1. Why bother doing fancy tests in patients with CLL?
Andrew R Pettitt
University of Liverpool

2. Some basic facts about CLL
Annual incidence about 5 per 100,000 per year
Male:Female ratio about 2:1
Less common in individuals from the Far East
Predominantly a disease of older people (7th decade)

3. Blood picture in CLL

4. Diagnosis of CLL CD19 PE Con PE CD2 PE CD22 PE CD79b PE CD19 Lambda PE
Con FITC
CD5 FITC
FMC7 FITC
CD23 FITC
CD20 FITC
Kappa FITC

5. Accumulation of CLL cells in bone marrow
Low red cells and platelets

6. Accumulation of CLL cells in liver and spleen
Low red cells and platelets

7. Accumulation of CLL cells in lymph nodes
Immune deficiency
Abnormal immune reactions
Haemolytic anaemia
ITP

8. Symptoms of CLL

9. Complications of CLL

10. CLL variability The clinical course of CLL varies between patients
Basic clinical features can predict survival
How much the disease has already grown by the time it is diagnosed (stage)
How fast it carries on growing after diagnosis (lymphocyte doubling time)

11. Tumour burden and prognosis

12. Lymphocyte doubling time and prognosis
Mollica S et al. Cancer 2001;92:713-9

13. Why do we need fancy tests?
Tumour burden at diagnosis predicts survival but not much else
Patients with low tumour burden want to know their prognosis without having to wait to see how quickly their disease grows
Doctors want information that helps with specific clinical decisions

14. Prognostic tests in newly diagnosed patients with low tumour burden “Big picture” from patient’s perspective
Chromosome abnormalities
“CLL FISH panel” for 17p-, 11q-, +12 and 13q-
Cell of origin
IGHV mutational status

15. Chromosome abnormalities
Fluorescence in-situ hybridisation
(FISH)
Dohner H et al. NEJM 2000; 343:

16. Cell of origin (IGHV “mutated” or “unmutated”)

17. Why do we need fancy tests?
Tumour burden at diagnosis predicts survival but not much else
Patients with low tumour burden want to know their prognosis without having to wait to see how quickly their disease grows
Doctors want information that helps with specific clinical decisions

18. Clinical decisions that doctors need help with
When to start treatment?
What treatment to give?
What to do once treatment has finished?

19. Bendamustine ± rituximab
What treatment to give?
More effective
Better tolerated
Bendamustine ± rituximab
Chlorambucil ± CD20 Mab
FCR
DNA-damaging chemotherapy

20. But… not all patients respond to chemotherapy
FCR arm of German CLL8 trial
Progression-free survival
17p deletion
Hallek M et al. Lancet 2010;376:

21. CLL cell with 17p deletion
What’s going on at 17p?
CLL cell with 17p deletion
Normal cell
TP53 gene on chromosome 17p
TP53 mutation
p53 mRNA
Non-functional mutant p53 protein
p53 protein
Wild-type p53 protein

22. TP53 mutation can occur in the absence of 17p- and vice versa; both have the same effect
17p deletion
TP53 mutation

23. What does wild-type p53 do that’s so important?‡
What does wild-type p53 do that’s so important?
p53 activation
Chemotherapy
Kills CLL cells
Stops CLL cells from growing
Stops CLL cells from turning even nastier
Non-chemo drugs
Steroids*
Campath*
Lenalidomide*
Ofatumumab
Ibrutinib
Idelalisib
Venetoclax
*Not approved in CLL

24. How do ibrutinib and idelalisib work?

25. How does venetoclax work?

26. What does NICE say?
Idelalisib in CLL (TA359; October 2015). Approved for
First-line treatment of patients with a 17p deletion or TP53 mutation
Previously treated CLL relapsing within 2 years of last therapy
Ibrutinib in CLL (TA429; Jan 2017). Approved for
Previously treated CLL
Venetoclax in CLL (STA944).
Rejected Feb 2017
Further committee meeting March 2017
Final outcome June 2017
Licenced for patients who have failed a BCR inhibitor and either have a 17p deletion or TP53 mutation, or have relapsed after chemotherapy.

27. Standard chemo-based approach
Take-home message #1
Treatment indicated
FISH
No 17p- or TP53 mutation
17p- or TP53 mutation
Standard chemo-based approach
Non-chemo drugs

28. Clinical decisions that doctors need help with
When to start treatment?
What treatment to give?
What to do once treatment has finished?

29. When to start treatment?
Trials have shown no benefit in treating patients with asymptomatic early stage disease
But… blanket approach with old-fashioned drugs
Ongoing studies with newer drugs targeting patients at high risk of early progression
IGHV, FISH and TP53 mutation may be useful outside of trials
To identify those patients who can be safely followed up infrequently and/or “remotely”
To identify those patients who might benefit from starting treatment sooner rather than later:
High risk of Richter transformation
Likely to grow quickly

30. Take-home message #2 FISH IGHV New diagnosis of CLL Low-risk
No 17p-/11q-
No TP53 mutation
IGHV mutated, no VH3-21, VH4-39 or stereotype
17p-/11q-
TP53 mutated
IGHV unmutated, VH3-21 VH4-39 or stereotype
Low-risk
Infrequent/ remote follow-up
High-risk
Low threshold for starting treatment

31. Clinical decisions that doctors need help with
When to start treatment?
What treatment to give?
What to do once treatment has finished?

32. What to do when treatment has finished?
If long remission predicted
Infrequent or remote follow-up
If high risk of early relapse
Potential role for maintenance therapy
If high risk of Richter transformation
Potential role for allogeneic transplantation

33. Tests that can predict what happens after treatment has finished
Pre-treatment IGHV status
IGHV unmutated = faster growing = earlier relapse
IGHV4-39 or stereotyped BCR = high risk of Richter transformation
Pre-treatment FISH
11q- = faster growing
17p- = faster growing and higher risk of Richter transformation
Pre-treatment TP53 mutation status
TP53 mutation = faster growing and higher risk of Richter transformation
Post-treatment minimal residual disease (MRD)
Can detect 1 CLL cells among 10,000 normal white blood cells
Deeper remissions = longer remissions

34. Infrequent/ remote follow-up
Take-home message #3
Treatment completed
Bone marrow for MRD
MRD -ve
MRD +ve
Infrequent/ remote follow-up
Close follow-up
Maintenance?

35. Summary of how tests can help with decision making
Result
Decisions at diagnosis
Treatment decisions
Post treatment decisions
IGHV analysis
Mutated
Infrequent/ remote follow-up
Limited
Unmutated or VH3-21
Close follow-up
Maintenance?
VH3-49 or stereotyped
Early treatment
Allograft?
FISH
17p-
Non-chemo drugs
11q-
TP53 mutation
TP53 mutated
Post-treatment MRD
Negative
N/A
Positive

36. Mutations in CLL – much still to learn
TP53, ATM, NOTCH1, SF3B1, BIRC3, LRP1B, SAMHD1, FBXW7, PCLO, HIST1H1E, XPO1, CHD2, MYD88, POT1 and ZFPM2
Detectable with “next generation sequencing”
TP53 mutation
Other mutations
ATM mutation
Sozan Karim, PhD student

37. Summary of key tests available in 2017 and when they should be performed
At diagnosis
Pre-treatment
Post-treatment
IGHV status
Yes
Not if already done No
FISH
Yes (can change)
TP53 mutation
MRD
N/A

38. Do currently available tests give all the answers?
Our understanding of why CLL behaves differently in different patients is very incomplete
Ongoing work to improve this understanding, e.g.
Genomics England Ltd allocated £3.5M to sequence the entire genetic code of up to 1000 samples stored in the UK CLL Trials Biobank in Liverpool (ARCTIC, AdMIRe, RIAltO, CLL210, CLEAR)
Analysis of all the proteins expressed by CLL cells to understand how alterations in the genetic code affect the expression of proteins and how this influences therapy response and disease behaviour
Clinical trials, sample collection and laboratory research are essential
Teamwork is paramount