and other cell types, such as stromal cells, T cells and nurse-like cells in the lymph nodes.
The clinical progression of CLL is heterogeneous and ranges from patients who require treatment
soon after diagnosis to others who do not require therapy for many years, if at all. Several factors,
including the immunoglobulin heavy-chain variable region gene (IGHV) mutational status, genomic
changes, patient age and the presence of comorbidities, should be considered when defining the
optimal management strategies, which include chemotherapy, chemoimmunotherapy and/or drugs
targeting B cell receptor signalling or inhibitors of apoptosis, such as BCL‑2. Research on the biology
of CLL has profoundly enhanced our ability to identify patients who are at higher risk for disease
progression and our capacity to treat patients with drugs that selectively target distinctive
phenotypic or physiological features of CLL. How these and other advances have shaped our
current understanding and treatment of patients with CLL is the subject of this Primer.
Chronic lymphocytic leukaemia (CLL) is a malignancy of somatic hypermutation and, in some cases, also immuno
CD5+ B cells that is characterized by the accumulation globulin isotype switching (FIG. 1), similar to what occurs
of small, mature-appearing neoplastic lymphocytes in the in normal B cells during an immune response to antigen.
blood, marrow and secondary lymphoid tissues, result- It should be emphasized that the high level of somatic
ing in lymphocytosis, leukaemia cell infiltration of the mutations that arise in IGHV in the germinal centre are
marrow, lymphadenopathy and splenomegaly. Genetic a natural part of affinity maturation of antibodies and,
factors contribute to the development of CLL; although unlike mutations in other genes, are not pathological. The
CLL is the most common adult leukaemia in western tumours are simply reflecting the stage of maturation of
countries, it is less common in Asia and relatively rare the parental B cell. In addition, some CLL cells have been
in Japan and Korea, even among Japanese people who described that are similar to unmutated IGHV CLL, but
immigrate to western counties. originate from B cells with limited somatic mutation, such
CLL can be divided into two main subsets, which differ as CLL with immunoglobulin heavy chains encoded by
in their clinical behaviour. These subsets are distinguished mutated IGHV3‑21 and immunoglobulin light chains
by whether CLL cells express an u nmutated or mutated encoded by u nmutated IGLV3‑21 (REFS 3,4).
immunoglobulin heavy-chain variable region gene The repertoire of immunoglobin molecules prod
Correspondence to T.J.K. (IGHV), reflecting the stage of normal B cell differenti- uced by the CLL cells of all patients is considerably
Division of Hematology- ation from which they originate1,2. CLL cells that express more limited than the repertoire of immunoglobulin
Oncology, Department of an unmutated IGHV originate from a B cell that has not molecules that can be made by the B cells of any one
Medicine, Moores Cancer
Centre, University of
undergone differentiation in germinal centres, which are person5,6, reflecting the biased use in CLL of certain
California, San Diego, the sites in the lymph nodes where B cells experience IGHV genes that have restricted somatic mutation and
3855 Health Sciences Drive somatic hypermutation in their immunoglobulin variable limited junctional and heavy–light chain combinatorial
M/C 0820, La Jolla, region genes and selection during an immune response. diversity. In as many as one-third of patients, the CLL
California 92093, USA.
Patients with CLL cells that express an unmutated IGHV cells express immunoglobulin ‘stereotypes’, which are
[email protected]
typically have more-aggressive disease than patients with stretches of primary structure in the variable region that
Article number: 16096 CLL cells that express a mutated IGHV. CLL cells with can also be identified in the immunoglobulins prod
doi:10.1038/nrdp.2016.96
Published online 19 Jan 2017; mutated IGHV arise from a post-germinal centre B cell uced by the CLL cells of other patients7. The restricted
corrected online 9 Feb 2017 that expresses immunoglobulin that has undergone immunoglobulin repertoire in CLL is underscored by the
NATURE REVIEWS | DISEASE PRIMERS VOLUME 3 | 2017 | 1

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PRIMER
Author addresses of individuals in eastern Asia to ~0.06% of individuals in

Europe and the United States. The risk of developing CLL
1
Division of Hematology-Oncology, Department of is about two‑times higher for men than for women and
Medicine, Moores Cancer Centre, University of California, increases with age; the median age at diagnosis ranges
San Diego, 3855 Health Sciences Drive M/C 0820, La Jolla, from 70 to 72 years11–14.
California 92093, USA.
The US National Cancer Institute Surveillance,
2
Southampton Cancer Research UK Centre, Cancer
Sciences Academic Unit, Faculty of Medicine, University Epidemiology, and End Results programme has estim
of Southampton, Southampton, UK. ated the number of new cases of CLL to be 6.3 per 100,000
3
Dana-Farber Cancer Institute, Boston, Massachusetts, USA. men and 3.3 per 100,000 women. The incidence in white
4
Department of Molecular Virology, Immunology and populations is estimated to be 6.8 per 100,000 men and
Medical Genetics, Ohio State University, Columbus, 3.5 per 100,000 women, 4.9 per 100,000 men and 2.4 per
Ohio, USA. 100,000 women in African Americans, 2.7 per 100,000
5
Department of Hematology, MD Anderson Cancer Centre, men and 1.6 per 100,000 women in Hispanic Americans,
Houston, Texas, USA. 1.7 per 100,000 men and 1.3 per 100,000 women in
6
Division of Hematology, Department of Medicine, Indigenous Americans, and 1.7 per 100,000 men and
University of California, Irvine, California, USA.
0.3 per 100,000 women in people of Asian or Pacific Island
7
Department of Haemato-Oncology, Barts Cancer
Institute, Queen Mary University of London, London, UK. descent in the United States13.
8
CLL Research and Treatment Program, Feinstein Institute
for Medical Research, Northwell Health, New Hyde Park, Hereditary factors
New York, USA. Genetic factors contribute to disease susceptibility;
among patients who are registered in the CLL Research
Consortium, 9% of patients have a relative with CLL.
finding that ~1 in 75 patients have CLL cells that express In addition, first-degree relatives of patients with CLL
immunoglobulin molecules that are virtually identical8. have an 8.5‑fold increased risk of developing this disease15,
The limited immunoglobulin diversity provides com- and the concordance of CLL is higher among mono
pelling evidence that CLL B cells are selected based on zygotic twins than among dizygotic twins16. Genome-
the binding activity of their expressed surface immuno wide association studies have identified SNPs in nearly
globulin, suggesting that B cell receptor (BCR) signalling 30 loci that are associated with familial CLL, demonstrat-
plays a crucial part in CLL pathogenesis. ing that common genetic variation contributes to heritable
Several large genetic studies have revealed numerous risk17–22 (see Supplementary information S1 (table)).
genetic alterations in CLL, including single-nucleotide The altered expression of genes that are located in or
polymorphisms (SNPs), chromosomal alterations and near CLL-associated SNPs might contribute to disease
alterations in non-coding RNA, such as microRNA development. For example, a SNP in IRF4 is associated
(miRNA), some of which can be used to determine prog- with low expression of interferon regulatory factor 4; mice
nosis and to guide management strategies. Interactions that are deficient in this protein can develop CLL23, partly
between CLL cells and their microenvironment, including owing to hyperactivation of Notch signalling 24. SNPs in
interactions with other cell types, such as T cells, nurse- LEF1 might be associated with high expression of lym-
like cells and stromal cells, can induce B cell proliferation phoid enhancer-binding factor 1, which is a downstream
and contribute to disease. effector of WNT signalling; normally, LEF1 is expressed
The distinctive cytogenesis of CLL contrasts with most at high levels in CLL and, among other functions, can
other B cell malignancies, such as follicular lymphoma, enhance resistance to cell death25. In addition, CLL-
which is a germinal centre neoplasm, or myeloma (a post- associated SNPs have been found in BCL2, which encodes
germinal centre neoplasm)9,10. However, diffuse large an anti-apoptotic protein that is expressed at high levels
B cell lymphoma (DLBCL) resembles CLL in consisting in CLL, and in PMAIP1, which encodes a pro-apoptotic
of two main subtypes: a germinal centre B‑type DLBCL, protein. A SNP that is associated with reduced expres-
which is derived from germinal centre light zone B cells, sion of mir‑15a and mir-16‑1 is associated with familial
and an activated B cell (or non-germinal centre) DLBCL, CLL26,27. Because mir‑15a and mir-16‑1 repress the expres-
which is derived from a later stage of germinal centre sion of BCL2 and ZAP70 (REFS 26,27), reduced expression
differentiation (before plasmablastic differentiation)10. of these miRNAs allows for the increased expression of
As in CLL, these two subtypes of DLBCL generally have these genes, which encode proteins that respectively
distinctive responses to therapy and clinical outcomes. confer increased resistance to cell death28 or enhanced
In this Primer, we describe the molecular patho BCR signalling 29. Similarly, New Zealand black mice
genesis of CLL and discuss the current advances that are have an allele at the mir-16‑1 locus with shared synteny
shaping our understanding and treatment of patients with to human 13q14, which is associated with low expression
this disease. of mir‑16‑1; this allele is linked to the genetic propensity of
these mice to develop a B cell lymphoproliferative disease
Epidemiology that resembles CLL30. Finally, a CLL-linked SNP in TERT
CLL is estimated to account for ~19,000 of all newly is associated with a long leukocyte telomere length31, con-
detected cancers in the United States in 2016 (REF. 11). The ceivably contributing to the high rates of telomeric sister
average incidence of CLL varies between individuals in chromatid exchange observed in CLL cells that could slow
different geographical regions and ranges from <0.01% telomere erosion leading to cellular senscence32.
2 | 2017 | VOLUME 3 www.nature.com/nrdp

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PRIMER
Environmental factors epidemiological studies have not found evidence that

The US Department of Veterans Affairs has accepted blood transfusions can transmit CLL37. No evidence
that exposure to Agent Orange is a risk factor for CLL, suggests that dietary factors or lifestyle factors increase
which has enabled veterans with CLL to claim benefits the risk of CLL.
if they were previously exposed to Agent Orange while
in military service33. In addition, evidence suggests that Mechanisms/pathophysiology
exposure to insecticides might be a risk factor for CLL34. Genetics
By contrast, little evidence indicates that ionizing radi Genetic alterations in CLL can include chromosomal
ation can increase the risk of CLL35,36. Furthermore, there alterations, mutations, alterations in the expression of
is scant evidence that viral infections are risk factors, and miRNAs and epigenetic modifications.
Chromosomal alterations. Approximately 80% of

Selection patients with CLL carry at least one of four common
Dark Light chromosomal alterations: a deletion in chromosome
zone zone
13q14.3 (del(13q)), del(11q), del(17p) and trisomy 12
(REF. 38). Del(13q) is the most common chromosomal
Low affinity
alteration, evident in >50% of patients, and is associ-
Apoptosis ated with favourable prognosis. Within this deleted
region is the DLEU2–mir-15‑16 cluster, which regu-
Proliferation lates the expression of proteins that can inhibit apop-
CD5+ Improved
B cell
and SHM
affinity tosis or that are involved in cell cycle progression39
FDC (see Supplementary information S2 (table)). Del(17p) is
found in 7% of patients and is associated with loss of the
tumour suppressor gene TP53 (REF. 40), whereas del(11q)
TH is found in 18% of patients and is often associated with
Constrained cell
SHM?
alterations in ATM (which encodes a protein involved
in DNA repair); each of these chromosomal alterations
Class
is associated with adverse clinical outcome38, although
switching this has improved in recent years41. Trisomy 12 is found
in 16% of patients with CLL and is associated with an
intermediate prognosis. Unlike the neoplastic B cells in
mantle cell lymphoma, CLL cells do not have the trans-
Class- location t(11;14)(q13;q32) or other genetic alterations
IgM+IgD+ switched
memory memory that enhance the expression of CCND1, which encodes
B cell B cell the cell cycle regulator cyclin D1.
Somatic mutations. The advent of massively p arallel

sequencing and the application of whole-exome
sequencing to CLL have transformed our understanding
IGHV-unmutated CLL with limited SHM IGHV-mutated IGHV-mutated of the genetic heterogeneity of CLL and have established
IgM+IgD+ CLL (e.g. IGHV3-12/IGLV3-21) IgM+IgD+ CLL Ig+ CLL
that CLL harbours a high degree of genetic variability 42–45
Figure 1 | Cellular origins of CLL cells. Normal naive B cells
Naturethat have undergone
Reviews | Disease Primers (FIG. 2). From these studies, recurrent somatic mutations
successful V(D)J recombination and express functional B cell receptors that are capable have been consistently observed in genes that have a
of binding to antigen interact with CD4+ T cells and accessory cells, which aggregate to role in DNA damage (for example, TP53 and ATM),
form follicles that become germinal centres. Germinal cells each have a dark zone, mRNA processing (for example, SF3B1 and XPO1),
comprising rapidly dividing B cells, and a light zone, comprising B cells mixed with
chromatin modification (for example, HIST1H1E,
follicular dendritic cells (FDCs), macrophages and helper T cells (TH cells). The B cells
enter the dark zone of the germinal centre where they experience rapid proliferation CHD2 and ZMYM3), WNT signalling, Notch signal-
and somatic hypermutation (SHM) in the genes encoding the immunoglobulin variable ling (for e xample, NOTCH1) and inflammatory path-
regions of the heavy chain (IGHV) and the light chain (IGVL). As they pass through to the ways (for example, MYD88). Other mutations, such as
light zone, the B cells that express the fittest B cell receptors for binding antigen are those found in EGR2 or BRAF, can affect B cell-related
selected and may undergo immunoglobulin class-switch recombination. Chronic signalling and transcription46 (FIG. 2).
lymphocytic leukaemia (CLL) cells that use unmutated IGHV apparently originate from The functional role of several putative driver muta-
CD5+ B cells prior to experiencing SHM, whereas CLL cells that use mutated IGHV most tions has been confirmed; for example, silencing
likely originate from CD5+ B cells that have passed through and differentiated in the mutated WNT pathway genes in primary CLL cells
germinal centre. Some CLL cells might be derived from B cells that also have undergone resulted in decreased cell viability 47. Mutations in POT1,
immunoglobulin class-switch recombination and express immunoglobulin isotypes other
which has a role in the protection of telomeres, pre-
than IgM and IgD, for example, IgG or IgA. Another subset is one with CLL cells that
express immunoglobulin with only modest somatic mutations, such as CLL cells that use vented the binding of protection of telomeres protein 1
IGHV3-21 with ~97% homology to the inherited IGHV3-21 gene and an immunoglobulin to telomeric DNA, resulting in numerous chromosomal
light chain encoded by an unmutated IGLV3-21; these cells might derive from a B cell abnormalities, in addition to the development of abnor-
that has had constrained SHM, possibly owing to a limited need for immunoglobulin mal telomeres. Mutations in SF3B1 have been found
somatic diveresification and selection. Dashed arrows indicate speculated pathways. to be associated with aberrant RNA splicing 45,48,49 and

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PRIMER
Notch signalling Inflammatory pathways BCR signalling WNT signalling

and differentiation
NOTCH1
CD79A CD21 CD22 Frizzled
IL-1R CD79B CD19 CD45
NOTCH3 TLR8 TNFR1 WNT LRP5/6
BCR
NOTCH4
CD14
Metalloprotease MYD88 MYD88 RIPK1 LYN SYK LYN Cytoplasm

γ-secretase
* Dishevelled
SHP1
IC
Multiprotein
BIRC3 ITPKB CARD11 destruction β-catenin
complex
MAPK–ERK P Proteosomal
FBXW7 NOTCH-IC DDX3X β-catenin degradation
pathway
TRAF3 KRAS β-catenin MYC-related pathway
TRAF2 NRAS FUBP1 MGA
–
SAMHD1 BRAF PTPN11 FBXW7
GNB1
MAP2K1 MYC
Nucleus
BCOR
C-NOTCH Co-A EGR2 β-catenin
Transcription Transcription Transcription
CSL IRF4 NF-κB MED12 TCF/LEF
DNA damage and cell cycle control Chromatin modification RNA and ribosomal processing
5' 3'
DNA damage Intron
POT1 Pre-mRNA Exon Exon
H1.5
H3 H2B
H4 H2A
TTAGGG Splicing
K36 H1.4
P K9 Spliceosome
ATM POT1
ATM EWSR1
Histone FUBP1 SF3B1
CHK2 K27 deacetylation NXF1
K4 K20 ZMYM3 3' end processing
DYRK1A POT1
p53 XPO4
H3K27 Nuclear mRNA Exon Exon XPO1
ELF4 ASXL1
methylation remodelling mRNA export DDX3X
IKZF3
Cell cycle DNA-damage H3K4 mRNA
BRCC3 methylation CHD2 translation RPS15
control repair BAZ2A
Figure 2 | Range of somatic mutations in CLL. Genes that are mutated in chronic lymphocytic leukaemia (CLL) are
involved in several cellular pathways (blue boxes). As such, mutations in these genes canNature
lead to Reviews
a range of| Disease
cellular Primers
consequences, such as aberrant DNA repair and B cell receptor (BCR) signalling, among others51,213. The minus sign from
GBN1 to the MAPK–ERK pathway indicates negative regulation. *For more detail of the BCR and its associated signalling,
see FIG. 3. ASXL1, additional sex combs-like protein 1; ATM, ataxia telangiectasia mutated; BAZ2A, bromodomain adjacent
to zinc-finger domain protein 2A; BCOR, BCL‑6 co-repressor; BIRC3, baculoviral IAP repeat-containing protein 3;
BRCC3, BRCA1/BRCA2‑containing complex subunit 3; C-NOTCH, carboxy-terminal domain of NOTCH; CARD11, caspase
recruitment domain-containing protein 11; CHD2, chromodomain-helicase-DNA-binding protein 2; CHK2, checkpoint
kinase 2; Co-A, co-activator; CSL, CBF1–Suppressor of Hairless–LAG1 (also known as RBPJ); DDX3X, ATP-dependent RNA
helicase DDX3X; DYRK1A, dual-specificity tyrosine-phosphorylation-regulated kinase 1A; EGR2, early growth response 2;
ELF4, ETS-related transcription factor Elf‑4; ERK, extracellular signal-regulated kinase; EWSR1, Ewing sarcoma breakpoint
region 1 protein; FBXW7, F-box/WD repeat-containing protein 7; FUBP1, far upstream element-binding protein 1; GNB1,
guanine nucleotide-binding protein G(I)/G(S)/G(T) subunit β1; H3K4, histone H3 lysine 4; IC, intracellular domain; IKZF3,
Ikaros family zinc-finger protein 3; IL-1R, IL-1 receptor; IRF4, interferon regulatory factor 4; ITPKB, inositol-trisphosphate
3‑kinase B; LRP, low-density lipoprotein receptor-related protein; MAP2K1, dual-specificity mitogen-activated protein
kinase kinase 1; MAPK, mitogen-activated protein kinase; MED12, Mediator of RNA polymerase II transcription subunit 12;
MGA, MAX gene-associated protein; MYD88, myeloid differentiation primary response protein MyD88; NF-κB, nuclear
factor-κB; NXF1, nuclear RNA export factor 1; P, phosphate; POT1, protection of telomeres protein 1; PTPN11,
tyrosine-protein phosphatase non-receptor type 11; RIPK1, receptor-interacting serine/threonine-protein kinase 1;
RPS15, 40S ribosomal protein S15; SAMHD1, SAM domain and HD domain-containing protein 1; SF3B1, splicing factor 3B
subunit 1; SHP1, Src homology region 2 domain-containing phosphatase 1 (also known as PTPN6); SYK, spleen tyrosine
kinase; TCF/LEF, T cell factor/lymphoid enhancer factor; TLR8, Toll-like receptor 8; TNFR1, tumour necrosis factor
receptor 1 (also known as TNFRSF1A); TRAF, TNFR-associated factor; XPO, exportin; ZMYM3, zinc-finger MYM-type
protein 3. Adapted with permission from REF. 51, Macmillan Publishers Limited.

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PRIMER
an altered DNA-damage response50. SAMHD1 encodes a of Bruton tyrosine kinase (BTK)), revealed mutations
protein involved in the regulation of intracellular deoxy associated with drug resistance that were distinct from
nucleotide pools, which are recruited to the site of DNA those observed in CLL cells of patients treated with
damage and are probably involved in the response to standard chemotherapy 58.
DNA double-strand breaks50.
The detection of somatic mutations and their miRNA alterations. CLL was the first human disease
relative frequencies is variable, which possibly reflects that was found to be associated with alterations in
differences in the composition of the cohorts stud- miRNA. Specifically, mir‑15a and mir‑16‑1 (REF. 59) are
ied worldwide. Two seminal studies have provided deleted, altered or downregulated in ~60% of patients
the largest sequenced collections to date51,52, in which with CLL and are dysfunctional in a few cases of famil-
>500 CLL samples were characterized by whole-exome ial CLL26. mir‑15a and mir‑16‑1 both target BCL2 and
sequencing or whole-genome sequencing. The clinical MCL1 (REF. 28), which encode anti-apoptotic proteins
and/or biological features of the patients examined in of the BCL‑2 family 60; reduced expression or loss of
each study were notably distinct; one study analysed these miRNAs can enhance the expression of these
matched pretreatment samples from patients who target genes. Attention has also focused on miRNAs
required initial treatment and noted mutations in SF3B1 that are dysregulated or that are differentially expressed
(21% of patients), ATM (15% of patients), TP53 (7% in subgroups with distinctive clinical and/or bio
of patients), NOTCH1 (6% of patients) or BIRC3 (4% of logical features61 (see Supplementary information S2
patients). The other study assessed patients with early- (table)). For example, miR‑29a/b, miR‑29c, miR‑34b,
stage CLL and patients with monoclonal B cell lympho- miR‑181b and miR‑3676 target the 3ʹ untranslated
cytosis and identified NOTCH1 (12.6% of patients), ATM region of TCL1A62; loss or reduced expression of all or
(11% of patients), BIRC3 (8.8% of patients) and SF3B1 some of these miRNAs can lead to enhanced expres-
(8.6% of patients) as the most frequently mutated genes. sion of TCL1A, which, when constitutively expressed
These large sample cohorts have provided the sensi in mature B cells, promotes the development of CLL in
tivity to discover novel candidate cancer genes that are transgenic mice63. By contrast, increased expression of
altered in CLL. Both studies also identified somatic mir‑155 is associated with enhanced BCR signalling,
mutations in MGA and PTPN11, which encode modu B cell p
roliferation and lymphomagenesis64,65.
lators of MYC, IKZF3, which encodes a key transcription
factor, and RPS15, which encodes 40S ribosomal protein Epigenetic changes. The CLL epigenome shows global
S15 and is recurrently mutated in ~20% of patients who hypomethylation combined with local hypermethyl
relapse after combination chemotherapy 53. Other recur- ation, as has been observed in other cancers66–68. Indeed,
rent somatic mutations include those in the 3ʹ untrans- comprehensive methylation profiling has demon-
lated region of NOTCH1 and a PAX5 enhancer, which strated substantial intra-tumoural methylation hetero
increases the expression of these B cell-associated tran- geneity 52,69–73. Increasing methylation heterogeneity
scription factors54,55. Patients with mutations in the has consistently been associated with increased genetic
3ʹ untranslated region of NOTCH1 have a shorter time complexity owing to the acquisition of subclonal muta-
from diagnosis to treatment and poorer overall sur- tions, thus linking genomic and methylomic evolution
vival, similar to that of patients with non-synonymous in CLL52,70,71. Indeed, locally disordered methylation in
mutations, which alter the amino acid sequence CLL might enhance the evolutionary adaptive capacity
of NOTCH1. of CLL cells by increasing the background ‘noise’ of the
Next-generation sequencing has revealed intra- genome, thereby providing increased opportunities for
tumoural heterogeneity in CLL. Some somatic muta- somatic mutations within the leukaemia clone. In sup-
tions, such as those in MYD88, or chromosomal port of this notion is the observed association between
abnormalities, such trisomy 12 or del(13q), are most methylation evolution and adverse clinical outcome52,70,71.
often found in all the CLL cells of any one patient, indi- Methylation signatures can classify distinct clinical
cating that these genetic alterations occurred early in CLL subgroups69,74. As these methylation patterns are
the evolution of the leukaemia. Other mutations, such a heritable trait, they have been used to ‘trace’ back to
as those found in SF3B1 or NOTCH1, or chromosomal the type of normal B cell from which the CLL cells were
alterations, such as del(17p), are typically found in only derived75. These studies revealed that the CLL cells of dif-
a fraction of the leukaemia cells and thus represent sub- ferent patients derive from a continuum of B cell matur
clonal events, which occur after the development of CLL. ation states, which are not restricted to discrete maturation
Across studies, subclonal driver mutations are associated stages. Nevertheless, CLL cells that use unmutated IGHV
with more-aggressive disease, particularly when two or versus mutated IGHV generally have distinctive methyl-
more are found concurrent in a leukaemia cell popula- ation patterns, which respectively approximate to those of
tion51,56,57. In addition, studies have demonstrated that pre-germinal centre versus post-germinal centre memory
large clonal shifts can occur following chemotherapy, B cells, as depicted in FIG. 1. The diversity in the likely cells
owing to increases in the proportions of CLL cells that of origin of CLL cells highlights the biological and pheno
have a TP53 mutation or del(17p), indicating that such typic heterogeneity of this disease. These findings also
genetic changes provide a strong fitness advantage in suggest that epigenetic programming that is dependent
the setting of therapy 51. By contrast, one study of CLL of transcription factors has a potentially important role
cells from patients treated with ibrutinib (an inhibitor in the development of CLL.

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PRIMER
Idelalisib Ibrutinib success of kinase inhibitors that block BCR signalling

Duvelisib ONO-4059 (see Management), although effects on other receptors
Antigen Pilaralisib ACP-196 might also have a role80.
TGR-1202
GS-9820
Like most cancers, CLL is heterogeneous and the
ACP-319 outcome of BCR signalling ranges from enhanced B cell
CD19
BCR activation to B cell anergy 81,82. The main pathways that
lead to cell survival and proliferation downstream of the
BCR are shown in FIG. 3, along with drugs targeted against
CD79A
CD79B
PI3K BTK
key signalling intermediates. BCR signalling that leads to
LYN SYK
BLNK AKT PLCγ2 anergy is less well defined, but seems to involve biased
VAV activation of inhibitory molecules with only partial activ
Fostamatinib ation of the pathways that are typically associated with
GS-9973 B cell activation81. One important molecule that may be
PRT-2070
MEK RAC1/2 Ins(1,4,5)P3 DAG
involved is the inositol lipid phosphatase SHIP1. SHIP1
RHOA/G is activated by the tyrosine-protein kinase LYN and may
limit B cell activation by counteracting phosphoinositide
Ca2+ RAS 3‑kinase (PI3K) activity at both chronically engaged
receptors and distant non-ligated BCRs, rendering them
insensitive to stimulation82,83.
ERK mTORC1 PKC MEK Enhanced B cell activation is more commonly
observed in CLL that expresses unmutated IGHV,
whereas anergy predominates in most cases of CLL that
IKK
express mutated IGHV84. Anergy is a state of cellular
lethargy induced by chronic engagement of the sur-
face antigen receptors in the absence of adequate T cell
NF-κB ERK help. Although capable of reversing their phenotype,
Figure 3 | B cell receptor signalling response. B cell receptor (BCR) signalling is initiated anergic cells are less likely to proliferate in response to
Nature Reviews | Disease Primers
by SRC-family kinase-dependent phosphorylation (mainly LYN) of CD79A and CD79B BCR signalling than more activated cells, which might,
that creates a docking site for the binding and activation of spleen tyrosine kinase (SYK). in part, account for the observation that patients with
SYK then triggers the formation of a multi-component ‘signalosome’, comprising Bruton CLL cells that express mutated IGHV generally have
tyrosine kinase (BTK), AKT, phosphoinositide 3‑kinase (PI3K), phospholipase Cγ2 (PLCγ2) more indolent disease than patients with CLL cells with
and B cell-linker protein (BLNK), among others. CD19 is a co‑receptor for BCR and is unmutated IGHV85. The fate of the cell (activation versus
important for PI3K activation, which recruits and activates PLCγ2, BTK and AKT.
anergy) might be influenced by the CLL cell of origin
PLCγ2 generates diacylglycerol (DAG) and inositol‑1,4,5‑trisphosphate (Ins(1,4,5)P3),
(FIG. 1), as the cell types that can form CLL differ in their
which triggers Ca2+ release from the endoplasmic reticulum, leading to the activation
of the MEK–extracellular signal-regulated kinase (ERK) and nuclear factor-κB (NF‑κB) patterns of DNA methylation73, and are likely to respond
signalling pathways. Other effects of BCR signalling include activation of mechanistic differently to autoantigens. An unresolved question is
target of rapamycin complex 1 (mTORC1) and of Rho-family GTPases, RAC1 and RHOA, whether anergy can be reversed in vivo, mirroring what
which can affect the cytoskeleton. Inhibitors of SYK, PI3K and BTK are shown. Note that occurs in vitro78.
this figure describes the main molecules and interactions that are involved in positive The BCR also coordinates the activity of other cell sur-
BCR signalling, but is not an exhaustive description of all signalling pathways or molecules face receptors, including integrins, such as α4β1 integrin.
activated. IKK, IκB kinase; PKC, protein kinase C. BCR stimulation can result in increased adhesion of CLL
cells to α4β1 integrin substrates, for example, fibronectin
BCR and B cell signalling and vascular cell adhesion protein 1 (REF. 86). By contrast,
The BCR is composed of a ligand-binding trans CXC-chemokine receptor 4 (CXCR4) is downmodulated
membrane immunoglobulin molecule (either IgA, IgD, by BCR engagement and both can trigger ‘inside-out’
IgE, IgG or IgM) and the signalling Igα (also known signalling, resulting in the activation of α4β1 integrin87,88.
as CD79A)–Igβ (also known as CD79B) heterodimer. Thus, recognized antigen encountered in lymphoid tissue
CLL cells typically co‑express IgD and IgM, although at is likely to affect adhesion and migration of CLL cells.
low levels compared with normal B cells; less than a few Modulation of these pathways, coupled with the role
per cent of CLL cases express class-switched isotypes, of BTK and PI3K in chemokine receptor signalling 89,
most commonly IgG. The CD79A and CD79B mol contribute to the increased lymphocytosis observed in
ecules contain immunoreceptor tyrosine-based activ patients upon initiation of treatment with inhibitors of
ation motifs, which can be phosphorylated following BTK or PI3K (see Management).
the crosslinking of surface immunoglobulin, thereby
triggering BCR signalling. A functional BCR is required Cancer microenvironment
for the survival of mature B cells76 and is maintained in CLL cells depend on survival signals that they receive in
most mature B cell malignancies, including CLL. In CLL, lymphoid tissues from neighbouring non-neoplastic cells
evidence suggests that the surface immunoglobulin of within the so‑called cancer microenvironment. CLL
CLL B cells is engaged by autoantigen, which leads to cells follow chemokine gradients into lymph nodes, where
constitutive BCR signalling in vivo 77–79. The impor- they form ‘proliferation centres’ (REF. 77), as opposed to
tance of this interaction is underscored by the clinical normal germinal centres. In these proliferation centres,

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the CLL cells contact non-malignant stromal cells, nurse- which activate canonical nuclear factor-κB (NF‑κB)90,
like cells (also known as lymphoma-associated macro before they exit to the blood. Activation of NF‑κB can
phages), T cells and mesenchymal-derived stromal cells induce the expression of mir‑155, which enhances BCR
(FIG. 4). Engagement with autoantigen may occur during signalling and activation by reducing the expression
this transit, thereby stimulating CLL cell activation and of INPP5D, which encodes SHIP1 (REF. 65). Cytokines
proliferation if sufficient T cell help is available. Only that are secreted by T cells, such as IL‑4, can upregu-
a few per cent of the CLL cells undergo proliferation late surface IgM, which potentially facilitates the inter-
at any one time; the remainder of the cells are either action of the CLL cell with autoantigen91. In addition,
unstimulated or driven into anergy 84. However, within the elaboration of various WNT proteins by cells in the
such proliferation centres, all CLL cells are exposed to microenvironment can activate canonical and non-
chemokines, integrins, cytokines and survival factors canonical WNT signalling pathways92,93. Activation of the
(such as tumour necrosis factor (TNF) ligand super- tyrosine-kinase-like transmembrane receptor ROR1 by
family member 13B (also known as BAFF) or TNF WNT5A can induce the activation of RAC1 and RHOA,
ligand superfamily member 13 (also known as APRIL)), and thereby enhance CLL cell proliferation and promote
T cell
CCR1/3
CCR4
IL-10
CD40L
IL-4
CCL3/4 CD40 CCL12/22
HEV
endothelial BCR Nurse-like
cell Antigen cell
CCL3/4
CCR1/3
CCL19
BAFFR
CCL21 TACI APRIL
CCR7 CLL
B cell BCMA BAFF
CD31
CD44
Hyaluronan
CXCR5 CD38
CXCR4
Frizzled CXCL13
CXCL12
ROR2
α4β1 ROR1
integrin
WNT CXCL12
WNT5A
VCAM1
Stromal cell
Figure 4 | CLL microenvironment. Migration of chronic lymphocytic leukaemia (CLL) cells into the lymphoid
Nature Reviews |tissue is Primers
Disease
primarily mediated through CXC-chemokine receptor 4 (CXCR4) in response to CXC-chemokine ligand 12 (CXCL12),
which is secreted mainly by nurse-like cells (NLCs) and mesenchymal-derived stromal cells. Migration of CLL cells into
lymph nodes also occurs via CC-chemokine receptor 7 (CCR7) in response to CC-chemokine ligand 19 (CCL19) and
CCL21, which are produced by the endothelial cells of high endothelial venules (HEVs). HEV endothelial cells also express
hyaluronan, which can interact with CD44, to facilitate B cell signalling and might enhance the production of active matrix
metalloproteinase 9 (MMP9). Once in tissues, several chemokines promote B cell survival, including CXCL12,
B cell-activating factor (BAFF; also known as TNFSF13B) and a proliferation-inducing ligand (APRIL; also known as
TNFSF13). In addition, CLL cell survival can be promoted through cognate interactions between CD31 and CD38, and
the production by stromal cells of WNT factors, which can interact with ROR1, ROR2 and/or various Frizzled receptors.
CLL cell contact with mesenchymal stromal cells can also be established through vascular cell adhesion protein 1
(VCAM1)–α4β1 integrin interactions that contribute to CLL cell survival. In turn, CLL cells can secrete chemokines,
such as CCL3 and CCL4, which can recruit T cells and NLC-precursor cells (monocytes) to the CLL microenvironment.
Activated T cells can provide CLL cells with proliferative signals through CD40 ligand (CD40L)–CD40 interactions and the
secretion of several cytokines, such as IL‑2, IL‑4 and IL‑10. In turn, activated CLL cells secrete CCL12 and CCL22, which
attract more T cells into the CLL microenvironment. In tissues, CLL cells can be exposed to environmental and/or
self-antigens that might trigger B cell activation through interactions with the surface immunoglobulin; this could amplify
the responsiveness of CLL cells to the signals and factors that are provided by the CLL microenvironment. BAFFR, BAFF
receptor (also known as TNFRSF13C); BCMA, B cell maturation protein (also known as TNFRSF17); BCR, B cell receptor;
TACI, transmembrane activator and CAML interactor (also known as TNFRSF13B).

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PRIMER
migration in response to chemokines93; in part, for Immune deficiency

this reason, high-level CLL cell expression of ROR1 is One clinically important aspect of CLL is the develop-
associated with accelerated disease progression94. Finally, ment of hypogammaglobulinaemia with consequent
Notch signalling in response to Jagged, or Hedgehog risk of infection. The mechanism involved is unclear,
signalling in response to Sonic Hedgehog or Desert but IL‑10, a known T cell-derived immunosuppressive
Hedgehog, can provide pro-survival stimulation for at factor, might have a role104. For CLL, emerging evidence
least a subset of patients with CLL, particularly those with suggests that the cancer cells themselves can produce
trisomy 12 (REFS 95–97). IL‑10 (REF. 105). Apparently, more IL‑10 is produced by
As CLL cells leave the tissue site, engagement with CLL cells that express mutated IGHV than by CLL cells
antigen will be transient and its effects are likely to that express unmutated IGHV. However, systemic levels
reverse in the blood, leading to variable increases in the of IL‑10 and other suppressive factors can also be influ-
expression of surface IgM and CXCR4 (REF. 98). CLL cell enced by the cumulative total-body numbers of cancer
expression of CXCR4 is downmodulated upon expo- cells, which are often higher in patients with CLL cells
sure to CXC-chemokine ligand 12 (CXCL12)99, which is that express unmutated IGHV. This might account in
produced by nurse-like cells in the microenvironment100. part for the finding of immune deficiency in patients
Consequently, CLL cells in the blood that have just exited with CLL cells that express either mutated IGHV or
lymphoid tissue express low levels of CXCR4 (known unmutated IGHV. Furthermore, CLL cells express high
as CXCR4dim cells) and higher levels of CD5 (known as levels of programmed cell death 1 ligand 1 (PD‑L1) and
CD5bright cells) relative to the CLL cells that are poised PD‑L2, which suppress the effector responses of T cells
to re‑enter lymphoid compartments101. For unexplained that express programmed cell death protein 1 (PD‑1),
reasons, a high level of expression of CXCR4 by circu- leading to an ‘exhausted’ T cell phenotype and impaired
lating CLL cells is associated with poorer prognosis in cellular immune function106.
patients with CLL that use mutated IGHV102, possibly
by influencing tissue re‑entry. In terms of treatment Diagnosis, screening and prevention
effects, kinase inhibitors, such as ibrutinib, inhibit Diagnostic work‑up
BCR-associated pathways, which remain important Most often, patients with CLL are asymptomatic at
for cancer cells that are retained in lymphoid tissues, the time of diagnosis and become aware of the disease
but can also directly inhibit integrin-mediated and following the detection of lymphocytosis in a routine
chemokine-mediated pathways, thereby contributing to blood count. However, CLL can have a range of clin
the increased lymphocytosis that occurs following the ical presentations; some patients feel well and are fully
initiation of kinase inhibitor therapy 103. active, but a minority have disease-related symptoms.
The usual symptoms of CLL include fatigue, involuntary
weight loss, excessive night sweats, abdominal fullness
Box 1 | Differential diagnosis of CLL with early satiety and increased frequency of infections,
Small lymphocytic lymphoma which might be associated with hypogammaglobulin
Diagnosis of small lymphocytic lymphoma is generally made following biopsy of an aemia. Some patients can present with symptoms of
enlarged lymph node, which typically has a disrupted architecture owing to the an autoimmune cytopenia (for example, autoimmune
infiltration of well-differentiated, clonal B cells with the same phenotype as chronic haemolytic anaemia or immune thrombocytopenic
lymphocytic leukaemia (CLL) cells. Patients with small lymphocytic lymphoma have purpura). Patients can also have or develop enlarged
<5,000 clonal B cells per μl in the blood, but over time, patients can develop lymphocyte lymph nodes, hepatomegaly and splenomegaly, which
counts of >5,000 cells per μl, which allows them to be reclassified as having CLL.
are palpable on physical examination. Enlarged lymph
Monoclonal B lymphocytosis nodes can be easily palpable at three sites: the cervical,
Monoclonal B lymphocytosis is defined as <5,000 clonal B cells per μl in the blood axillary and inguino-femoral regions.
without other signs of lymphoma, such as enlarged lymph nodes (>1.5 cm), which would
suggest the diagnosis of small lymphocytic lymphoma204. In most, but not all, cases, the Laboratory features. Laboratory assessment for CLL
clonal B cells in monoclonal B lymphocytosis express CD5 and have the same immune
includes a full blood cell count and flow cytometry.
phenotype as CLL205. Although biopsies are not generally performed, the incidental
finding of CLL-like cells in the marrow or in normal-sized lymph nodes does not exclude The most consistent laboratory abnormality observed
the diagnosis of monoclonal B lymphocytosis. is an increase in the absolute number of blood lympho
Cases of monoclonal B lymphocytosis are classified as being low count cytes above the normal adult upper limit of ~3,500
(<500 monoclonal B cells per μl) or high count (>500 monoclonal B cells per μl). cells per μl, detected by a blood count. Most patients
Approximately 5% of adults of European ancestry >40 years of age have low-count present with ≥10,000 cells per μl, but some might have
monoclonal B lymphocytosis, as assessed via flow cytometry on blood mononuclear fewer n umbers of blood lymphocytes upon relapse
cells. Although subjects with low-count monoclonal B lymphocytosis rarely progress after therapy. The initial diagnosis requires detection of
to CLL, 1–2% of patients with high-count monoclonal B lymphocytosis will develop ≥5,000 cells per μl of clonal CLL B cells107, which typically
CLL per year206. express low levels of surface immunoglobulin with either
Other lymphoproliferative diseases κ-immunoglobulin or λ-immunoglobulin light chains.
Other chronic B cell lymphoproliferative diseases can present like CLL, including B cell Flow cytometric or immunohistochemical analy-
prolymphocytic leukaemia, follicular lymphoma, hairy cell leukaemia, mantle cell ses of the mononuclear cells in the blood, marrow or
lymphoma or marginal zone lymphoma. In addition to clinical features and pathology, lymph nodes can help to distinguish CLL from other
which are characteristic of these other conditions, the immune phenotype of neoplastic
types of lymphoma (BOX 1). CLL B cells typically express
lymphocytes helps to differentiate these conditions from CLL.
CD5, CD19 and CD23 (also known as low-affinity

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PRIMER
typically have a diffuse infiltration of well-differentiated

a b c
small lymphocytes, often obliterating the normal nodal
architecture, and scattered, vaguely nodular, pale haema-
toxylin and eosin-staining areas, appearing as pseudo
follicles (FIG. 7a), which are enriched with prolymphocytes
and paraimmunoblasts (FIG. 7b); these areas comprise the
proliferation centres113. The pseudofollicles or prolifer
ation centres are hallmark features in the lymph nodes
of patients with CLL or small lymphocytic lymphoma,
as they are not observed in other types of lymphomas.
Figure 5 | Blood smears from patients with CLL. Wright–Giemsa-stained blood Primers
Nature Reviews | Disease
smears showing the typical chronic lymphocytic leukaemia (CLL) B lymphocyte (part a), Staging
smudge cell (part b) and a prolymphocyte with a prominent nucleolus (part c).
Two clinical staging systems are widely used to divide
Magnification ×500. Images courtesy of H. E. Broome, University of California, San Diego,
La Jolla, California, USA. patients with CLL into three broad prognostic groups114,115.
The Rai staging system (TABLE 1) is more commonly used
in the United States, whereas the Binet classification
immunoglobulin-ε Fc receptor), and have low levels of (TABLE 2) is more commonly used in Europe. The staging
CD20, but lack expression of CD10 and stain poorly, systems each recognize the importance of marrow func-
if at all, with the FMC7 monoclonal antibody, which tion and define late-stage, or high-risk, disease by the
recognizes an epitope of CD20 (REF. 108). CLL cells also presence of pronounced anaemia or thrombocytopenia.
express CD200 (also known as OX‑2 membrane glyco-
protein), which can help to distinguish CLL from mantle Prognostic factors and nomograms
cell lymphoma109. In addition, the CLL cells of >95% of The clinical course of newly diagnosed CLL is extremely
patients express the onco-embryonic surface antigen variable; some patients remain free of symptoms and are
ROR1 (REFS 94,110). fully active for decades, whereas others rapidly become
Morphologically, CLL cells are small mature- symptomatic or develop high-risk disease, which
appearing lymphocytes with dense chromatin, a nucleus requires treatment soon after diagnosis and might result
that virtually fills the cell with only a rim of visible cyto- in death due to therapy-related and/or disease-related
plasm and no (or occasionally small) nucleoli (FIG. 5a). complications. However, most patients have a clinical
In CLL, the presence of smudged cells on the blood course that is in between these two extremes.
smear is common and represents lymphocytes that were Prognostic factors that can help to identify patients
crushed in the process of making the slide (FIG. 5b). CLL who require therapy relatively soon after diagnosis
cells also can appear as prolymphocytes, which are larger include certain clinical features and genetic, molecu
than typical CLL cells, have less-condensed nuclei and a lar and biochemical characteristics of the CLL cell.
single prominent nucleolus (FIG. 5c). However, if >55% of Multivariable models, prognostic indexes116–118 and
cells on the blood smear are prolymphocytes, a diagnosis nomograms119 have been developed to consolidate
of prolymphocytic leukaemia should be considered111. such prognostic factors so that they can more robustly
No abnormalities are considered specific for CLL in predict clinical outcome. Commonly used parameters
the blood chemistry panel. Quantitative levels of serum that are associated with poorer outcome are male sex,
immunoglobulins (for example, IgA, IgG and IgM) are ≥65 years of age, poor performance status due to medical
usually normal at diagnosis, but generally decline with comorbidities, certain CLL cell characteristics, such as the
disease progression. A direct Coombs test (which is used expression of unmutated IGHV1,2, ZAP70 (REFS 120,121),
to detect erythrocytes that are coated with anti-red blood CD49d (also known as integrin α4)122 or CD38 (REF. 2), the
cell autoantibodies) might be positive in the absence of presence of del(17p)38 or del(11q)123, high serum levels
overt autoimmune haemolytic anaemia in a large minor- of β2‑microglobulin (>3.5 mg per l)124, complex karyo-
ity of patients; however, patients with a positive direct type (that is, the presence of three or more chromosomal
Coombs test might be at increased risk of developing aberrations observed on a karyotype test)125,126, or a high
this autoimmune disease. absolute lymphocyte count (>50,000 cells per μl) and/or
Although not required for establishing a diagnosis of late-stage disease at initial presentation. Del(17p) is often
CLL, a marrow biopsy is often performed; this usually associated with inactivating mutations in TP53 and is a
shows hypercellularity owing to an increased percent- predictor of poor outcome to treatment with regimens
age of mature-appearing lymphocytes. Four patterns that involve conventional chemotherapy 127.
of lymphocytic infiltration in the marrow have been Currently, the most reliable prognostic models are
described: nodular, interstitial, mixed (nodular and inter- those developed for treatment-free survival, as evolving
stitial) or diffuse; the diffuse pattern is typically associ treatments have yet to change the indications for therapy.
ated with advanced disease112 (FIG. 6). In addition, the Predictive models to define overall survival with a given
marrow u sually shows reduced numbers of myeloid and type of therapy are challenged by the chronicity of CLL
erythroid cells, which otherwise have normal maturation. and the fact that patients often receive serial treatments,
A lymph node biopsy might be performed in a patient each of which can affect outcome; moreover, death might
with an enlarged lymph node as part of a diagnostic evalu be due to an indirect or unrelated cause. Furthermore,
ation for suspected lymphoma. Excised lymph nodes treatment options are changing, with newly identified,

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a b Nonetheless, development of frequent or serious i nfections

is not an indication for CLL-directed therapy.
I For patients who need treatment, the presence of
del(17p) or mutated TP53 are the most important features
that are currently directing the choice of therapy (FIG. 8).
Next, advanced age of >65 years, the presence of med-
N
ical comorbidities and the objectives of treatment have
substantial bearing on the choice of therapy. Increasingly,
IGHV mutational status is considered as a parameter
when determining the type of therapy; for example,
Nature Reviews
chemotherapy-based regimens are reserved for patients
Figure 6 | Marrow biopsies from patients with CLL. Tissue sections of a| Disease
marrow Primers
biopsy with CLL and mutated IGHV. Conversely, the specific Rai
specimen stained with haemotoxylin and eosin showing interstitial (I) or nodular (N)
or Binet stage of the patient who requires treatment does
chronic lymphocytic leukaemia (CLL) cell involvement (part a) or diffuse CLL cell marrow
involvement (part b), which is typically associated with advanced-stage disease (original not necessarily influence the choice of therapy.
magnification ×100). Images courtesy of H. E. Broome, University of California, San Diego,
La Jolla, California, USA. Systemic treatments
The treatment of patients with CLL can include chemo-
therapy, a combination of chemotherapy and immuno
highly effective agents that are clearly prolonging sur- therapy, or drugs that target the signalling pathways
vival and have activity among patients who would have that promote the growth and/or survival of CLL cells
been considered high risk when the only option was (for example, BCR signalling and BCL‑2)128,129.
conventional chemotherapy.
Chemotherapy. Chemotherapy has been the main-
Management stay of therapy for the past 50 years. Purine analogues
Generally, indications to initiate therapy include pro- (most commonly fludarabine, but also pentostatin or
nounced disease-related anaemia or thrombocytopenia cladribine) and alkylating agents (including chloram-
(patients with Rai stage III or stage IV disease, or Binet bucil, cyclophosphamide or bendamustine) are used in
stage C disease), symptomatic lymphadenopathy and/or the treatment of CLL130–132. Chemotherapy-based regi-
symptoms that are associated with active disease, such as mens can cause myelosuppression, an increased risk of
night sweats, fatigue, unintentional weight loss or fever infections and, in a small subset of patients, post-therapy
without evidence of infection107. However, when basing myelodysplasia or secondary cancers, such as acute
a treatment decision on constitutional symptoms alone, myeloid leukaemia (see Secondary cancers).
the physician should consider other medical conditions,
such as hypothyroidism, hyperthyroidism, hypoglycae Chemoimmunotherapy. Phase III clinical trials have
mia, chronic inflammation, uncommon opportunistic validated the benefit of anti‑CD20 monoclonal antibod-
infections or sleep disorders, including sleep apnoea. ies, such as rituximab, obinutuzumab or ofatumumab,
No established absolute lymphocyte count or lymph in combination with chemotherapy for the treatment
node size alone should form the basis for the initiation of patients with CLL. In one trial (the CLL8 trial of
of therapy. Instead, patients who are asymptomatic with the German CLL Study Group), patients who received
early-stage or intermediate-stage disease (such as Rai stage fludarabine and cyclophosphamide with rituximab had
I or stage II, or Binet stage A or stage B) are not recom- higher response rates and a longer median progression-
mended for therapy unless they have symptomatic disease free survival (PFS) than patients who were treated with
or evidence for disease progression. Evidence for dis- fludarabine and cyclophosphamide133. In a separate study
ease progression can include a lymphocyte doubling time (the CLL11 trial), patients >65 years of age with med-
of <1 year, progressive palpable lymphadenopathy and/or ical comorbidities who were treated with chlorambucil
progressive palpable splenomegaly in serial examinations. and either obinutuzumab or rituximab had improved
In the absence of indications for treatment, patients are response rates and longer median PFS than patients
examined for palpable lymphadenopathy and spleno- who were treated with chlorambucil alone134. However,
megaly and have complete blood counts at 3–12‑month the median PFS was significantly longer for patients
intervals, the frequency of which depends on the pres- who received obinutuzumab (26.7 months) than in
ence of signs of disease progression. Clinical or laboratory those who received rituximab (11.1 months). In a third
features of anaemia or thrombocytopenia should prompt phase III trial, median PFS significantly improved from
evaluation for autoimmune haemolytic anaemia or 13.1 months for patients treated with chlorambucil to only
immune thrombocytopenic purpura, respectively; such 22.4 months for patients treated with chlorambucil and
autoimmune cytopenias might require treatment that is ofatumumab135. As a consequence of these three trials, the
independent of the consideration for therapy directed US FDA approved the use of rituximab, obinutuzumab or
against the underlying CLL. Finally, patients should be ofatumumab in combination with chemotherapy for the
cautioned to seek prompt medical attention for signs or first-line treatment of patients with CLL. The FDA also
symptoms of infection; because of the acquired immune approved the use of ofatumumab as a single agent for the
deficiency associated with CLL, the threshold for con- treatment of patients with relapsed or refractory disease
sidering the use of antimicrobial therapy should be low. based on data from a phase II study 136.

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PRIMER
Bendamustine is commonly used with rituximab Inhibitors of BCR signalling. Three main classes of drugs
and has good response rates in treatment-naive patients that each can inhibit BCR signalling have been evaluated
without del(17p)137, although no randomized trials in patients with CLL: BTK inhibitors, PI3K inhibitors
comparing bendamustine and rituximab versus benda and spleen tyrosine kinase (SYK) inhibitors86,143. CLL
mustine alone have been conducted. Bendamustine has cells with unmutated IGHV seem to be more sensitive to
also been used in combination with obinutuzumab, inhibitors of BCR signalling than CLL cells with mutated
which showed highly encouraging results138 and is being IGHV144, but whether inhibitors, such as ibrutinib, are
evaluated in larger clinical trials. more effective in patients with CLL and unmutated
In a randomized trial, the rates of complete response IGHV, remains to be validated in clinical trials.
and complete response without evidence for min Ibrutinib has been approved in the United States and
imal residual disease (MRD) were higher in patients Europe for use as initial therapy, as well as in patients
treated with fludarabine, cyclophosphamide and ritux- with relapsed disease, which followed results from a ran-
imab than in those treated with bendamustine and domized trial that showed a significantly higher response
rituximab, and the median PFS was ~1 year longer 139. rate to therapy with ibrutinib than with ofatumumab145.
However, patients in the bendamustine and ritux In addition, with continuous therapy, patients treated
imab treatment subgroup were older and had a higher with ibrutinib had a significantly longer median PFS and
proportion of patients who had CLL cells expressing overall survival than patients treated for 8 months with
unmutated IGHV, making this cohort at higher risk for ofatumumab. Approval of ibrutinib as initial therapy was
a poorer outcome than the cohort of patients treated based on the results of a randomized trial that showed
with fludarabine, cyclophosphamide and rituximab. a significant improvement in median PFS and overall
It also should be noted that patients treated with survival in patients ≥65 years of age without del(17p)
fludarabine, cyclophosphamide and rituximab had who were treated indefinitely with ibrutinib than in
higher rates of neutropenia and infections than patients patients treated for up to 48 weeks with chlorambucil146.
treated with bendamustine and rituximab. Because of Upon initiation of treatment with ibrutinib, lympha
this, many physicians currently provide patients with denopathy is rapidly reduced, which is associated with a
growth factors (for example, filgrastim or pegfilgrastim) concomitant increase in absolute lymphocyte count 147.
and prophylactic antimicrobial therapy when they are The rise in absolute lymphocyte count is related to the
treated with the fludarabine, cyclophosphamide and inhibition of chemokine receptor signalling, which
rituximab regimen, but such measures were not recom inhibits the migration of CLL cells from the blood into
mended for patients treated in this trial139. In any case, the lymphoid tissues. This resulting lymphocytosis
there has not been significant difference observed in should not be considered a sign of progression; over
overall survival between the two treatment arms, time, the lymphocytosis subsides as the overall tumour
but events are limited. burden decreases with continued therapy.
Some patients can experience a prolonged PFS Adverse effects of ibrutinib include fatigue, diar-
following treatment with fludarabine, cyclophospha- rhoea, bleeding, ecchymoses, rash, arthralgia, myalgia,
mide and rituximab, particularly those with CLL with increased blood pressure and atrial fibrillation. Clinical
mutated IGHV that lack del(17p) or del(11q), which trials are currently evaluating second-generation BTK
are associated with chemotherapy resistance or rela- inhibitors (for example, acalabrutinib148, ONO/GS‑4059
tively short PFS, respectively. Long-term follow‑up data (REF. 149) or BGB‑3111) to determine whether any one
on patient outcomes following therapy with this regi- of these drugs has a superior therapeutic index than
men indicate that patients with mutated IGHV might that of ibrutinib150.
achieve a long-term survival benefit (and possible ‘cure’) PI3K inhibitors include idelalisib, duvelisib (also
with chemoimmunotherapy 140–142. known as IPI‑145), TGR‑1022 and ACP‑319 (also known
as AMG‑319)151; the latter three drugs are being evalu-
ated in clinical trials, whereas idelalisib was approved
a b in the United States and Europe for the treatment of
patients with relapsed CLL; this approval was based on
the outcome of a clinical trial that showed that patients
treated with rituximab and idelalisib had significantly
higher response rates and a significantly longer median
PFS and overall survival than patients treated with
rituximab and placebo152. As with ibrutinib, patients
who initiate therapy with idelalisib can experience a
rapid reduction in lymphadenopathy that is associated
with lymphocytosis. Similarly, this event should not be
considered as a sign of disease progression.
Figure 7 | Lymph node of patients with CLL. a | Tissue Nature
sectionsReviews | Disease
of a lymph Primers
node stained
with haemotoxylin and eosin showing numerous pale-staining pseudofollicles, which are Adverse effects of idelalisib include transaminitis
circled (original magnification ×20). b | Higher (×400) magnification of a proliferation (usually in the first few months of therapy), pneumonitis
centre. Representative lymphocytes (arrows), prolymphocytes (arrowheads) or and colitis; the latter usually occurs >6 months after the
paraimmunoblasts (circles) in a proliferation centre are shown. Images courtesy of initiation of therapy with this drug and is often severe
H.-Y. Wang, University of California, San Diego, La Jolla, California, USA. enough to require cessation of therapy 153. Transaminitis

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PRIMER
seemed to be more severe in patients who received known as BCL2L11)158. As such, venetoclax is effective
idelalisib as their initial therapy for CLL than in patients in patients with relapsed and/or refractory disease159 or in
with relapsed disease153, suggesting that transaminitis is patients with relapsed disease and del(17p)160. Indeed,
not directly caused by idelalisib. This is also suggested the overall response rate for patients with relapsed dis-
by the observations that mild increases in the levels of ease and del(17p) was 79%, with 8% achieving a com-
serum transaminase can subside over time with con- plete response. In addition, the estimated 12‑month PFS
tinued drug administration; furthermore, patients who was 72% and overall survival was 87%. On the basis of
have had idelalisib withheld because of transaminitis can these results, the FDA approved the use of venetoclax
be restarted on this drug without experiencing apparent for patients with relapsed disease and del(17p). Ongoing
hepatic toxicity. The decision to halt therapy or to re‑ studies have shown that venetoclax can be safely com-
administer the drug following resolution of transamin bined with rituximab or obinutuzumab. Moreover, stud-
itis should consider the severity and duration of hepatic ies are examining the use of venetoclax with or without
function test abnormalities, which often do not recur an anti‑CD20 monoclonal antibody, and with or with-
upon re‑institution of idelalisib therapy 154. out ibrutinib161,162, which might provide higher response
In 2016, the FDA recommended the closure of clin rates to therapy than that with venetoclax alone.
ical trials investigating idelalisib and rituximab combin Toxicities of venetoclax include gastrointestinal dis-
ation therapy for first-line treatment of patients with turbances, neutropenia and tumour lysis syndrome159,
CLL, owing to a higher number of infections and deaths which is characterized by hyperkalaemia, hyper
in the experimental arm. As such, patients undergoing uricaemia and/or azotaemia. Tumour lysis syndrome
therapy with idelalisib and rituximab should be consid- results from the rapid destruction of cancer cells and the
ered for concomitant treatment with prophylactic low- release of their cellular contents into the blood. Tumour
dose acyclovir to protect against reactivation of varicella lysis syndrome typically occurs when initiating veneto-
zoster virus, which causes chicken pox and shingles. clax therapy or when dosing is increased. Thus, patients
Patients also should be treated with prophylactic anti start venetoclax with a low daily dose, which is escalated
biotics to mitigate the risk for opportunistic infection, each week over 5 weeks to mitigate the risk of develop
such as that caused by Pneumocystis jiroveci. Finally, ing tumour lysis syndrome. Even with this strategy,
as with any patient receiving therapy with anti‑CD20 patients who are at high risk for tumour lysis syndrome
monoclonal antibodies, patients should be screened because of bulky lymphadenopathy and/or lympho-
for active infection with hepatitis B virus before the cytosis of >25,000 cells per μl must be hydrated and
initiation of therapy 155, and periodically monitored for closely monitored during therapy initiation and during
reactivation of cytomegalovirus, especially if they should dose escalation.
develop unexplained symptoms of infection.
Phase I/II clinical trials of fostamatinib, an oral Assessment of response
SYK inhibitor, caused reduction in lymphadenopathy Historically, a favourable response to therapy has been
with concomitant lymphocytosis, an improvement in defined as a partial remission or complete remission.
disease-related cytopenias and relief of disease-related Partial remission requires a 50% reduction in tumour
symptoms in most of the treated patients with CLL156. bulk (for example, lymphadenopathy and splenomegaly),
However, dose-limiting toxicities of fostamatinib treat- a 50% reduction in lymphocytosis, and platelet counts of
ment include neutropenia, thrombocytopenia and diar- >100,000 cells per μl (or 50% improvement over base-
rhoea. Other inhibitors of SYK, such as entospletinib, line) or a haemoglobin level of >11 g per dl (or 50%
are being evaluated in preclinical and clinical studies. improvement over baseline) without requiring transfu-
sions or exogenous growth factors107. Complete remission
BCL‑2 inhibitors. Venetoclax is a small molecule requires the normalization of blood counts, resolution
that functions as a BH3 mimetic to inhibit BCL‑2 in lymphadenopathy and splenomegaly, and normal
(REF. 157). This drug is highly potent in inducing apop- marrow function. The use of CT to assess response in
tosis in CLL cells, possibly by diminishing the capacity CLL is becoming more common, particularly in clinical
of BCL‑2 to sequester the pro-apoptotic molecule trials. However, the benefit of using repeated CT scans
BCL‑2‑interacting mediator of cell death (BIM; also to monitor disease is uncertain, and seems unlikely to
change patient outcome. Because of the distinct pattern of
response observed with BCR inhibitors, a new response
Table 1 | Rai staging system category, namely, partial response with lymphocytosis,
Risk group Clinical features Median life has been described. Partial response with lymphocyto-
expectancy* sis is defined as a >50% reduction in lymphadenopathy
Low risk Lymphocytosis without cytopenia, 13 years and splenomegaly, with persistent lymphocytosis; often
(Rai stage 0/I) lymphadenopathy or splenomegaly the blood lymphocyte counts are equal to or greater than
Intermediate risk Lymphocytosis, lymphadenopathy and/or 8 years those observed prior to therapy.
(Rai stage II) splenomegaly, but without cytopenia In clinical trials, it is becoming more common to
High risk Lymphocytosis and cytopenia (a haemoglobin 2 years evaluate for MRD with ≥0.01% of CLL cells among
(Rai stage III/IV) level of ≤11 g per dl and/or a platelet count of the total population of mononuclear cells in the blood
≤100,000 cells per μl) or marrow. MRD can be measured by flow cytometry or
*These life-expectancy estimates are increasing with the advent of newer therapies. PCR with next-generation sequencing of the clonal

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PRIMER
Table 2 | Binet staging system Maintenance therapy with an anti‑CD20 monoclonal

antibody after chemoimmunotherapy has been shown
Risk group Clinical features Median life to prolong PFS, but not overall survival, and was associ
expectancy*
ated with a significantly higher incidence of neutropenia
Low risk Less than three palpably enlarged sites‡ without 13 years and risk for infections168. This regimen is currently not
(Binet stage A) cytopenia considered the standard of care, but might be useful in
Intermediate risk Three or more palpably enlarged sites‡ without 8 years patients with medical comorbidities that limit other
(Binet stage B) cytopenia treatment options.
High risk Cytopenia (a haemoglobin level of ≤10 g per dl 2 years
(Binet stage C) and/or a platelet count of ≤100,000 cells per μl) Quality of life
*These life-expectancy estimates are increasing with the advent of newer therapies. ‡There are Comorbidities
five sites of lymphoid organs: cervical, axillary and inguinal nodes, the spleen and the liver. As CLL is a disease of the elderly population, assessing
the effect of CLL on the patient’s quality of life (QOL)
immunoglobulin variable region gene rearrangements163. and the coexisting comorbidities that occur in this
In most clinical trials for patients with CLL, particularly patient population is important 169. Awareness regard-
those conducted in Europe, evaluation of MRD has been ing the importance of a patient’s QOL, not only during
performed by flow cytometry of mononuclear cells from and after treatment but also during the watch-and-wait
the marrow aspirate (the preferred method) or from the period, is increasing.
peripheral blood. In the 6 months following anti‑CD20 Until recently, few clinical trials included elderly or
monoclonal antibody treatment, the assessment of MRD frail patients, who account for most patients with CLL.
is more sensitive on the mononuclear cells of the marrow As such, the recommendations for therapy were largely
aspirate than on cells that are isolated from the blood, based on results from clinical trials that were conducted
which will often lack detectable CLL even when they with younger patients who could better tolerate combin
are readily found in the marrow. Beyond a complete ation drug therapies. Trials have moved away from using
response, the best predictor of long-term PFS and over- eligibility criteria based on age or creatinine clearance,
all survival is the achievement of a complete remission to using more objective measures of fitness, such as
without evidence for MRD. the cumulative illness rating score, which can stratify
patients for appropriate first-line or subsequent therapy.
Relapsed disease This has led to an increased number of published clin-
The treatment landscape for relapsed and refractory CLL ical trials targeting patients who would not be deemed
will be changing owing to the first-line approval of ibru- fit for aggressive chemoimmunotherapy approaches.
tinib. Currently, most patients with relapsed or refractory Importantly, this has also demonstrated that ‘unfit’
disease receive chemoimmunotherapy. Standard salvage patients with CLL can be recruited to clinical trials in
regimens include BCR inhibitors or BCL‑2 inhibitors, a timely manner.
particularly for patients with CLL and del(17p). For
patients who received first-line BTK inhibitor therapy, Risk of other diseases
salvage options include chemoimmunotherapy (fludara- Patients with CLL have an increased risk of other med
bine, cyclophosphamide and rituximab (or bendamus- ical conditions, such as infections, autoimmune dis
tine with an anti‑CD20 monoclonal antibody), PI3K orders or secondary cancers, any one of which can result
inhibitor and an anti‑CD20 monoclonal antibody 152, in substantial morbidity and mortality.
high-dose methylprednisolone and an anti‑CD20
monoclonal antibody 164, or lenalidomide alone or with Infections. CLL is characterized by progressive defects
an anti‑CD20 monoclonal antibody, although lenalido- in both cell-mediated and antibody-mediated immunity,
mide has not been approved for the treatment of patients including hypogammaglobulinaemia and B cell and
with CLL by the FDA165,166. Treatment choice depends T cell quantitative and functional defects170. The risk
on individual patient characteristics and the intent of of infections increases with worsening hypogamma
treatment. Scant data are available regarding the activity globulinaemia. The degree of immune impairment
of small-molecule inhibitors in patients who are refrac- worsens with disease progression and can be exacerbated
tory to another small-molecule inhibitor; better efficacy by the immunosuppressive effects of purine analogue
is expected for patients who discontinued use of another chemotherapy, anti‑CD20 monoclonal antibodies or
small-molecule inhibitor due to intolerance167. Ibrutinib drugs that inhibit kinases involved in immune receptor
resistance is an adverse predictor of clinical outcome, signalling. Consequently, infectious complications rep-
particularly for patients who were previously exposed resent a frequent cause of morbidity and mortality in
to chemoimmunotherapy. If a previously treated patients with CLL.
patient develops del(17p), or mutated TP53, treatment Infections are typically bacterial and frequently
options include ibrutinib, venetoclax, or idelalisib and involve the respiratory tract. Intravenous immuno-
an anti‑CD20 monoclonal antibody. The patient could globulin replacement therapy can mitigate the risk of
also participate in a clinical trial. The preference for infection, particularly in patients with hypogamma
non-chemotherapy-based treatment should be driven globulinaemia who have frequent infections or a severe
by prior exposure to a small-molecule inhibitor and a life-threatening infection171. Immunoglobulin formula-
review of the safety profile of the drug. tions that are administered subcutaneously seem to be

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PRIMER
Does the patient have active disease No as effective and might be less costly 172. Unfortunately,
Observation randomized studies assessing the relative benefit of
(e.g. LDT <1 year), disease-associated and monitoring
symptoms, or Rai stage III or stage IV disease? Progression intravenous immunoglobulin replacement therapy
versus prophylactic antibiotics in patients with CLL,
Yes hypogammaglobulinaemia and recurrent or serious
infections have not been conducted. However, the
Presence of del(17p) development of another infection soon after complet-
or mutations in TP53?
ing a course of antibiotics, requiring repeated antibiotic
therapy, is not uncommon in patients with CLL. These
No patients should be considered for immunoglobulin
Mutations in IGVH?
replacement therapy. The use of prophylactic antimicro-
Yes or bial agents to prevent opportunistic infections should
undetermined
be considered, particularly in patients undergoing ther-
No
Amenable to CIT? BTK inhibitor apy with drugs that might worsen immune function173.
Finally, because of their suppressed immune function,
Yes No Yes patients should avoid having live vaccines, such as those
Aged (>65 years) with used to v accinate against shingles.
comorbidities?
Resistance or Autoimmune complications. Autoimmune complica-
No Yes intolerance
tions are common in patients with CLL and occur in up to
CIT Reduced-dose CIT 25% of patients. Autoimmunity in CLL primarily targets
the haematological lineages, resulting in autoimmune
Resistance or Resistance or haemolytic anaemia, immune thrombocytopenic pur-
intolerance intolerance
pura, pure red cell aplasia or autoimmune granulo
Presence of del(17p) cytopenia174. Spontaneous or drug-related autoimmune
Yes or no No
BTK inhibitor or mutations in TP53? PI3K inhibitor haemolytic anaemia is the most common auto
immune complication of CLL, the prevalence of which
Resistance or
is related to disease stage and progression. For example,
Yes Resistance or the prevalence of autoimmune haemolytic anaemia is
intolerance
intolerance
2.9% in patients with stable Binet stage A disease and
Venetoclax >10% in patients with Binet stage B or stage C disease.
Approximately 1–5% of patients with CLL develop clin-
Figure 8 | Management algorithm for patients with CLL. Indications for therapy of ically apparent immune thrombocytopenic purpura,
Nature Reviews | Disease Primers
patients with chronic lymphocytic leukaemia (CLL) include late-stage disease, evidence which makes CLL the most common disease associated
for rapid disease progression or disease-related symptoms. Patients with del(17p) or with this disorder in adults. Pure red cell aplasia, in which
mutated TP53 should be treated with therapy that does not require functional TP53,
the marrow ceases to produce erythrocytes resulting in
such as ibrutinib (a Bruton tyrosine kinase (BTK) inhibitor), given the relatively poor
outcome for such patients with chemotherapy. For patients without del(17p) or known reticulocytopenia, occurs in <1% of patients174; diagnos-
mutations in TP53, immunoglobulin heavy-chain variable region (IGHV) mutational tic evaluation requires a marrow biopsy showing virtual
status can help to define the treatment strategy; patients with unmutated IGHV could absence of erythroid precursor cells without myelo
be considered for therapy with a BTK inhibitor (such as ibrutinib) and patients with dysplasia, as well as the exclusion of viral infections
mutated IGHV might be good candidates for chemoimmunotherapy (CIT), if amenable. that can impair erythropoiesis, such Parvovirus B19,
Indeed, patients with mutated IGHV can have excellent outcomes with CIT regimens, Epstein–Barr virus, viral hepatitis B or hepatitis C and
such as fludarabine, cyclophosphamide and rituximab, with >50% of patients having HIV infections. Even rarer is secondary autoimmune
a median progression-free survival of >10 years, including the potential for cure. If the granulocytopenia, which occurs in <0.2% of patients174;
patient is amenable to CIT, age, medical comorbidities and myeloid reserve should be the diagnosis requires a marrow biopsy showing matur
taken into consideration. Patients >65 years of age commonly have medical
ation arrest at a late stage in granulocyte differentiation
comorbidities and are less able to tolerate myelosuppressive regimens, such as
fludarabine, cyclophosphamide and rituximab. Thus, considerations should be given to and exclusion of other causes of isolated acquired neutro
using reduced dose or less myelosuppressive chemotherapy regimens, such as penia, such as myelodysplasia, concomitant granular
chlorambucil or reduced-dose bendamustine and an anti‑CD20 monoclonal antibody lymphocyte leukaemia or diseases that might cause
for patients with limited myeloid reserve. Patients who either do not respond, have a secondary immune neutropenia, such as rheumatoid
poor tolerance to CIT or relapse following CIT, should be re‑evaluated for del(17p) or arthritis, systemic lupus erythematosus, Crohn’s disease,
TP53 mutations. Patients who develop de novo del(17p) or TP53 mutations, or have and related systemic autoimmune diseases.
known del(17p) and/or TP53 mutations, or who develop resistance or intolerance to No systematic controlled trials of treatment for auto-
ibrutinib, could be considered for therapy with idelalisib and rituximab or the BCL‑2 immune cytopenias in patients with CLL have been con-
inhibitor venetoclax. Patients treated with CIT who do not have del(17p) or TP53 ducted. Corticosteroids remain the mainstay of i nitial
mutations could be considered for repeat CIT if their progression-free survival after
treatment, but mycophenolate and thrombopoietin-
CIT is >2 years and the patient has sufficient myeloid reserve. Such patients also might
be treated with a BTK inhibitor or a phosphoinositide 3‑kinase (PI3K) inhibitor, which like agents might be helpful for patients with immune
also could be considered for patients who develop intolerance or resistance to thrombocytopenic purpura175,176. Second-line treatments
therapy with ibrutinib. Patients who develop resistance or intolerance to inhibitors include cyclosporine or rituximab. Splenectomy can be
of BTK, PI3K and/or BCL‑2 should be considered for clinical trials or alternative agents. helpful in patients with severe or recurrent immune
LDT, lymphocyte doubling time. cytopenias who are good-risk surgical candidates,

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PRIMER
Box 2 | Molecular biology of Richter syndrome a prolymphocyte on a blood smear. Diagnosis of pro
lymphocytic leukaemia is made by evaluation of the
The lymphoma cells in Richter syndrome are malignant B cells that most often resemble blood smear, immunophenotyping and molecular
those of non-germinal centre diffuse large B cell lymphoma (DLBCL), differing genetics. The clinical behaviour of prolymphocytic
morphologically from the original chronic lymphocytic leukaemia (CLL) population. leukaemia is generally more aggressive than CLL,
In addition, the lymphoma cells of over half the patients with Richter syndrome might
although some patients still might have indolent dis-
not express CD5 or CD23, which are almost invariably expressed by CLL cells.
Nevertheless, the DLBCL-like lymphoma in Richter syndrome often shares the same ease. Patients with prolymphocytic leukaemia are typ-
IGHV‑DJ rearrangement as the original CLL clone207. As such, the lymphoma cells in ically treated with combination purine analogue-based
Richter syndrome can express unmutated immunoglobulin heavy-chain variable chemoimmunotherapy. However, drugs that inhibit
region gene (IGHV), unlike de novo DLBCL, which virtually always expresses IGHV with BCR signalling, such as ibrutinib or idelalisib, might be
somatic mutations. However, ~20% of the DLBCL-type Richter syndrome and ~50% of effective in the management of some patients, especially
Hodgkin lymphoma-type Richter syndrome have IGHV‑DJ rearrangements that differ those with del(17p) or inactivating mutations in TP53.
from that of the original CLL clone, suggesting that these lymphomas might
represent a de novo secondary malignancy; some of these seem to be associated with Richter syndrome. Richter syndrome is the transfor-
Epstein–Barr virus infection and may resemble post-transplant lymphomas, particularly mation of CLL to an aggressive lymphoma, commonly
in patients with severe disease-related immune dysfunction and/or treatment-related
DLBCL (BOX 2) , classic Hodgkin lymphoma or an
immune suppression208.
Although the lymphoma cells of DLBCL-type Richter syndrome resemble those of unusual histology of Hodgkin–Reed–Sternberg-like
de novo DLBCL, they have distinctive genetic differences209. Of DLBCL-type Richter cells surrounded by CLL cells without the polymorphous
syndrome lymphomas, ~60% have inactivating mutations and/or deletions in TP53, reactive infiltrate of classic Hodgkin lymphoma181.
often with deregulation of MYC, which is observed in ~40% of cases; such deregulation Approximately 2–7% of patients with CLL develop
is caused by translocations juxtaposing MYC to immunoglobulin loci, gene Richter syndrome, with an incidence rate of ~0.5% per
amplification of MYC at 8q24 or somatic mutations affecting MYC trans-regulatory year of observation182. Richter syndrome may occur
factors, such as NOTCH1, which is mutated in ~30% of cases210,211. CDKN2A, which more frequently in patients with CLL cells that harbour
encodes p16, a negative regulator of cell cycle progression from G1 to S phase, NOTCH1 mutations or that express certain stereotypical
is mutated and/or deleted in ~30–50% of cases, but rarely so in CLL or de novo immunoglobulin molecules, particularly those with
DLBCL209,211. Finally, Richter syndrome lymphomas typically do not have mutations
a heavy-chain variable region encoded by IGHV4-39
in genes encoding proteins that are involved in nuclear factor‑κB signalling or
in the transcriptional repressors PRDM1/BLIMP1 or BCL6, which are common in and a heavy-chain third complementarity-determining
de novo DLBCL. region (HCDR3) encoded by IGHD6-13 and IGHJ5,
the so-called ‘HCDR3 subset 8’ (REF. 183).
Clinical suspicion of Richter syndrome is raised if a
but risks further impairment of immune function. patient develops new or worsening symptoms, such as
Refractory autoimmune haemolytic anaemia or immune night sweats, fatigue and involuntary weight loss, a sharp
thrombocytopenic purpura might require treatment of increase in the levels of serum lactic dehydrogenase,
the underlying CLL, preferably with therapy that does and/or a rapidly enlarging lymph node (or nodes) or
not substantially impair compensatory haematopoiesis. an extra-nodal lymphoid mass (or masses). PET imag-
ing can be used to evaluate these patients184, including
Secondary cancers. Several large retrospective analy directing where to perform a biopsy, which is required
ses have demonstrated that patients with CLL have to establish the diagnosis. The mainstay of treatment is
an increased incidence of several secondary primary chemoimmunotherapy, although newer therapies are
malignancies compared with an age-matched popula- being investigated using some of the BCR inhibitors
tion, particularly non-melanoma skin cancers, but also and/or BCL‑2 inhibitors or immune checkpoint inhib
for melanoma, sarcomas, and lung, renal and prostate itors. Nevertheless, the prognosis of patients with Richter
cancers177. The immune deficiencies that are associated syndrome generally is poor, particularly for those who
with CLL might contribute to this increased risk, but the are heavily pretreated for CLL and/or who have transfor-
malignancies observed do not mirror those in patients mation involving lymphocytes that are clonally related to
with other immune-deficiency diseases. Exceptions to the underlying CLL182. Younger, fit patients who respond
this observation are Merkel cell carcinoma178, which is to induction therapy should be considered for allogeneic
associated with Merkel cell polyomavirus infection, and stem cell transplantation to prolong survival.
Bowen disease, which is an aggressive form of squamous
cell carcinoma associated with human papillomavirus Acute leukaemia and myelodysplastic syndrome.
infection179. Although initial studies had suggested that Acute leukaemia and myelodysplastic syndrome are
the risk of secondary cancers was increased following uncommon in CLL. Overall prognosis is poor and new
chemotherapy, subsequent studies have suggested that treatment approaches are needed185. The rates of therapy-
the risk is similar in untreated patients who continue on related acute myeloid leukaemia or myelodysplastic
watch and wait 180. syndrome following purine analogue-based chemo-
immunotherapy are ~5%, and are greatly increased
Prolymphocytic transformation. B cell prolymphocytic in patients who undergo autologous stem cell trans-
transformation is a rare event, occurring in <1% of plantation. Studies are underway to evaluate whether
patients. This disease is characterized by symptomatic the use of novel agents, which do not expose normal
splenomegaly, rapidly rising numbers of leukaemia cells haematopoietic cells to genotoxic stress, will decrease
in the blood, >55% of which have the morphology of the incidence of this serious complication.

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PRIMER
Outlook patients receiving lenalidomide compared with those

The outlook for patients with CLL has improved sub- receiving chlorambucil191. A 7‑month treatment course
stantially over the past several years. Through research with lenalidomide in combination with rituximab was
on the immune biology and genetics of CLL, patients well tolerated in a multi-institutional phase II study and
can be stratified into subgroups with distinctive clin yielded higher response rates; for patients <65 years
ical features, which has improved our capacity to assess of age, the overall response rate was 95%, with a 20%
prognosis or govern therapy. However, an understanding complete response rate, and for patients ≥65 years of
of the mechanisms that contribute to immune dysfunc- age, the overall response rate was 78%, with an 11%
tion or how it contributes to autoimmune disease, such complete response rate166. The PFS after completion
as autoimmune haemolytic anaemia, therapy resistance of therapy was ~20 months for both groups. Therapy
or therapy-related complications is unknown. Whether with an anti‑CD20 monoclonal antibody 9 days before
tyrosine kinase inhibitors can affect clonal evolution, initiation of lenalidomide therapy also seems to mitigate
induce and/or select for drug resistance, or can achieve the risk for tumour flare reaction192,193. The use of lena-
complete responses if used earlier in the course of the lidomide after chemoimmunotherapy has been evalu-
disease is also unknown. ated in a phase III maintenance trial (Continuum Trial;
ClinicalTrials.gov identifier: NCT00774345) and results
Future treatments are forthcoming. Ongoing trials are also examining
Several therapies are currently under preclinical and clin- the activity in CLL of a novel lenalidomide analogue,
ical investigation for the treatment of patients with CLL, CC‑122 (REF. 194).
including new drugs and treatment modalities that can
modulate the immune system, and cell transplantation. Allogeneic stem cell transplantation. Allogeneic stem
cell transplantation is a potentially curative strategy
Immune-modulatory drugs. Immune-modulatory for patients with relapsed or refractory CLL, including
drugs, such as thalidomide and lenalidomide, are patients with high-risk features such as del(17p). In two
approved for the treatment of patients with multiple clinical studies with patients who lacked serious medical
myeloma, mantle cell lymphoma or myelodysplastic comorbidities and had a median age of 53 or 58 years, the
disease. Although these drugs have clinical activity PFS at 3–5 years was 40–50% and overall survival was
in patients with CLL, they have had limited applica- 50–70%, but the non-relapse mortality at 3–5 years
tion unless used in combination with an anti‑CD20 was 25–40% 195,196. Research efforts are ongoing to
monoclonal antibody 166,186. In CLL, lenalidomide can develop better-tolerated cell-based therapy with a similar
induce the expression of p21WAF1/CIP1, which inhibits curative potential that can be used without the immuno
cyclin-dependent kinase and CLL cell proliferation187, suppression and associated long-term m orbidity and
and can improve immune synapse formation, poten- mortality of allogeneic stem cell transplantation.
tially enhancing immune function188. In patients with Donor availability, advanced patient age, associated
CLL, lenalidomide can mitigate the severity of hypo toxicities of myelosuppression, graft-versus-host disease
gammaglobulinaemia189, but myelosuppression is a and impaired resistance to infections limit the applica-
dose-limiting toxicity. Other dose-limiting toxicities tion of allogeneic stem cell transplantation in patients
associated with the use of lenalidomide, particularly as with CLL. In addition, the advent of BCR signalling
a first-line therapy, include tumour flare and tumour inhibitors and BCL‑2 inhibitors provide multiple treat-
lysis syndrome. For unknown reasons, patients with CLL ment options that afford well-tolerated, long-term dis-
seem to be more sensitive to lenalidomide than patients ease control, making allogeneic stem cell transplantation
with other haematological indications, mandating the the least desirable option for most patients. Ongoing dis-
use of low doses (for example, 2.5–5 mg per day) when cussion exists around who are the appropriate patients
initiating therapy. Low-dose aspirin is frequently used to for allogeneic stem cell transplantation.
mitigate the risk for thromboembolic complications that
are associated with lenalidomide therapy. T cell therapy with chimeric antigen receptors. T cells
Thalidomide has little activity in patients with CLL as can be modified ex vivo to express new surface receptors,
a monotherapy, but has shown efficacy when combined known as chimeric antigen receptors (CARs), which
with other drugs, such as anti‑CD20 monoclonal anti- have been engineered to target cancer cells, expanded
bodies190. Conversely, lenalidomide m onotherapy has in vitro and then reintroduced into the patient as a
an overall response rate of 60% (15% complete response treatment for CLL (BOX 3).
rate) as a first-line therapy and 40% (8% complete Both normal and malignant B cells (including CLL
response rate) as a salvage treatment 165,189. However, cells) express surface CD19, which has been targeted
trials assessing the use of lenalidomide as a mono with CAR technology. CD19‑targeted CAR T cells have
therapy or combination therapy have yielded mixed yielded long-term PFS and relapse-free survival dur
results. One phase II study reported that lenalidomide ations in patients with CLL; in 14 patients with relapsed
was well tolerated as initial therapy in patients >65 years or refractory CLL, four patients achieved a complete
of age, with an overall response rate of 65% and a com- response and four patients achieved a partial response197.
plete response rate of 10%189. However, a multicentre None of the complete responders had MRD and none
phase III trial for the same patient population had to be relapsed (a median follow-up of 19 months). However,
terminated owing to an increased number of deaths in the efficacy of CAR T cell therapy in patients with CLL

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PRIMER
Box 3 | Chimeric antigen receptors of PD‑1‑expressing effector T cells106, leading to an

exhausted (that is, no longer functional) T cell pheno-
Chimeric antigen receptors (CARs) are composed type. T cell exhaustion in CLL is also mediated in part
of an antigen-binding domain, a stalk and by lymphocyte activation gene 3 protein and T cell
transmembrane region, an intracellular Antigen-binding immunoglobulin mucin receptor 3 (TIM3; also known
co‑stimulatory signalling domain and CD3ζ (see domain
as HAVCR2). TIM3 negatively regulates the function
the figure)212. Co‑stimulatory signalling domains
include CD28 and CD137, which provide the of type 1 helper T cells and type 1 CD8+ T cells, by
‘second signal’ to fully activate and expand T cells triggering cell death upon ligand binding. Other recep-
upon antigen binding. tors on CLL cells have demonstrated negative immune
Retrovirus vectors are used to introduce the feedback, including CD276, CD200 and TNF receptor
CAR gene into T cells, which integrates into the superfamily member 14.
genome of the T cell for stable expression. When Co-stimulatory A partial list of immune checkpoint inhibitors
the CAR T cells are exposed to the respective domain
that are being evaluated in the therapy of patients
antigen, antigen binding triggers activation and with CLL or other cancers include monoclonal anti
expansion of the CAR T cells and eliminates the
bodies against PD‑1, cytotoxic T lymphocyte protein 4,
cells with target antigen. The binding domain
B lymphocyte and T lymphocyte attenuator and its
of the CAR can be directed against any CAR
surface antigen. ligand TNF superfamily member 14, the adenosine
Nature Reviews | Disease Primers A2A receptor, indoleamine 2,3‑dioxygenase, the V‑type
immunog lobulin domain-containing suppressor of
has been modest compared with that in patients with T cell activation, lymphocyte activation gene 3 protein
acute lymphoblastic leukaemia; this might be owing to and TIM3.
qualitative defects in the T cells of patients with CLL, Preclinical studies in mouse models have demon-
who are generally older than patients with acute lympho strated that checkpoint inhibitors can reactivate immune
blastic leukaemia and already have immune dysfunction effector cells to have anti-leukaemia activity 202. However,
that reflects disease-associated anergy (see BCR and ongoing phase I/II trials of immune checkpoint inhib
B cell signalling). Ibrutinib might partially correct some itors in patients with relapsed CLL have yet to show much
of these defects198. Larger phase II trials assessing the clinical activity, possibly reflecting the highly immune
use of CAR T cell therapy for CLL are in development, suppressive nature of CLL cells and/or the ‘exhausted’
including the use of CAR T cells that can target antigens phenotype of T cells in patients with this disease.
other than CD19, such as ROR1 (REFS 199,200).
The major adverse effect of CAR T cell therapy is a Combination targeted therapy. We can now target the
cytokine release syndrome, which occurs as a result of distinctive phenotypic or physiological features of CLL
CAR T cell activation, cytokine production and T cell with targeted therapeutic agents, which have a higher
expansion following target antigen encounter. Cytokine therapeutic index than standard chemotherapy. Through
release syndrome is characterized by fever, hypotension the use of combination therapy, which targets different
and capillary leakage, but neurological toxicity, which B cell survival signalling pathways and/or achieves better
can manifest as confusion and seizures, has also been eradication of CLL cells, we might be able to define
observed in some of the treated patients. Cytokine curative treatments for most patients with this disease.
release syndrome is associated with high cytokine Research on leukaemia cell survival signalling path-
levels, particularly IL‑6, and can be managed with an ways, such as those governed by interactions between
IL‑6‑binding factor, such as tocilizumab, supportive leukaemia cells and cells or secreted factors within the
measures, and glucocorticoids for severe cases. This syn- microenvironment (FIG. 4), might identify pathways
drome seems to be proportionate to the antigen-bearing that are not affected by BCR inhibitors. For e xample,
tumour burden, potentially making CAR T cell therapy BCR inhibitors, such as ibrutinib, cannot block
more amenable to treatment of patients with MRD. ROR1‑dependent WNT5A signalling, which enhances
CLL cell proliferation, migration and survival93; as such,
Immune checkpoint inhibitors. Immune checkpoints are antibodies that block ROR1‑dependent signalling
proteins that are expressed on the surface of antigen- could potentially have synergistic activity when used
presenting cells that regulate the immune system by in combination with BCR inhibitors203. Furthermore,
providing co‑stimulatory or co‑inhibitory signals to the interaction between CLL cells and accessory cells
ligands expressed on T cells and other immune effector in the microenvironment might enhance CLL cell
cells. The finding that cancer cells can evade immune expression of anti-apoptotic proteins other than BCL‑2,
detection and destruction by inhibiting T cells has such as MCL1, thereby contributing to therapy resist-
led to the development of immune checkpoint inhib- ance. As such, the therapeutic use of a selective BCL‑2
itors to treat solid tumours, Hodgkin lymphomas and antagonist, such as venetoclax, might be more effective
non-Hodgkin lymphomas201. when used in combination with BCL‑2 inhibitors161,162,
The immune checkpoint receptor PD‑1, and its which also interfere with the homing of CLL cells to
ligands PD‑L1 and PD‑L2, is the most important the microenvironment. Conceivably, combination
cognate receptor involved in the suppression of cellular target therapy with agents that have synergistic activ-
immune activation. CLL cells express high levels of ity will provide highly effective and potentially curative
PD‑L1 and PD‑L2 and can suppress the responses treatment of patients with CLL.

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memory T‑cell populations. PLoS ONE 10, e0128151 leukemia: molecular heterogeneity revealed by high- ALL LINKS ARE ACTIVE IN THE ONLINE PDF
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CORRECTION
CORRECTION
Chronic lymphocytic leukaemia

Thomas J. Kipps, Freda K. Stevenson, Catherine J. Wu, Carlo M. Croce, Graham Packham,
William G. Wierda, Susan O’Brien, John Gribben and Kanti Rai
Nature Reviews Disease Primers 3, 16096 (2017)
In the version of the article originally published, a typographical error has now been corrected. The statement now
reads: Approval of ibrutinib as initial therapy was based on the results of a randomized trial that showed a significant
improvement in median PFS and overall survival in patients ≥65 years of age without del(17p) who were treated indefinitely
with ibrutinib than in patients treated for up to 48 weeks with chlorambucil146.
NATURE REVIEWS | DISEASE PRIMERS www.nature.com/nrdp

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Primer: Chronic Lymphocytic Leukaemia

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PRIMER

Chronic lymphocytic leukaemia

NATURE REVIEWS | DISEASE PRIMERS VOLUME 3 | 2017 | 1

Author addresses of individuals in eastern Asia to ~0.06% of individuals in

2 | 2017 | VOLUME 3 www.nature.com/nrdp

Environmental factors epidemiological studies have not found evidence that

Chromosomal alterations. Approximately 80% of

Somatic mutations. The advent of massively p ­ arallel

NATURE REVIEWS | DISEASE PRIMERS VOLUME 3 | 2017 | 3

Notch signalling Inﬂammatory pathways BCR signalling WNT signalling

Metalloprotease MYD88 MYD88 RIPK1 LYN SYK LYN Cytoplasm

4 | 2017 | VOLUME 3 www.nature.com/nrdp

NATURE REVIEWS | DISEASE PRIMERS VOLUME 3 | 2017 | 5

Idelalisib Ibrutinib success of kinase inhibitors that block BCR signalling

6 | 2017 | VOLUME 3 www.nature.com/nrdp

NATURE REVIEWS | DISEASE PRIMERS VOLUME 3 | 2017 | 7

migration in response to chemokines93; in part, for Immune deficiency

8 | 2017 | VOLUME 3 www.nature.com/nrdp

typically have a diffuse infiltration of well-differentiated

NATURE REVIEWS | DISEASE PRIMERS VOLUME 3 | 2017 | 9

a b Nonetheless, development of frequent or serious i­ nfections

10 | 2017 | VOLUME 3 www.nature.com/nrdp

NATURE REVIEWS | DISEASE PRIMERS VOLUME 3 | 2017 | 11

12 | 2017 | VOLUME 3 www.nature.com/nrdp

Table 2 | Binet staging system Maintenance therapy with an anti‑CD20 monoclonal

NATURE REVIEWS | DISEASE PRIMERS VOLUME 3 | 2017 | 13

14 | 2017 | VOLUME 3 www.nature.com/nrdp

NATURE REVIEWS | DISEASE PRIMERS VOLUME 3 | 2017 | 15

Outlook patients receiving lenalidomide compared with those

16 | 2017 | VOLUME 3 www.nature.com/nrdp

Box 3 | Chimeric antigen receptors of PD‑1‑expressing effector T cells106, leading to an

NATURE REVIEWS | DISEASE PRIMERS VOLUME 3 | 2017 | 17

18 | 2017 | VOLUME 3 www.nature.com/nrdp

NATURE REVIEWS | DISEASE PRIMERS VOLUME 3 | 2017 | 19

20 | 2017 | VOLUME 3 www.nature.com/nrdp

NATURE REVIEWS | DISEASE PRIMERS VOLUME 3 | 2017 | 21

Chronic lymphocytic leukaemia

NATURE REVIEWS | DISEASE PRIMERS www.nature.com/nrdp

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Somatic mutations. The advent of massively p arallel

a b Nonetheless, development of frequent or serious i nfections