Fracture and Harry Potter

This new movie starring Tony Hopkins and Ryan Gosling is not so much a "Who dunnit" as a "How did he do it?". On this basis I should have a job in the DA's office because I spotted it very early on. Hopkins keeps changing accents, which is was disconcerting. Was it deliberate? Was he trying to add mystery to his character? Was it just lazy? In a sort of sub-Lecter character Hopkins acts everyone else off the screen, but it's still a lazy performance; it's too easy for him. So what's wrong with the film? The love interest with Rosamund Pike is pointless and without chemistry - probably there to introduce her father. The final twist was telegraphed long before it needed to be. The business with the confusion over the cell phones was put in as a heavy hint when most people would have solved the puzzle, but the main problem was Gosling. He just can't carry a film. I've not seen him before in anything. He is apparently Canadian, so he can't be all bad, and he was nominated for an Oscar for Half Nelson, which I haven't seen. Perhaps it's unfair to play him alongside Hopkins, but even a lazy Hopkins makes him look like an amateur. He reminds me of Edward Norton. In a famous Master Class on acting, Michael Caine emphasized the importance of being still for the camera. Both these young actors seem to have taken this on board. They have thin-lipped expressionless faces that hardly move during a performance.

I absolve David Strathairn from criticism. He was the only other convincing actor in the movie.

Daniel Radcliffe is what is wrong with the latest Harry Potter film. He is so wooden that he must have thought he was playing the part of his wand rather than Harry Potter himself. This franchise is getting to the darker end of the books; there's not much humor in this one. The supporting acting is generally excellent. Imelda Staunton, once again astonishes with her range, Michael Gambon looked much more of a Dumbledore than last time, Robbie Coltrane still convinces as Hagrid, an ageing Rober Hardy plays Fudge, but then there are Emma Thompson, David Thewlis, Richard Griffiths, Fiona Shaw, Helena Bonham-Carter, Ralph Feinnes, Brendan Gleeson, Gary Oldman, Mark Williams, Maggie Smith, Julie Walters, Jason Isaacs and Alan Rickman. A special mention for David Bradley. This veteran actor has been playing villains, tramps and petty criminals for many years, and has been able to construct the horrible Filch in all the films. No-one does loathsome better.

Emma Watson may have a career after Harry Potter. The jury is still out on Rupert Grint. As for Daniel Ratcliffe - take the money and run.

CLL: Immunochemotherapy

Rituximab—the chimeric monoclonal anti-CD20—is only moderately active as a first-line agent in chronic lymphocytic leukaemia,[131] with an overall response rate of 51% and a complete remission rate of only 4%. However, when it is added to fludarabine or fludarabine plus cyclophosphamide, impressive responses have been reported. In a randomised phase II study,[132] rituximab added to fludarabine produced higher responses when given concurrently than when given sequentially. When compared with historical selected controls in a multivariate analysis controlling for pretreatment characteristics (but not for modern prognostic markers), addition of rituximab seemed to enhance significantly progression-free and overall survival.[133]

The combination of fludarabine, cyclophosphamide, and rituximab has been tested in first-line and relapsed and refractory settings (see also section on Drug-resistant chronic lymphocytic leukaemia). As first-line therapy,[134] overall response rates of 95% and complete remission rates of 70% were reported. In historical controls treated with fludarabine plus cyclophosphamide, the same research group recorded overall response rates of 88%, with 35% complete remission. However, only 33% of patients treated with fludarabine, cyclophosphamide, and rituximab were Rai stage III and IV, compared with 50% of those given fludarabine plus cyclophosphamide, and no modern prognostic markers have been reported for either patients or historical controls. In another phase II study, addition of mitoxantrone to fludarabine, cyclophosphamide, and rituximab seemed to add only toxic effects rather than increased efficacy.[135] Phase III comparisons of fludarabine, cyclophosphamide, and rituximab and fludarabine plus cyclophosphamide are currently underway, and these findings should be reported in 2008 or 2009.

Another purine analogue, pentostatin, has been assessed in combination with cyclophosphamide and rituximab in a phase II trial of previously untreated patients with chronic lymphocytic leukaemia.[136] This trial is valuable in that the prognostic markers IGHV gene mutations, CD38 expression, ZAP70 expression, and interphase cytogenetics were reported. The overall response rate was 91%, with 41% complete remission. Patients with TP53 anomalies had poor responses. The researchers claim that this regimen is less toxic than fludarabine, cyclophosphamide, and rituximab.

Although not yet published, even in abstract form, the Roche website has this statement concerning the German/French CLL8 trial: The pivotal CLL8 trial, initiated by the German CLL study group, successfully met its primary endpoint, by showing that patients treated with MabThera in combination with the current standard chemotherapy achieved a significant improvement in progression free survival, compared to patients treated with chemotherapy alone.

This result became apparent following the first interim analysis in January 2008. An abstract is being prepared for ASH 2008.

Alemtuzumab seems to be one of the few agents capable of killing chronic lymphocytic leukaemia cells with mutated or deleted TP53 genes. The drug has been used as first-line therapy in a phase III trial, in which it was compared with chlorambucil at a dose of 40 mg/m2 per month. Overall response rates and progression-free survival were significantly better for alemtuzumab than for chlorambucil.[137]

Unfortunately, Alemtuzumab seems to be incapable of penatrating large tumor masses and is regarded as contraindicated if lymph nodes have a diameter of greater than 5 cm. However, when used in combination with high dose methylprednisolone (another drug that is effective in CLL lacking p53 function) in a small phase II study, teh overall response rate was 100% with a 60% CR rate. [161]

References

131 JD Hainsworth, S Litchy and JH Barton et al., Single-agent rituximab as first-line and maintenance treatment for patients with chronic lymphocytic leukemia or small lymphocytic lymphoma: a phase II trial of the Minnie Pearl Cancer Research Network, J Clin Oncol 21 (2003), pp. 1746–1751.

132 JC Byrd, BL Peterson and VA Morrison et al., Randomized phase 2 study of fludarabine with concurrent versus sequential treatment with rituximab in symptomatic, untreated patients with B-cell chronic lymphocytic leukemia: results from Cancer and Leukemia Group B 9712 (CALGB 9712), Blood 101 (2003), pp. 6–14.

133 JC Byrd, K Rai and BL Peterson et al., Addition of rituximab to fludarabine may prolong progression-free survival and overall survival in patients with previously untreated chronic lymphocytic leukemia: an updated retrospective comparative analysis of CALGB 9712 and CALGB 9011, Blood 105 (2005), pp. 49–53.

134 MJ Keating, S O'Brien and M Albitar et al., Early results of a chemoimmunotherapy regimen of fludarabine, cyclophosphamide, and rituximab as initial therapy for chronic lymphocytic leukemia, J Clin Oncol 23 (2005), pp. 4079–4088.

135 S Faderl, WG Wierda and S O'Brien et al., Fludarabine, cyclophosphamide, mitoxantrone plus rituximab (FCM-R) as frontline therapy for CLL: results of a phase 2 study, Blood 108 (2006), p. 2836.

136 NE Kay, SM Geyer and TG Call et al., Combination chemoimmunotherapy with pentostatin, cyclophosphamide, and rituximab shows significant clinical activity with low accompanying toxicity in previously untreated B chronic lymphocytic leukemia, Blood 109 (2007), pp. 405–411.

137 P Hillmen, AB Skotnicki and T Robak et al., Alemtuzumab compared with chlorambucil as first-line therapy for chronic lymphocytic leukemia, J Clin Oncol 25 (2007), pp. 5616–5623.

161 AR Pettitt, E Matutes and D Oscier, Alemtuzumab in combination with high-dose methylprednisolone is a logical, feasible and highly active therapeutic regimen in chronic lymphocytic leukaemia patients with p53 defects, Leukemia 20 (2006), pp. 1441–1445.

The Illusionist

After 'The Prestige' now comes 'The Illusionist'. Oscar nominated for Cinematography it was another period piece about conjurers. Less difficult than the Prestige and the trick more easily guessed. After Star Trek we are used to both teleportation and holograms. "Even if we escaped he would hunt us down until we are dead" says the Duchess and that is the clue. In a way, the human interest story was more accessible than that of the Prestige, but the tricks were not explained - the sword in the stone in particular when he would have had no apparatus to make it work.

The Prestige was much darker, with Hugh Jackman playing against type and Christian Bale apparently sacrificing his queen. I certainly never spotted the Tessler answer until it was revealed, but I did guess the twin. Of the two, my wife preferred the Illusionist, but I preferred the Prestige.

CLL Treatment: Purine analogues

With the introduction of purine analogues, a class of drug better able to achieve complete remission in chronic lymphocytic leukaemia, the possibility has arisen of treating the disease in a similar way to other leukaemias—eg, with induction chemotherapy to achieve complete remission followed by consolidation treatment to eliminate minimal residual disease. Progress towards this end has been limited for several reasons. Complete remission in chronic lymphocytic leukaemia allows for up to 30% of chronic lymphocytic leukaemia cells to remain in the bone marrow;[121] many patients live long and symptom-free lives without achieving complete remission; and most are elderly and are not candidates for more intensive treatments. Purine analogues cause profound suppression of T-cell immunity [122] and can trigger autoimmunity.[123] If the induction-consolidation strategy is not to be followed, these hazards could outweigh the benefits.

The purine analogue fludarabine, alone or in combination, has become the standard of care in most countries other than the UK. Researchers in a meta-analysis [124] looked at five trials of 1838 patients randomly allocated either an alkylator-based regimen or a purine analogue. Individuals treated with purine analogues had significantly higher overall and complete response rates and longer progression-free survival than did those treated with alkylator-based regimens, but overall survival did not differ between treatment groups. Three further large trials had not been assessed at the time the meta-analysis was undertaken, and a difference in overall survival could yet arise as further data accumulate. However, because patients who fail one regimen can respond very well to another, this question might never be resolved. Because of this factor and because the natural history of chronic lymphocytic leukaemia is so long, researchers doing clinical trials have adopted progression-free survival as a surrogate for overall survival as the primary endpoint. However, such a strategy can be misleading.[125]

Findings of a trial in which a higher monthly dose of chlorambucil (70 mg/m2) was compared with fludarabine showed that response rates and median progression-free and overall survival did not differ between groups. Furthermore, fewer toxic effects arose in the chlorambucil group—ie, neutrophil counts lower than 1×109/L, admission for more than 1 day, and grade 1 and 2 diarrhoea. The frequency of autoimmune haemolytic anaemia was similar in both groups but seems to have been more severe in the fludarabine group than in the chlorambucil group, since two patients treated with fludarabine died from the complication.[126]

Combinations of purine analogues and alkylating agents have been tested in three randomised trials. In an Intergroup trial,[127] a fludarabine plus chlorambucil regimen had to be abandoned as too toxic. Workers on a German CLL4 trial compared fludarabine plus cyclophosphamide with fludarabine alone as first-line therapy in 375 patients younger than age 66 years,[128] and a similar comparison was undertaken in a British CLL4 trial [126] in 390 patients without age restriction. Findings of both CLL4 studies showed the combination was significantly better than fludarabine alone in terms of overall and complete response rates and progression-free survival, but overall survival did not differ between groups. Moreover, the combination was significantly more toxic than fludarabine alone in terms of neutrophil counts lower than 1×109/L, admission to hospital for more than 1 day, grade 3 and 4 nausea and vomiting, grade 1 or 2 alopecia, and grade 1 or 2 diarrhoea. However, autoimmune haemolytic anaemia was significantly less frequent with the combination. In Intergroup trial E2997,113 complete response rates were reported as 24·6% for fludarabine plus cyclophosphamide and 5·3% for fludarabine alone. Median progression-free survival was 33·5 months and 19·9 months, respectively. Both these differences were statistically significant.

Another purine analogue, cladribine, has been assessed in a three-way, randomised phase III study.[129] Researchers compared the agent alone and in combination with cyclophosphamide or cyclophosphamide plus mitoxantrone. The three-drug combination produced significantly more responses and complete remissions at the expense of more bone-marrow toxic effects. Progression-free and overall survival did not differ between groups. Mitoxantrone has also been used in combination with fludarabine plus cyclophosphamide in a phase II trial in relapsed or resistant chronic lymphocytic leukaemia.[130] The findings of this trial were remarkable because the complete remission rate was 50%, with a third of these patients having no detectable disease with a very sensitive method.

References

121 BD Cheson, JM Bennett and M Grever et al., National Cancer Institute-sponsored Working Group guidelines for chronic lymphocytic leukemia: revised guidelines for diagnosis and treatment, Blood 87 (1996), pp. 4990–4997.

122 MJ Keating, S O'Brien and S Lerner et al., Long-term follow-up of patients with chronic lymphocytic leukemia (CLL) receiving fludarabine regimens as initial therapy, Blood 92 (1998), pp. 1165–1171.

123 H Myint, JA Copplestone and J Orchard et al., Fludarabine-related autoimmune haemolytic anaemia in patients with chronic lymphocytic leukaemia, Br J Haematol 91 (1995), pp. 341–344.

124 M Steurer, G Pall and S Richards et al., Single-agent purine analogues for the treatment of chronic lymphocytic leukaemia: a systematic review and meta-analysis, Cancer Treat Rev 32 (2006), pp. 377–389.

125 M Cavo and M Baccarani, The changing landscape of myeloma therapy, N Engl J Med 354 (2006), pp. 1076–1078.

126 D Catovsky, S Richards and E Matutes et al., Assessment of fludarabine plus cyclophosphamide for patients with chronic lymphocytic leukaemia (the LRF CLL4 Trial): a randomised controlled trial, Lancet 370 (2007), pp. 230–239.

127 KR Rai, BL Peterson and FR Appelbaum et al., Fludarabine compared with chlorambucil as primary therapy for chronic lymphocytic leukemia, N Engl J Med 343 (2000), pp. 1750–1757.

128 BF Eichhorst, R Busch and G Hopfinger et al., Fludarabine plus cyclophosphamide versus fludarabine alone in first-line therapy of younger patients with chronic lymphocytic leukemia, Blood 107 (2006), pp. 885–891.

129 T Robak, JZ Blonski and J Gora-Tybor et al., Cladribine alone and in combination with cyclophosphamide or cyclophosphamide plus mitoxantrone in the treatment of progressive chronic lymphocytic leukemia: report of a prospective, multicenter, randomized trial of the Polish Adult Leukemia Group (PALG CLL2), Blood 108 (2006), pp. 473–479.

130 F Bosch, A Ferrer and A Lopez-Guillermo et al., Fludarabine, cyclophosphamide and mitoxantrone in the treatment of resistant or relapsed chronic lymphocytic leukaemia, Br J Haematol 119 (2002), pp. 976–984.

CLL: when to start treatment

Most patients with chronic lymphocytic leukaemia present without symptoms or signs; they are identified simply because a blood test has been requested for an unrelated reason. Many of these people never progress or need treatment; however, those who do need treatment usually present in the same way.

Findings of a meta-analysis of seven trials including 2048 early-stage patients randomly allocated either immediate or deferred treatment with chlorambucil (with or without prednisolone) showed no benefit for either treatment group.[120] In a French study,[96] 51% of Binet stage A patients allocated to the deferred group eventually needed treatment and 27% of this group died of a cause related to chronic lymphocytic leukaemia.

Standard management of chronic lymphocytic leukaemia, therefore, includes a period of watchful waiting until features of progression are noted. These signs—of bulk disease, lymphoma-related symptoms, and marrow failure—have been codified by a working group sponsored by the American National Cancer Institute.[121] The document is currently under revision and is unlikely to include recommendations for changes in treatment based on new prognostic markers, but it is likely to recommend new randomised clinical trials with stratification based on such markers. Readers can view the new guidelines here.

With more effective treatments than chlorambucil and better ways of establishing which patients are unlikely to progress, the strategy of watchful waiting should be revisited. Randomised trials of early versus delayed treatment for early-stage patients with poor-risk prognostic markers are planned or underway in Germany, France, the USA, and the UK. In a meta-analysis of ten trials including 2035 advanced-stage patients,[120] addition of anthracycline or a vinca alkyloid to the alkylating agent was not shown to affect outcome.

References

96 G Dighiero, K Maloum and B Desablens et al., Chlorambucil in indolent chronic lymphocytic leukemia, N Engl J Med 338 (1998), pp. 1506–1514.

120 CLL Trialists' Collaborative Group, Chemotherapeutic options in chronic lymphocytic leukemia: a meta-analysis of the randomized trials, J Natl Cancer Inst 91 (1999), pp. 861–868.

121 BD Cheson, JM Bennett and M Grever et al., National Cancer Institute-sponsored Working Group guidelines for chronic lymphocytic leukemia: revised guidelines for diagnosis and treatment, Blood 87 (1996), pp. 4990–4997.

Fundamentalist or Evangelical

We have a problem with names. The term 'fundamentalist' means someone who religion is based on the fundamentals (the basics) of the faith. But words change their meaning. Nowadays the term is most commonly applied to Muslims who like blowing up themselves and everyone around them. When applied to Christians it refers to the Religious Right, but it can be applied to anyone whose attitudes are inflexible and hostile. Richard Dawkins has been called a fundamentalist atheist.

'Evangelical' is similarly traduced. Originally, it referred to the good news, and applied to Wycliffe, Whitefield and Wesley and later to the social reformers, Wilberforce and the Clapham sect, a recent survey of British parliamentarians though it referred to those opposed to condoms (I though that was Catholics). Indeed Hansard also reveals a whole set of negative meanings; those who are opposed to contraception of any sort, who campaign against homosexuals, are opposed to women priests and bishops, open private 'creationist' schools, and preach witchcraft!

No word of the fact that Evangelicals led the campaign against slavery, the abuse of women and children in coalmines and factories, founded charities like Oxfam, Action Aid, Barnardos, the Salvation Army, Help the Aged, Tear Fund and many others. We are called anti-intellectual when we can boast Michael Faraday among our numbers.

Nevertheless, words change their meanings and we can't stick to the old terms if they now mean something else. It has been suggested that we call ourselves Biblical Christians, or Classic, Orthodox, Creedal, Historic or perhaps Committed Christians.

CLL; Assessment of prognosis

In chronic lymphocytic leukaemia, a third of patients never need treatment and have long survival; in another third, an initial indolent phase is followed by disease progression; the remaining third exhibit aggressive disease at onset and need immediate treatment.[95] The Rai and Binet staging systems have enabled individuals with chronic lymphocytic leukaemia to be divided into three prognostic groups (good, intermediate, and poor) and have provided a foundation for clinicians to design therapeutic strategies for the disease. However, with neither the Rai nor the Binet staging system can we predict who in the good prognosis group will develop progressive disease.[96] Several attempts have been made to address this deficiency. Lymphocyte doubling time, the pattern of bone-marrow involvement, and concentrations in serum of β2 microglobulin, thymidine kinase, and soluble CD23 all have some value but also important drawbacks.[97] Lymphocyte counts can double in response to infection, vaccination, and steroid treatment; patterns of marrow involvement need invasive investigation; measurement of thymidine kinase in serum needs a radioassay; and amounts of CD23 and β2 microglobulin indicate both bulk of disease and rates of progression.

As reported above in the section on Genetic abnormalities, chronic lymphocytic leukaemias with mutated immunoglobulin genes have good prognosis and those with unmutated genes show poor prognosis.[67], [68] and [98] The mutational profile of immunoglobulin genes delineates prognostic groups within all Binet's stages.[67] and [99] The IGHV mutational profile has the advantage that it remains constant during clonal evolution, which contrasts with genomic aberrations and serum markers. Since sequencing IGHV genes is seen as costly and time consuming (though this is probably not true), and it is unavailable at most medical facilities, detection of appropriate, reliable surrogate markers for IGHV mutational status has attracted worldwide attention.

An early candidate surrogate marker was expression of CD38. However, although CD38 expression is associated with poor prognosis, its relation to immunoglobulin mutational status remains controversial.[68] and [100] Furthermore, expression of CD38 can change during disease evolution and concerns exist with respect to interlaboratory variations and the definition of the best cutoff value.[97] and [101]

Crespo and colleagues [102] developed a multivariable flow-cytometric test for ZAP70 that showed 95% correlation with IGHV gene mutational status; this finding was confirmed by a similar assay that used a slightly different way of expressing the results.[103] However, these tests used indirect immunofluorescence, and a more convenient assay using direct immunofluorescence gave only 77% concordance with mutational status of IGHV genes.[104] With the direct assay, ZAP70 seemed to be superior to IGHV genes in prediction of time-to-first treatment, whereas in ZAP70-negative patients, IGHV mutational status delineated good from intermediate prognosis.104 So far, this assay has not exported well to other laboratories and considerable dispute remains about how ZAP70 amounts should be estimated.[105]

LPL is consistently overexpressed in patients with unmutated chronic lymphocytic leukaemia and has also been proposed as a surrogate marker.[106] By contrast with ZAP70, which sometimes fails to identify advanced forms of disease, this marker seems to be an independent prognostic factor for individuals with Binet stage B and C disease.[106] and [107] Assay by real-time quantitative PCR is less widely applicable than flow cytometry, but data suggest that this method is as good as IGHV mutational analysis and more reliable than ZAP70 as a prognostic factor.[108]

For laboratories with facilities to measure concentrations in serum of thymidine kinase, high amounts at diagnosis identified patients categorised into good prognosis groups by other biomarkers (IGHV, ZAP70, CD38, del13q14) who subsequently progressed to advanced disease.[109] Measurement of telomere length also refined the prognostic analysis of IGHV unmutated cases. Patients with short telomeres had significantly shorter progression-free and overall survival than did those with long telomeres.[110] Low amounts of the chemokine receptor CXCR3 predict reduced survival independent of IGHV mutations and CD38 levels.[111] The degree of upregulation of CLLU1 is an independent prognostic marker in patients younger than age 70 years.[112]

Although all these markers provide useful prognostic information, the mutational status of IGHV genes and del 17p and del 11q are the most robust prognostic indicators, having been validated in prospective phase III clinical trials. Findings of a US Intergroup study comparing fludarabine with fludarabine plus cyclophosphamide[113] showed that median progression-free survival was significantly lower for patients with del 17p13 or del 11q23 than for those with other cytogenetic findings. Although progression-free survival was longer for individuals with mutated IGHV genes than for those with unmutated genes, the study was insufficiently powered for this finding to reach significance.[113] In the UK Leukaemia Research Fund CLL4 trial comparing fludarabine, fludarabine plus cyclophosphamide, and chlorambucil, the effect of prognostic markers on outcome was assessed prospectively.[114] Importantly, prognostic factors had a greater effect on overall survival than did choice of treatment. Patients with del 17p in more than 20% of cells had a significantly poorer response rate and median overall survival than did all other individuals, whereas those with unmutated IGHV genes or del 11q23 had significantly shorter progression-free and overall survival than did those with mutated IGHV genes, no matter which treatment they were given. Findings of a CALGB 9712 phase II comparison of different schedules of rituximab given with fludarabine [115] showed that median progression-free and overall survival were significantly greater in patients with mutated IGHV genes than in those with unmutated genes. Survival was also significantly increased with the Döhner hierarchical classification of FISH results moving from del 17p13 to del 13q14.

Combinations of prognostic factors might be more useful than individual factors. CD38 and IGHV mutations100 or CD38 and ZAP70[116] and [117] both perform better than any one factor. A scoring system based on six surface molecules (CD62L [SELL], CD54 [ICAM1], CD49c [ITGA3], CD49d [ITGA4], CD38, and CD79B) detectable by flow cytometry has been proposed.118 Another using the easily available factors of age, sex, Rai stage, number of lymph nodes involved, absolute lymphocyte count, and β2 microglobulin has been assessed in many patients.[119]

By multivariate analysis, both Binet staging and IGHV genes retain their independent prognostic significance in chronic lymphocytic leukaemia and are complementary.[67] and [99] As table 2 shows, addition of Binet staging to the mutational profile of immunoglobulin genes and 17p13 deletion, which is the strongest independent prognostic marker, allows segregation of patients into five prognostic subgroups. We do not claim this prognostic system to be definitive; undoubtedly incorporation of other factors will give greater refinement, but it makes use of the best established and validated factors.

In conclusion, recognition of novel biological variables has had a major effect on our understanding of chronic lymphocytic leukaemia. Some variables seem to be of considerable prognostic importance but, as yet, no evidence is available to suggest that changing therapeutic approaches on the basis of these results will lead to improvement in outcome. Prospective clinical trials are needed to address the stratification of patients according to these factors.

References

95 G Dighiero, Unsolved issues in CLL biology and management, Leukemia 17 (2003), pp. 2385–2391.

96 G Dighiero, K Maloum and B Desablens et al., Chlorambucil in indolent chronic lymphocytic leukemia, N Engl J Med 338 (1998), pp. 1506–1514.

97 E Montserrat, Classical and new prognostic factors in chronic lymphocytic leukemia: where to now?, Hematol J 3 (2002), pp. 7–9.

98 K Maloum, F Davi and H Merle-Beral et al., Expression of unmutated VH genes is a detrimental prognostic factor in chronic lymphocytic leukemia, Blood 96 (2000), pp. 377–379.

99 Y Vasconcelos, F Davi and V Levy et al., Binet's staging system and VH genes are independent but complementary prognostic indicators in chronic lymphocytic leukemia, J Clin Oncol 21 (2003), pp. 3928–3932.

100 TJ Hamblin, JA Orchard and RE Ibbotson et al., CD38 expression and immunoglobulin variable region mutations are independent prognostic variables in chronic lymphocytic leukemia, but CD38 expression may vary during the course of the disease, Blood 99 (2002), pp. 1023–1029.

101 P Ghia, G Guida and S Stella et al., The pattern of CD38 expression defines a distinct subset of chronic lymphocytic leukemia (CLL) patients at risk of disease progression, Blood 101 (2002), pp. 1262–1269.

102 M Crespo, F Bosch and N Villamor et al., ZAP-70 expression as a surrogate for immunoglobulin-variable-region mutations in chronic lymphocytic leukemia, N Engl J Med 348 (2003), pp. 1764–1775.

103 JA Orchard, RE Ibbotson and Z Davis et al., ZAP-70 expression and prognosis in chronic lymphocytic leukaemia, Lancet 363 (2004), pp. 105–111.

104 LZ Rassenti, L Huynh and TL Toy et al., ZAP-70 compared with immunoglobulin heavy-chain gene mutation status as a predictor of disease progression in chronic lymphocytic leukemia, N Engl J Med 351 (2004), pp. 893–901.

105 G Marti, A Orfao and C Goolsby, ZAP-70 in CLL: towards standardization of a biomarker for patient management: history of clinical cytometry special issue, Cytometry B Clin Cytom 70 (2006), pp. 197–200.

106 P Oppezzo, Y Vasconcelos and C Settegrana et al., The LPL/ADAM29 expression ratio is a novel prognosis indicator in chronic lymphocytic leukemia, Blood 106 (2005), pp. 650–657.

107 D Heintel, D Kienle and M Shehata et al., High expression of lipoprotein lipase in poor risk B-cell chronic lymphocytic leukemia, Leukemia 19 (2005), pp. 1216–1223.

108 MB van't Veer, AM Brooijmans and AW Langerak et al., The predictive value of lipoprotein lipase for survival in chronic lymphocytic leukemia, Haematologica 91 (2006), pp. 56–63.

109 C Matthews, MA Catherwood and TC Morris et al., Serum TK levels in CLL identify Binet stage A patients within biologically defined prognostic groups most likely to undergo disease progression, Eur J Haematol 77 (2006), pp. 309–317.

110 I Ricca, A Rocca and D Drandi et al., Telomere length identifies two different prognostic subgroups among VH-unmutated B-cell chronic lymphocytic leukemia patients, Leukemia 21 (2007), pp. 697–705.

111 E Ocana, L Delgado-Perez and A Campos-Caro et al., The prognostic role of CXC3R expression by chronic lymphocytic leukemia B cells, Haematologica 92 (2007), pp. 349–356.

112 P Josefsson, CH Geisler and H Leffers et al., CLLU1 expression analysis adds prognostic information to risk prediction in chronic lymphocytic leukemia, Blood 109 (2007), pp. 4973–4979.

113 MR Grever, DM Lucas and GW Dewald et al., Comprehensive assessment of genetic and molecular features predicting outcome in patients with chronic lymphocytic leukemia: results from the US intergroup phase III trial E2997, J Clin Oncol 25 (2007), pp. 799–804.

114 DG Oscier, R Wade and J Orchard et al., Prognostic factors in the UK LRF CLL4 trial, Blood 108 (2005), p. 299.

115 JC Byrd, JG Gribben and BL Peterson et al., Select high-risk genetic features predict earlier progression following chemoimmunotherapy with fludarabine and rituximab in chronic lymphocytic leukemia: justification for risk-adapted therapy, J Clin Oncol 24 (2006), pp. 437–443.

116 I Del Giudice, A Morilla and N Osuji et al., Zeta chain associated protein 70 and CD38 combined predict the time to first treatment in patients with chronic lymphocytic leukemia, Cancer 104 (2005), pp. 2124–2132.

117 R Schroers, F Griesinger and L Trumper et al., Combined analysis of ZAP-70 and CD38 expression as a predictor of disease progression in B-cell chronic lymphocytic leukemia, Leukemia 19 (2005), pp. 750–758.

118 A Zucchetto, R Bomben and M Dal Bo et al., A scoring system based on the expression of six surface molecules allows the identification of three prognostic risk groups in B-cell chronic lymphocytic leukemia, J Cell Physiol 207 (2006), pp. 354–363.

119 WG Wierda, S O'Brien and X Wang et al., Prognostic nomogram and index for overall survival in previously untreated patients with chronic lymphocytic leukemia, Blood 109 (2007), pp. 4679–4685.

FISH and mutations

I have recently been asked whether del 11q is also influenced by the mutational status of IgVH genes. As you can see by these two survival curves, the answer is yes. I had not asked our data the question before, but the answer is clearly that for untreated patients the IgVH mutations trumps FISH. It ought to be publicised amongst oncologists because not a lot of people know this.

Fish oil scam

In a recent Doctor Who story aliens took over a school and fed chips fried in a special alien brain-improving oil to the kids. Students who performed poorly were taken out of class and eaten. This was fiction but not a million miles away from what actually happened in schools in Durham in 2006-7. In September 2006 all year 11 pupils at the county’s 36 comprehensive schools were offered omega-3 fish oil supplements. Dave Ford, the county’s chief schools inspector, said: “We are able to track pupils’ progress and we can measure whether their attainments are better than their predicted scores.”

Although the GCSE results were published last summer, the county has still to say whether the omega-3 supplement had any effect.

County councillor Michelle Hodgson: “Our evaluation of levels of take-up and perceptions of staff, pupils and parents will be made public once all of the relevant information from participating schools has been properly collated and analysed.”

She added: “As we have said previously it was never intended, and the county council never suggested, that it would use this initiative to draw conclusions about the effectiveness or otherwise of using fish oil to boost exam results.”

Really?

Take a look at Ben Goldacre's blog.

Dr Madeleine Portwood, senior educational psychologist at Durham county council, who ran the “trial”, says: “Previous trials have shown remarkable results and I am confident that we will see marked benefits in this one as well.”

In the Daily Mail article from September 5 2006 headlined “Fish oil study launched to improve GCSE grades“, Dave Ford, the council’s chief schools inspector, says: “We will be able to track pupils’ progress and measure whether their attainments are better than their predicted scores.”

Durham county council’s own press release from the beginning of the “trial” reads: “Education chiefs in County Durham are to mount a unique back-to-school initiative today which they believe could result in record GCSE pass levels next summer.”

It says that children are being given pills “to see whether the proven benefits it has already brought children and young people in earlier trials can boost exam performances too”. The council’s chief schools inspector is “convinced” that these pills “could have a direct impact on their GCSE results … the county-wide trial will continue until the pupils complete their GCSE examinations next June, and the first test of the supplement’s effectiveness will be when they sit their ‘mock’ exams this December.”

Unfortunately the GCSE results for Durham were rather disappointing this year. This fact was not press-released by the county council.

CLL: apoptosis and proliferation

Accumulation of mature B cells that have escaped programmed cell death and undergone cell-cycle arrest in the G0/G1 phase is the hallmark of chronic lymphocytic leukaemia.[83] These cells have a low proliferative activity, and data lend support to the hypothesis that in-vivo defective apoptosis accounts for accumulation of B cells. In chronic lymphocytic leukaemia cells, translocations of the BCL2 gene are rare (fewer than 1% of cases)[84] despite high amounts of the BCL2 protein. The role of BCL2 in apoptosis inhibition is not clear, since no correlation exists between in-vitro apoptosis and the amount of BCL2 expression.[85] However, other members of the BCL2 family, such as anti-apoptotic proteins BCL-XL (alternative splice variant of BCL2L1), BAG1, and MCL1, are overexpressed whereas proapoptotic proteins, such as BAX and BCL-XS (alternative splice variant of BCL2L1), are underexpressed.[83]

Deregulation of cell-cycle regulatory genes might also contribute to accumulation of malignant cells in early phases (G0/G1) of the cell cycle. In chronic lymphocytic leukaemia cells, raised amounts of the cyclin negative regulator CDKN1B protein are recorded in most patients.[85] In view of the key role of this protein in cell-cycle progression, its overexpression in chronic lymphocytic leukaemia cells could account for the accumulation of B cells in early phases of the cell cycle. These data suggest that chronic lymphocytic leukaemia is a disease resulting from accumulation rather than proliferation.

By contrast with in-vivo results, apoptosis happens after in-vitro culture, indicating a role of the microenvironment in chronic lymphocytic leukaemia cell survival.[86] and [87] Findings showing that apoptosis in vitro is prevented by exposure to interleukin 4 and by stimulation via surface CD40 also favour this view. In vivo, such inhibition can happen in pseudo-follicles seen in the lymph nodes and in cell clusters described in bone marrow.[88] These pseudo-follicles include, in close contact with proliferating B cells, increased numbers of CD4 T cells expressing CD40 ligand. These activated CD4 T cells could be recruited by tumour B cells, since they constitutively express the T-cell-attracting chemokines CCL17 and CCL22.[88] and [89] This idea could be in agreement with a model of selective survival of certain clonal submembers, which would receive survival signals in these particular sites.

With a non-radioactive, stable isotopic labelling method to measure chronic lymphocytic leukaemia kinetics, Messmer and colleagues [90] showed that B-cell chronic lymphocytic leukaemia is not a static disease, resulting simply from accumulation of long-lived lymphocytes, but is a disease with a dynamic process in which cells proliferate and die, sometimes at appreciable levels. This finding is in conflict with the view that chronic lymphocytic leukaemia is characterised almost exclusively by cell accumulation due to a defect in apoptosis. This mechanism might compensate for the clonal decrease that could take place in the periphery by apoptosis and, depending on its importance, could have a major role in regulation of tumour burden.

A picture is emerging that emphasises the importance of proliferation centres in lymph nodes spleen and bone marrow. Here, stimulation by CD31 on endothelial cells and CD154 on T-cells activates chronic lymphocytic leukaemia cells, upregulating CD38 and perhaps ZAP-70, provoking cell division and reinforcing resistance to apoptosis. From the proliferation centre the cell emerges into the circulation, where levels of activation markers begin to decline at a rate determined by intrinsic qualities of the cell. Cells that are better at retaining activation markers are drawn back into the tissues by chemokines and once there repeat the whole cycle. CD38 can be seen as an index of how recently the CLL cell has visited a proliferation center. [91], [92], [93] and [94]

References

83 F Caligaris-Cappio and TJ Hamblin, B-cell chronic lymphocytic leukemia: a bird of a different feather, J Clin Oncol 17 (1999), pp. 399–408.

84 MJS Dyer, VJ Zani and WZ Lu et al., BCL2 translocations in leukemias of mature B cells, Blood 83 (1994), pp. 3682–3688.

85 R Vrhovac, A Delmer, R Tang, JP Marie, R Zittoun and F Ajchenbaum-Cymbalista, Prognostic significance of the cell cycle inhibitor p27Kip1 in chronic B-cell lymphocytic leukemia, Blood 91 (1998), pp. 4694–4700.

86 L Lagneaux, A Delforge, C Dorval, D Bron and P Stryckmans, Excessive production of transforming growth factor-beta by bone marrow stromal cells in B-cell chronic lymphocytic leukemia inhibits growth of hematopoietic precursors and interleukin-6 production, Blood 82 (1993), pp. 2379–2385.

87 F Caligaris-Cappio, Role of the microenvironment in chronic lymphocytic leukaemia, Br J Haematol 123 (2003), pp. 380–388.

88 L Granziero, P Ghia and P Circosta et al., Survivin is expressed on CD40 stimulation and interfaces proliferation and apoptosis in B-cell chronic lymphocytic leukemia, Blood 97 (2001), pp. 2777–2783.

89 FK Stevenson and F Caligaris-Cappio, Chronic lymphocytic leukemia: revelations from the B-cell receptor, Blood 103 (2004), pp. 4389–4395.

90 BT Messmer, D Messmer and SL Allen et al., In vivo measurements document the dynamic cellular kinetics of chronic lymphocytic leukemia B cells, J Clin Invest 115 (2005), pp. 755–764.

91 C Pepper, R Ward and TT Lin et al., Highly purified CD38+ and CD38− sub-clones derived from the same chronic lymphocytic leukemia patient have distinct gene expression signatures despite their monoclonal origin, Leukemia 21 (2007), pp. 687–696.

92 S Deaglio, T Vaisitti and S Aydin et al., CD38 and ZAP-70 are functionally linked and mark CLL cells with high migratory potential, Blood 110 (2007), pp. 4012–4021. Full

93 RN Damle, S Temburni and C Calissano et al., CD38 expression labels an activated subset within chronic lymphocytic leukemia clones enriched in proliferating B cells, Blood 110 (2007), pp. 3352–3359.

94 S Willimott, M Baou, S Huf, S Deaglio and SD Wagner, Regulation of CD38 in proliferating chronic lymphocytic leukemia cells stimulated with CD154 and interleukin-4, Haematologica 92 (2007), pp. 1359–1366.

Mad monks and a flat earth

'Can you imagine Julie Andrews in The Sound of Music staying with the Captain if the romance went out of their marriage? Would she not divorce him and grab his children to be her toys? All the elements of pornography are there...'

'The Sound of Music is an immoral film because it puts friendliness and fun in the place of authority'.

I report these sayings of Bishop Richard Williamson because he has recently hit the news by claiming that the Protocols of the Elders of Zion, a notorious anti-Semitic forgery that enjoys widespread currency in neo-Nazi circles, is authentic.

The dateline in The Catholic Herald is April 1st, so make of it what you will, but according to reports Richard Williamson who was an Anglican who defected to Archbishop Lefevre's Society of St Pius X where he was ordained a bishop in defiance of the Pope is currently ministering in Argentina to extreme right wing groups. He is widely regarded as the "Borat" of the Catholic Church.

I came across the Protocols of the Elders of Zion again yesterday while I was reading Serendipidies by Umberto Eco. Eco's books are erudite but hard to read. His most famous book is The Name of the Rose, a tribute to Sherlock Holmes set in the Middle Ages, but the other volumes of his that I have on my shelves have remained half read.

Serendipities is a series of essays, the first of which discusses among other things the idea that the Christian Church once believed that the earth was flat. It was a charge leveled at the church in the Darwin versus religion debate of the nineteenth century. It is claimed that Columbus was opposed by the clergy because they thought he would sail over the edge of the world as in Terry Pratchett's Discworld. Just like the Protocols of the Elders of Zion, the flat earth theory is a nonsense. That the world was spherical was known to the Ancient Greeks like Pythagoras and Euclid and certainly to the Church Fathers like Origen and Augustine,. Thomas Aquinas is very clear about it. There was a monk in the 4th century who believed the world was shaped like the Tabernacle of the Pentateuch, but no-one took any notice of him until he was translated into English by the Darwinists for a debating point.

As Richard Williamson demonstrates, you can always find a mad clergyman.

Genetic abnormalities in CLL

Although multiple instances of chronic lymphocytic leukaemia in some families, and low frequency of the disease in individuals of Japanese origin, suggest that genetic effects might be stronger than environmental factors in the pathogenesis of chronic lymphocytic leukaemia, the nature of this genetic predisposition remains uncertain and different genes may be involved in different families. A recent paper has identified a family in which a single nucleotide polymorphism down-regulates the expression of DAPK1 transcription. The same polymorphism has been identified in one sporadic case of chronic lymphocytic leukaemia, but not in other familial cases. DAPK1 is a pro-apoptotic protein whose expression is also suppressed in sporadic cases of chronic lymphocytic leukaemia by an epigenetic mechanism. [63] The many unsuccessful attempts to establish genetic linkages have been reviewed by Goldin and Slager.[64] None of the reported genetic aberrations is constant, and whether they constitute initial events or arise during evolution is presently unclear. By contrast with observations in other B-cell malignant diseases, which typically exhibit balanced chromosomal translocations, in chronic lymphocytic leukaemia the most frequent abnormalities are mutations, deletions, or trisomies. Translocations do arise but are usually unbalanced, resulting in loss of genetic material.[65]

Early attempts at karyotyping chronic lymphocytic leukaemia cells identified trisomy 12 and deletions at 13q,[66] but most laboratories were unable to satisfactorily bring chronic lymphocytic leukaemia cells into mitosis. Only in the past few years have cytogenetic techniques been developed that make this proposition feasible.[65] and [67] Döhner and colleagues showed in a series of 325 patients with chronic lymphocytic leukaemia that chromosomal aberrations can be detected in interphase cells by fluorescence in-situ hybridisation (FISH) in 82% of cases. The most frequent alterations are a deletion on chromosome 13q (55%), trisomy 12 (18%), and a deletion on chromosome 11q (16%). A deletion on chromosome 17p, affecting the TP53 protein, is seen less frequently (7%). The presence of a 17p or 11q deletion is associated with poor prognosis and predominates in advanced stages of chronic lymphocytic leukaemia and in patients with unmutated IGHV genes, whereas the 13q deletion or a normal karyotype are associated with good prognosis, initial stages of the disease, and mutated IGHV genes. Controversy exists about whether trisomy 12 is associated with an unmutated status and poor prognosis.[67] and [68] Patients with mutated and unmutated chronic lymphocytic leukaemia differ clearly in terms of prognosis.

Genetic lesions associated with deletions of the short arm of chromosome 17 (del17p13), which encodes the TP53 tumour-suppressor gene, and the long arm of chromosome 11 (del11q23), which encodes the ataxia telangiectasia mutated (ATM) gene, result in a loss of function of TP53. TP53 is a transcription factor activated by strand breaks in DNA. It can trigger apoptosis or cell-cycle arrest. Thus, by controlling repair or elimination of cells with damaged DNA, TP53 maintains the integrity of the genome and prevents clonal progression. ATM is a kinase that regulates TP53. Many cytotoxic drugs require the ATM/TP53 pathway to be intact for them to be effective. A simple screening test that assesses how intact this pathway is has been described.[69] Defects in the ATM/TP53 pathway constitute the strongest independent predictors for disease that is resistant to standard treatment.

Deletions of the ATM gene do not produce such a severe syndrome as do deletions of TP53, with some patients having a fairly benign disease course. Possibly, for ATM function to be impaired, mutations are necessary on the other ATM allele.[70] Conversely, Kalla and co-workers have identified other genes affecting regulation of the cell cycle and apoptosis—namely NPAT, CUL5, and PPP2R1B—in the commonly deleted 11q22-q23 segment, which might underlie the severity of the chronic lymphocytic leukaemia.[71]

The pathogenic role of trisomy 12 in chronic lymphocytic leukaemia remains unresolved.[72] CLLU1—the first disease-specific gene identified in people with chronic lymphocytic leukaemia—has been located to 12q22, but there seems to be no difference in protein expression in patients with or without trisomy 12.[73]

MicroRNA molecules (miRNAs) have an important role in regulation of gene expression during human development. Using a microarray containing hundreds of human precursors and mature miRNA oligonucleotide probes, Calin and colleagues recorded significant differences in miRNA expression between chronic lymphocytic leukaemia B cells and normal CD5+ cells. They showed the absence of two miRNAs (miR15 and miR16) associated with mutations in expressed IGHV genes and with deletions in the 13q14 region.[74] As part of normal control of gene expression, miR15 and miR16 seem to target BCL2, and their absence in chronic lymphocytic leukaemia could be a major factor in prevention of apoptosis.[75] However, Fulci and coworkers [76] have been unable to confirm these findings. They reported low expression of these miRNAs in only 12% of patients, despite 58% having del13q14. All individuals with a deletion of both 13q14 alleles showed striking miR15a downregulation, but such pronounced downregulation of both miRNAs was not paralleled by any significant increase in BCL2 expression levels. Fulci's team also noted overexpression of miR150, miR223, and miR29b and miR29c in IGHV-mutated chronic lymphocytic leukaemia compared with unmutated cases.

Despite clinical and molecular differences, chronic lymphocytic leukaemia is characterised by a common gene-expression signature that differs from other lymphoid cancers and normal lymphoid subpopulations, suggesting that patients with the disease—in agreement with the monotonous phenotypic signature—share a common mechanism of transformation, cell of origin, or both. [77] However, despite sharing a common signature, chronic lymphocytic leukaemias expressing mutated and unmutated IGHV genes differentially express more than 100 genes. Of these, overexpression of genes encoding ZAP70, lipoprotein lipase (LPL), BCL7A, dystrophin (DMD), and gravin (AKAP12) are noted in individuals with aggressive unmutated disease, whereas people with stable mutated chronic lymphocytic leukaemia overexpress WNT3, CTLA4, the gene encoding nuclear receptor interacting protein 1 (NRIP1), ADAM29, and TCF7.[78], [79] and [80] Furthermore, evidence suggests that for particular IGHV genes, such as IGHV1-69 and IGHV3-21, different genomic aberrations might be associated with differential gene expression.[80], [81] and [82] These results indicate that indolent mutated and aggressive unmutated chronic lymphocytic leukaemias constitute two variants of the same disease. The reasons for these striking differences in clinical outcomes remain unsolved.

References

63 A Raval, SM Tanner and JC Byrd et al., Downregulation of death-associated protein kinase 1 (DAPK1) in chronic lymphocytic leukemia, Cell 129 (2007), pp. 879–890.

64 LR Goldin and SL Slager, Familial CLL: Genes and Environment, Hematology Am Soc Hematol Educ Program 2007 (2007), pp. 339–345.

65 F Dicker, S Schnittger, T Haferlach, W Kern and C Schoch, Immunostimulatory oligonucleotide-induced metaphase cytogenetics detect chromosomal aberrations in 80% of CLL patients: a study of 132 CLL cases with correlation to FISH, IgVH status, and CD38 expression, Blood 108 (2006), pp. 3152–3160.

66 G Juliusson, DG Oscier and M Fitchett et al., Prognostic subgroups in B-cell chronic lymphocytic leukemia defined by specific chromosomal abnormalities, N Engl J Med 323 (1990), pp. 720–724.

67 DG Oscier, AC Gardiner and SJ Mould et al., Multivariate analysis of prognostic factors in CLL: clinical stage, IGVH gene mutational status, and loss or mutation of the p53 gene are independent prognostic factors, Blood 100 (2002), pp. 1177–1184.

68 A Krober, T Seiler and A Benner et al., V(H) mutation status, CD38 expression level, genomic aberrations, and survival in chronic lymphocytic leukemia, Blood 100 (2002), pp. 1410–1416.

69 K Lin, PD Sherrington, M Dennis, Z Matrai, JC Cawley and AR Pettitt, Relationship between p53 dysfunction, CD38 expression, and IgV(H) mutation in chronic lymphocytic leukemia, Blood 100 (2002), pp. 1404–1409.

70 B Austen, JE Powell and A Alvi et al., Mutations in the ATM gene lead to impaired overall and treatment-free survival that is independent of IGVH mutation status in patients with B-CLL, Blood 106 (2005), pp. 3175–3182.

70 C Kalla, MO Scheuermann and I Kube et al., Analysis of 11q22-q23 deletion target genes in B-cell chronic lymphocytic leukaemia: evidence for a pathogenic role of NPAT, CUL5, and PPP2R1B, Eur J Cancer 43 (2007), pp. 1328–1335.

72 D Winkler, C Schneider and A Krober et al., Protein expression analysis of chromosome 12 candidate genes in chronic lymphocytic leukemia (CLL), Leukemia 19 (2005), pp. 1211–1215.

73 AM Buhl, J Jurlander and FS Jorgensen et al., Identification of a gene on chromosome 12q22 uniquely overexpressed in chronic lymphocytic leukemia, Blood 107 (2006), pp. 2904–2911.

74 GA Calin, CG Liu and C Sevignani et al., MicroRNA profiling reveals distinct signatures in B cell chronic lymphocytic leukemias, Proc Natl Acad Sci USA 101 (2004), pp. 11755–11760.

75 A Cimmino, GA Calin and M Fabbri et al., miR-15 and miR-16 induce apoptosis by targeting BCL2, Proc Natl Acad Sci USA 102 (2005), pp. 13944–13949.

76 V Fulci, S Chiaretti and M Goldoni et al., Quantitative technologies establish a novel microRNA profile of chronic lymphocytic leukemia, Blood 109 (2007), pp. 4944–4951.

77 U Klein, Y Tu and GA Stolovitzky et al., Gene expression profiling of B cell chronic lymphocytic leukemia reveals a homogeneous phenotype related to memory B cells, J Exp Med 194 (2001), pp. 1625–1638.

78 A Wiestner, A Rosenwald and TS Barry et al., ZAP-70 expression identifies a chronic lymphocytic leukemia subtype with unmutated immunoglobulin genes, inferior clinical outcome, and distinct gene expression profile, Blood 101 (2003), pp. 4944–4951.

79 Y Vasconcelos, J De Vos and L Vallat et al., Gene expression profiling of chronic lymphocytic leukemia can discriminate cases with stable disease and mutated Ig genes from those with progressive disease and unmutated Ig genes, Leukemia 19 (2005), pp. 2002–2005.

80 D Kienle, A Benner and A Krober et al., Distinct gene expression patterns in chronic lymphocytic leukemia defined by usage of specific VH genes, Blood 107 (2006), pp. 2090–2093.

81 DL Kienle, C Korz and B Hosch et al., Evidence for distinct pathomechanisms in genetic subgroups of chronic lymphocytic leukemia revealed by quantitative expression analysis of cell cycle, activation, and apoptosis-associated genes, J Clin Oncol 23 (2005), pp. 3780–3792.

82 C Haslinger, N Schweifer and S Stilgenbauer et al., Microarray gene expression profiling of B-cell chronic lymphocytic leukemia subgroups defined by genomic aberrations and VH mutation status, J Clin Oncol 22 (2004), pp. 3937–3949.

Goya's Ghost

The critics called it a mess, which is probably why we get such rubbish movies in the theaters these days. This is a movie that requires you to concentrate on the plot and listen to the dialogue. You require a modicum of intelligence to understand it and to know a little bit more about the Spanish Inquisition than the fact that it appeared in a Monty Python sketch. This is the first Milos Foreman film since 1999 (remember he made Amadaus and One Flew Over the Cuckoos Nest). It is set over a period of 20 years and uses the character of Goya (played by Stellan Skarsgaard - Good Will Hunting), the famous Spanish painter as a backbone for the story. Brother Lorenzo is played by Spanish actor Javier Bardem (No Country for Old Men). He directs the Spanish Inquisition who hit upon Ines Bilbatua (Natalie Portman) because she refuses pork at a restaurant (she must be a Judaizer). She is also Goya's model and truth be told Lorenzo has the hots for her. On the pretext of aiding her release he seduces her and fathers a daughter on her.

Goya is pressed by her father to get her released, but Lorenzo won't be bribed. When he is himself 'put to the question' by her family he realises that people will admit to anything under torture; such 'confessions' are worthless. He attempts to influence the Cardinal (played by Michael Lonsdale - Day of the Jackal) in vain and became an outcast. Ines remains in prison. Her father goes to the King for aid, but news comes that Napoleon has invaded. In the name of Liberty, Equality, Fraternity, the French army sweeps all before it. The Inquisition is disbanded and prosecuted by none other than Lorenzo, now very secular with a wife and three children. He discovers from Goya that he has another daughter (also played by Portman) who is now a prostitute. He attempts to cover it up and seems to be succeeding. The French turn out to be just as brutal as the Spanish Inquisition and at last they are deposed by the British under Wellington (whose famous painting by Goya was stolen in real life and later turned up in an early Bond film). Lorenzo is captured and when the Inquisition is re-established he is offered redemption if he will repent. He refuses and is executed in a particularly unpleasant way. Ines by now is completely insane, has picked up a stray abandoned baby and follows the cart carrying his corpse while clinging to his dead hand. Her daughter has become the mistress of an English officer and Goya, completely deaf, is still one of the greatest artists of all time. his paintings and etchings provide an impressive backdrop to this film, which is sumptuously realized.

About half the critics gave this movie 4 or 5 stars (out of 5) but a lot gave it only one. It clearly polarizes people, but I think it was wonderful.

PG Wodehouse

I have been reading the biography of PG Wodehouse by Robert McCrum. Everyone knows of Wodehouse (pronounced woodhouse), the author of Jeeves and Wooster, but few now remember that he was persona non grata for many years because he broadcast over the radio from Nazi Germany. Indeed there was a distinct possibility that he might have been hanged for treason in 1945.

His early life was spent at Dulwich College in south east London, the same public school later attended by Raymond Chandler. His people couldn't afford to send him to Oxford or Cambridge so he went to work in a bank. He wanted to be a writer and eventually by selling short stories he was able to earn enough to leave it. Thereafter he wrote and wrote and sold most of his output. His first successful novels were about schoolboys, but he followed their careers after leaving school and created unforgettable characters such as Psmith, Jeeves, Bertie, Gussie Finknottle, the inhabitants of the Drones club and the denizens of Blandings Castle.

He was extremely successful on both sides of the Atlantic. Quite apart from his novels and short stories he was at the center of the pre-war Broadway scene, collaborating with the Gershwin brothers, Jerome Kern and Cole Porter. He even went to Hollywood when the talkies came in, though the producers didn't quite know what to do with him. In the end MGM paid him a lot of money to keep him on the 'bench'. While there he wrote and revised his stories while making minor adjustments to scripts making a morning's work last three months.

He was peripatetic - largely to avoid double taxation. By the late 1930s he had settled in Le Touquet in France, but got trapped there by the advancing German army. Interned for more than a year, he was let out of prison when an American reporter explained to the Nazis just what an important writer he was. Ensconced in a luxury hotel in Berlin, the German Foreign Office, in the person of ex-Hollywood colleagues, persuaded him that it would be a jolly wheeze to broadcast over the radio his experience of life in an internment camp. In his Edwardian, self effacing manner, he made light of the experience and handed the Germans a propaganda coup. It was probably naivete that led him to fall in with their plans, but also extreme foolishness. Following the war he never again set foot in Britain, but gradually his popularity returned and in his nineties, having lived in Long Island for a long time and become an American citizen, he was eventually restored to the fall and made an honorary knight commander of the British Empire.

I also read 'Mike and Psmith' and early novel from 1913 yesterday. A slight and mildly amusing offering similar to the Billy Bunter novels I read when I was 10.

The B cell receptor

The B-cell receptor

The B-cell receptor is a multimeric complex formed by the assembly of a surface immunoglobulin homodimer and a non-covalently-bound heterodimer Igα/Igβ (CD79A/CD79B). Low expression of the B-cell receptor is the hallmark of lymphocytes in chronic lymphocytic leukaemia.[23]

The mechanisms accounting for poor expression of the B-cell receptor in chronic lymphocytic leukaemia remain elusive. With the exception of one report of mutation in CD79B,[24] no genetic defects in B-cell-receptor components have been recorded.[25] and [26] By contrast with their poor expression at the membrane level, transcription and intracellular synthesis of components of the B-cell receptor are normal,[26] and [27] but they cannot be assembled and transported from the endoplasmic reticulum to the cell surface because of a folding and glycosylation defect of the μ and CD79A chains, although not of the CD79B chain. Poor expression of the CD22 molecule in B-cell chronic lymphocytic leukaemia cells was also shown to result from a folding defect arising in CD79A.[28]

Most B-cell chronic lymphocytic leukaemia cells express CD5 and IgM/IgD and, thus, have a mantle zone-like phenotype of naive cells that, in normal conditions, express unmutated immunoglobulin genes.[29] However, 50–70% of cases of chronic lymphocytic leukaemia have somatic mutations of IGHV genes,[30] as if they had matured in a lymphoid follicle. Presence or absence of somatic mutations is associated with particular IGHV genes. Specific alleles of the IGHV1-69 gene [31] and the IGHV4-39 gene have an unmutated profile.32 Subsequently, workers have reported [32] that more than 20% of patients with chronic lymphocytic leukaemia carry stereotypic B-cell receptors.[33], [34] and [35] Of note, the IGHV3-21 gene shows strikingly homologous IGHV and IGLV gene rearrangements and is associated with poor prognosis, whether expressed in a mutated or unmutated form.[36] and [37] These results strongly suggest that a common antigen epitope is recognised by these highly homologous molecules. With respect to the epitope recognised, research has shown that unmutated chronic lymphocytic leukaemia cells express highly polyreactive antibodies, whereas most mutated ones do not.[38] and [39] Infections with encapsulated organisms might be a trigger for development of chronic lymphocytic leukaemia, and work has shown that individuals with a history of pneumonia are significantly more likely to develop chronic lymphocytic leukaemia than are people without this history, and that the risk increases with number of attacks.[40] and [41]

When stimulated through the B-cell receptor pathway, the response of chronic lymphocytic leukaemia cells is impaired. Low expression of the B-cell receptor correlates with reduced induction of protein tyrosine kinase activity and defective intracellular calcium mobilisation and tyrosine phosphorylation.[42] Individuals have differing responses to IgM ligation, related to IGHV gene status. Findings of one study showed that chronic lymphocytic leukaemia cells expressing unmutated IGHV genes had a better response in most cases to stimulation via the B-cell receptor than did cells expressing mutated IGHV genes.[43]

Unexpectedly, high amounts of ZAP70—a receptor-associated protein tyrosine kinase usually found in T cells and natural killer cells but not in normal circulating B cells—are detected in most patients with unmutated chronic lymphocytic leukaemia.[44] Chronic lymphocytic leukaemia B cells that express ZAP70 are more likely to respond to IgM crosslinking with increased tyrosine phosphorylation and calcium flux than are those that do not express ZAP70. This effect might happen for any or all of the following reasons. First, after B-cell receptor ligation, ZAP70 undergoes tyrosine phosphorylation and becomes associated with surface immunoglobulin and CD79B.[45] Second, ZAP70 mediates inhibition events that terminate the signalling response.[46] Finally, ZAP70 expression is associated with advantageous survival responses because of enhanced access to proliferation centres.[47] Altogether, expression of ZAP70 in chronic lymphocytic leukaemia allows effective IgM signalling in B cells, which might lead to an aggressive disease course.

The apparently anomalous expression of ZAP70 in chronic lymphocytic leukaemia cells is not accounted for completely. Heat-shock protein 90 (HSP90) is a molecular chaperone that catalyses the conformational maturation of many signalling proteins in cancer, known collectively as clients. With inhibitors of HSP90, Castro and colleagues [48] showed that ZAP70 is a client protein in tumour cells, but not in T cells, from patients with ZAP70-positive chronic lymphocytic leukaemia, suggesting that the presence of ZAP70 is an oncogenic event. On the other hand, ZAP70 is expressed at various stages of B-cell maturation and in other B-cell malignant diseases. It is present in normal pre-B cells and pro-B cells and in acute leukaemias derived from them.[49] By studying normal tonsillar cells, Nolz and coworkers [50] and Cutrona and colleagues [51] detected ZAP70-positive B cells, concentrated particularly in germinal centres. ZAP70 seems to be coexpressed with other activation markers. In chronic lymphocytic leukaemia, higher amounts of ZAP70 are expressed by lymph-node cells than by circulating cells.[52] In turn, high levels of ZAP70 expression lead to increased sensitivity to chemokine migratory signals.[53] Whether expression of ZAP70 in chronic lymphocytic leukaemia cells is a result of frequent visits to proliferation centres or is the cause of enhanced access to them is still not clear.

Another unexpected molecule expressed by a subset of chronic lymphocytic leukaemia B cells is CD38. In the B-cell compartment, CD38 is not a lineage marker, but this molecule is expressed at times during B-cell development when cell-to-cell interactions are crucial.[54] Examples include an early bone-marrow precursor cell, cells in the germinal centre, and plasma cells.[55] In chronic lymphocytic leukaemia, expression of CD38 predominates in patients with unmutated IGHV genes and is associated with poor prognosis.18 Expression of CD38 in chronic lymphocytic leukaemia B cells favours B-cell growth and survival through sequential interactions between CD38 and CD31 and between CD100 and plexin B1 (PLXNB1).[56]

The activation-induced cytidine deaminase (AICDA), a B cell-restricted enzyme needed for somatic mutation and isotype switching, is upregulated in unmutated chronic lymphocytic leukaemia cells.[57], [58] and [59] Although evidence exists that AICDA expression could be confined to a small proportion of the clone,[60] AICDA seems to be functional, since unmutated cases of chronic lymphocytic leukaemia can generate isotype-switched transcripts and proteins and mutations in the pre-switch μ region.[57] Upregulation of AICDA could be associated with loss of target specificity, resulting in mutations in non-immunoglobulin genes such as BCL6, MYC, PAX5, and RHOH, which are linked to aggressive disease.[61] and [62]

References

23 F Vuillier, G Dumas and C Magnac et al., Lower levels of surface B-cell-receptor expression in chronic lymphocytic leukemia are associated with glycosylation and folding defects of the mu and CD79a chains, Blood 105 (2005), pp. 2933–2940.

24 AA Thompson, JA Talley and HN Do et al., Aberrations of the B-cell receptor B29 (CD79b) gene in chronic lymphocytic leukemia, Blood 90 (1997), pp. 1387–1394.

25 B Payelle-Brogard, C Magnac, FR Mauro, F Mandelli and G Dighiero, Analysis of the B-cell receptor B29 (CD79b) gene in familial chronic lymphocytic leukemia, Blood 94 (1999), pp. 3516–3522.

26 A Alfarano, S Indraccolo and P Circosta et al., An alternatively spliced form of CD79b gene may account for altered B-cell receptor expression in B-chronic lymphocytic leukemia, Blood 93 (1999), pp. 2327–2335.

27 B Payelle-Brogard, C Magnac, A Alcover, P Roux and G Dighiero, Defective assembly of the B-cell receptor chains accounts for its low expression in B-chronic lymphocytic leukaemia, Br J Haematol 118 (2002), pp. 976–985.

28 B Payelle-Brogard, G Dumas, C Magnac, AI Lalanne, G Dighiero and F Vuillier, Abnormal levels of the alpha chain of the CD22 adhesion molecule may account for low CD22 surface expression in chronic lymphocytic leukemia, Leukemia 20 (2006), pp. 877–878. )

29 V Pascual, YJ Liu, A Magalski, O de Bouteiller, J Banchereau and JD Capra, Analysis of somatic mutation in five B cell subsets of human tonsil, J Exp Med 180 (1994), pp. 329–339.

30 HW Schroeder Jr and G Dighiero, The pathogenesis of chronic lymphocytic leukemia: analysis of the antibody repertoire, Immunol Today 15 (1994), pp. 288–294.

31 TJ Kipps and DA Carson, Autoantibodies in chronic lymphocytic leukemia and related systemic autoimmune diseases, Blood 81 (1993), pp. 2475–2487.

32 N Chiorazzi and M Ferrarini, B cell chronic lymphocytic leukemia: lessons learned from studies of the B cell antigen receptor, Annu Rev Immunol 21 (2003), pp. 841–894.

33 K Stamatopoulos, C Belessi and C Moreno et al., Over 20% of patients with chronic lymphocytic leukemia carry stereotyped receptors: pathogenetic implications and clinical correlations, Blood 109 (2007), pp. 259–270.

34 BT Messmer, E Albesiano and DG Efremov et al., Multiple distinct sets of stereotyped antigen receptors indicate a role for antigen in promoting chronic lymphocytic leukemia, J Exp Med 200 (2004), pp. 519–525.

35 F Ghiotto, F Fais and A Valetto et al., Remarkably similar antigen receptors among a subset of patients with chronic lymphocytic leukemia, J Clin Invest 113 (2004), pp. 1008–1016.

36 G Tobin, U Thunberg and A Johnson et al., Somatically mutated Ig V(H)3-21 genes characterize a new subset of chronic lymphocytic leukemia, Blood 99 (2002), pp. 2262–2264.

37 M Thorselius, A Krober and F Murray et al., Strikingly homologous immunoglobulin gene rearrangements and poor outcome in VH3-21-using chronic lymphocytic leukemia patients independent of geographic origin and mutational status, Blood 107 (2006), pp. 2889–2894.

38 O Pritsch, C Magnac, G Dumas, C Egile and G Dighiero, V gene usage by seven hybrids derived from CD5+ B-cell chronic lymphocytic leukemia and displaying autoantibody activity, Blood 82 (1993), pp. 3103–3112.

39 M Herve, K Xu and YS Ng et al., Unmutated and mutated chronic lymphocytic leukemias derive from self-reactive B cell precursors despite expressing different antibody reactivity, J Clin Invest 115 (2005), pp. 1636–1643.

40 T Hamblin, Is chronic lymphocytic leukemia a response to infectious agents?, Leuk Res 30 (2006), pp. 1063–1064.

41 O Landgren, JS Rapkin and NE Caporaso et al., Respiratory tract infections and subsequent risk of chronic lymphocytic leukemia, Blood 109 (2007), pp. 2198–2201.

42 F Michel, H Merle-Beral, E Legac, A Michel, P Debre and G Bismuth, Defective calcium response in B-chronic lymphocytic leukemia cells: alteration of early protein tyrosine phosphorylation and of the mechanism responsible for cell calcium influx, J Immunol 150 (1993), pp. 3624–3633.

43 S Lanham, T Hamblin, D Oscier, R Ibbotson, F Stevenson and G Packham, Differential signaling via surface IgM is associated with VH gene mutational status and CD38 expression in chronic lymphocytic leukemia, Blood 101 (2003), pp. 1087–1093.
44 A Rosenwald, AA Alizadeh and G Widhopf et al., Relation of gene expression phenotype to immunoglobulin mutation genotype in B cell chronic lymphocytic leukemia, J Exp Med 194 (2001), pp. 1639–1647.

45 L Chen, J Apgar and L Huynh et al., ZAP-70 directly enhances IgM signaling in chronic lymphocytic leukemia, Blood 105 (2005), pp. 2036–2041.

46 S Gobessi, L Laurenti, PG Longo, S Sica, G Leone and DG Efremov, ZAP-70 enhances B-cell-receptor signaling despite absent or inefficient tyrosine kinase activation in chronic lymphocytic leukemia and lymphoma B cells, Blood 109 (2007),

47 SJ Richardson, C Matthews and MA Catherwood et al., ZAP-70 expression is associated with enhanced ability to respond to migratory and survival signals in B-cell chronic lymphocytic leukemia (B-CLL), Blood 107 (2006), pp. 3584–3592.

48 JE Castro, CE Prada and O Loria et al., ZAP-70 is a novel conditional heat shock protein 90 (Hsp90) client: inhibition of Hsp90 leads to ZAP-70 degradation, apoptosis, and impaired signaling in chronic lymphocytic leukemia, Blood 106 (2005), pp. 2506–2512.

49 M Crespo, N Villamor and E Gine et al., ZAP-70 expression in normal pro/pre B cells, mature B cells, and in B cell acute lymphoblastic leukemia, Clin Cancer Res 12 (2006), pp. 726–734.

50 JC Nolz, RC Tschumper, BT Pittner, JR Darce, NE Kay and DF Jelinek, ZAP-70 is expressed by a subset of normal human B-lymphocytes displaying an activated phenotype, Leukemia 19 (2005), pp. 1018–1024.

51 G Cutrona, M Colombo and S Matis et al., B lymphocytes in humans express ZAP-70 when activated in vivo, Eur J Immunol 36 (2006), pp. 558–569.

52 J Boelens, J Philippe and F Offner, B cells from lymph nodes express higher ZAP-70 levels than B-CLL cells from peripheral blood, Leuk Res 31 (2007), pp. 719–726.

53 SJ Richardson, C Matthews and MA Catherwood et al., ZAP-70 expression is associated with enhanced ability to respond to migratory survival signals in B-cell chronic lymphocytic leukemia (B-CLL), Blood 107 (2006), pp. 3584–3592.

54 F Malavasi, A Funaro, S Roggero, A Horenstein, L Calosso and K Mehta, Human CD38: a glycoprotein in search of a function, Immunol Today 15 (1994), pp. 95–97.

55 S Deaglio, K Mehta and F Malavasi, Human CD38: a (r)evolutionary story of enzymes and receptors, Leuk Res 25 (2001), pp. 1–12.

56 S Deaglio, T Vaisitti and L Bergui et al., CD38 and CD100 lead a network of surface receptors relaying positive signals for B-CLL growth and survival, Blood 105 (2005), pp. 3042–3050.

57 P Oppezzo, F Vuillier and Y Vasconcelos et al., Chronic lymphocytic leukemia B cells expressing AID display dissociation between class switch recombination and somatic hypermutation, Blood 101 (2003), pp. 4029–4032.

58 P Oppezzo, G Dumas and AI Lalanne et al., Different isoforms of BSAP regulate expression of AID in normal and chronic lymphocytic leukemia B cells, Blood 105 (2005), pp. 2495–2503.

59 H McCarthy, WG Wierda and LL Barron et al., High expression of activation-induced cytidine deaminase (AID) and splice variants is a distinctive feature of poor prognosis chronic lymphocytic leukemia, Blood 101 (2003), pp. 4903–4908.

60 E Albesiano, BT Messmer, RN Damle, SL Allen, KR Rai and N Chiorazzi, Activation induced cytidine deaminase in chronic lymphocytic leukemia B cells: expression as multiple forms in a dynamic, variably sized fraction of the clone, Blood 102 (2003), pp. 375–382.

61 SS Sahota, Z Davis, TJ Hamblin and FK Stevenson, Somatic mutation of bcl-6 genes can occur in the absence of V(H) mutations in chronic lymphocytic leukemia, Blood 96 (2000), pp. 1089–1095.

62 L Reininger, C Bodor and A Bognar et al., Richter's and prolymphocytic transformation of chronic lymphocytic leukemia are associated with high mRNA expression of activation-induced cytidine deaminase and aberrant somatic hypermutation, Leukemia 20 (2006), pp. 1089–1095.

High White Counts

Patients and doctors get very worried about high white counts. Need they be?

I remember one holiday weekend spending days at the hospital with a young 13-year old boy with priapism - a prolonged and painful penile erection - caused by a high white count. What happens in these cases is that the blood vessels get blocked by aggregated white blood cells, so that normal circulation is prevented. We connected the lad up to a cell separator and performed leucocytapheresis on him to rapidly lower the white count. He also had to have a surgical procedure to decompress the organ, but I'm glad to say this combination of treatments was successful and sexual function was restored, although since his disease was chronic myeloid leukaemia (CML)in the days before imatanib and matched unrelated bone marrow transplantation, he eventually succumbed to blast transformation of his disease.

Priapism is a well known complication of CML but is seldom seen in other types of leukemia. It is one version of the leukostasis syndrome. Other features include rapidly progressive breathing difficulties and mental problems. It is thought to be caused very sticky bits of white cells and platelets forming aggregates and thrombi, and blocking the circulation. Some authors distinguish this from the hyperviscosity syndrome which produces similar effects because the blood becomes very viscous or treacly (thick and sticky, not actually sweet). This can be due to high cell content (either red or white) or high protein content (especially IgM or immune complexes). Nowadays, patients are seldom allowed to get high white cell counts except in CLL. The question everybody asks is whether hyperviscosity can occur in CLL. I think that the answer is probably in exceptional cases both hyperviscosity and leukostasis can occur.

Looking back over the old literature, my old mate Eric Preston reported three cases from Sheffield in 1978. The white counts were 500, 647 and 1000 respectively. The symptoms of hyperviscosity were relatively minor, but they did resolve after leucocytapheresis. These three patients did have raised blood viscosity measurements, but the authors noted that CLL does not raise the viscosity by as much as other leukemias for a given white count. There is another report from Kurlander and colleagues of a patient with a white count of 901 who had retinal hemorrhages, which can be a feature of hyperviscosity, though this patient also had hyperkalemia (a high potassium level) and kidney failure, which could also have caused them. Then in 1985 Maria Baer from Nashville reported a study of 16 CLL patients with white counts over 500. In one of them, with a white count of 968 there was a full blown hyperviscosity syndrome with headache, double vision, loss of balance, slurred speech, deafness and other neurological signs, which all recovered after leucocytapheresis (in America people talk about leukapheresis which implies that the machine takes the whiteness out of the blood, like a reverse washing machine). A second patient had what were in retrospect features of hyperviscosity, but she was treated as if she had leukemic meningitis and died. A third patient had retinal hemorrhages, but these can be caused by a lot of different things including high blood pressure. The 16 high white counts were drawn from a series of 210 patients in Nashville.

One of the problems about the early CLL papers is that before good immunophenotyping we could not be sure that the patient actually had CLL – it could have been mantle cell lymphoma or a variant. A study from Sweden published in 1992 said this:

In order to evaluate the effects of different cell types of leukaemic cell origin on skin capillary circulation we have studied patients with (a) chronic lymphocytic leukaemia (CLL) (n = 6) and (b) acute non-lymphocytic leukaemia (ANLL) (n = 6) or chronic granulocytic leukaemia (CGL) (n = 5). Capillary blood cell velocity (CBV) in fingernail-fold capillaries was measured by videophotometric capillaroscopy. After a 1-min arterial occlusion at the finger base, the post-occlusive reactive hyperaemia was evaluated by measuring the peak (p) CBV and the time to pCBV. In patients with ANLL/GGL, both resting CBV and pCBV were lower than in healthy control subjects. In the CLL patients these values were not significantly different compared to controls.

More recently there have been occasional patients with very high white counts due to CLL that have caused either hyperviscosity or leukostasis, but they are so rare that they are almost certain to be reported in the literature.

In Paris in 1988:
A 50 year old man with chronic lymphocytic leukemia (CLL) and extreme hyperleukocytosis (600 x 10(9)/liter) presented with a respiratory distress syndrome, congestive heart failure with cardiomegaly, endotoxic shock and anuria. Examination revealed nodes in all areas and hepatosplenomegaly; laboratory studies showed hypoxemia and a chest X-ray diffuse bilateral alveolar infiltrates. He was treated twice by leukapheresis using a cell separator. This procedure removed 10.1 x 10(10) white blood cells with marked clinical improvement and resolution of air-space diseases over the subsequent 48 hours.

In Germany in 1991
An 82-year-old woman with CLL developed acute neuropsychiatric signs (confusion, disorders of speech and vision) together with ataxic gait and left hemiparesis mainly affecting the lower limb. Her white count was 1,300, most of the cells being morphologically atypical lymphocytes. Significant reduction of leucocyte count with considerable improvement in clinical signs was achieved after three doses of vincristine and prednisone together with one cycle of COP

In the Netherlands in 1996
The authors mistook pulmonary infiltrates with CLL cells for leukostasis. The white count was only 153.

In Poland in 1999
A severe leukostasis syndrome was observed in a case of CLL with peripheral lymphocyte count of 1,120. Typical symptoms of respiratory and central nervous system were developed (tachypnoe, hypoxia, headache, slurred speech, somnolence and confusion). Leukapheresis decreased the lymphocyte count to 305 rapidly and reversed the leukostasis syndrome.

And in Israel in 2002
We describe a 73-year-old woman who presented with newly diagnosed CLL, leukostasis, and hyperleukocytosis (2000 x 10(9)/l), affecting the respiratory and nervous system. We hypothesize that in our patient the extreme number of circulating lymphocytes resulted in an abnormal accumulation of lymphocytes possibly causing stasis and occlusion of a larger vessel, which resolved after leukapheresis.

In CLL patients with high white counts there are usually other reasons to begin treatment, but in patients without symptoms there should be no urgency to begin treatment just because the white count has reached 100 or 200 or 300 or 400 or even 500 because of the possibility of leukostasis or hyperviscosity. This makes CLL different from other types of leukemia, where a high white count carries its own dangers.

CLL: Diagnosis and Pathophysiology

Clinical diagnosis of chronic lymphocytic leukaemia is defined by absolute lymphocytosis of at least 5×109/L mature-appearing lymphocytes and an appropriate immunophenotype (figure). [13] These characteristics distinguish chronic lymphocytic leukaemia from mantle-cell lymphoma and splenic marginal-zone lymphoma, the diseases that most frequently mimic chronic lymphocytic leukaemia. [14] In a few individuals, tumour is confined to lymph nodes or other tissues without blood or bone marrow involvement. In these people, the disorder is known as small lymphocytic lymphoma: histological findings and immunophenotype are identical to chronic lymphocytic leukaemia and management should be the same.[15] Individuals without involvement of lymph nodes or other tissues, who have a population of small lymphocytes immunophenotypically similar to chronic lymphocytic leukaemia cells in blood or bone marrow below the threshold necessary for diagnosis of chronic lymphocytic leukaemia, are designated as having monoclonal B-cell lymphocytosis.[16] Molecular and cellular markers have been identified that could predict disease progression. In particular, the mutational profile of immunoglobulin genes[17] and [18] and some cytogenetic abnormalities [19] show strong prognostic value. However, these biological differences do not separate chronic lymphocytic leukaemia into two different disorders; it remains one disease with heterogeneous features. [20]

Pathophysiology

Despite the ready availability of tumour cells in chronic lymphocytic leukaemia, up to now, very little has been known about the pathophysiology of the disease. The cells themselves are remarkably inert in vitro. Most, if not all, cell lines attributed to chronic lymphocytic leukaemia are either from patients with mantle-cell lymphoma masquerading as chronic lymphocytic leukaemia or B-cell lymphoblastoid lines from contaminating normal lymphocytes. [21] Until the past few years, no animal model had existed for chronic lymphocytic leukaemia. The TCL1 transgenic mouse develops a CD5+ B-cell lymphoproliferative disease that serves as a model for aggressive forms of chronic lymphocytic leukaemia but not for the frequent indolent form. [22]

The discovery that the mutational status of IGHV genes affects profoundly the prognosis of chronic lymphocytic leukaemia has acted as such a spur to our understanding of the disease's pathology, but full review of this topic is not possible within the space confines of this Seminar. Instead, we will concentrate on three topics: the B-cell receptor; genetic abnormalities revealed by interphase cytogenetics; and the balance between proliferation and apoptosis.

References

13 JL Binet, F Caligaris-Cappio and D Catovsky et al., Perspectives on the use of new diagnostic tools in the treatment of chronic lymphocytic leukemia, Blood 107 (2006), pp. 859–861.

14 E Matutes, K Owusu-Ankomah and R Morilla et al., The immunological profile of B-cell disorders and proposal of a scoring system for the diagnosis of CLL, Leukemia 8 (1994), pp. 1640–1645.

15 HK Muller-Hermelink, E Montserrat, D Catovsky and NL Harris, Chronic lymphocytic leukaemia/small lymphocytic lymphoma. In: ES Jaffe, NL Harris, H Stein and JW Vardiman, Editors, World Health Organization classification of tumours: pathology and genetics of tumours of haematopoietic and lymphoid tissues, IARC Press, Lyon (2001), pp. 127–130.

16 GE Marti, AC Rawstron and P Ghia et al., Diagnostic criteria for monoclonal B-cell lymphocytosis, Br J Haematol 130 (2005), pp. 325–332.

17 TJ Hamblin, Z Davis, A Gardiner, DG Oscier and FK Stevenson, Unmutated Ig V(H) genes are associated with a more aggressive form of chronic lymphocytic leukemia, Blood 94 (1999), pp. 1848–1854.

18 RN Damle, T Wasil and F Fais et al., Ig V gene mutation status and CD38 expression as novel prognostic indicators in chronic lymphocytic leukemia, Blood 94 (1999), pp. 1840–1847.

19 H Döhner, S Stilgenbauer and A Benner et al., Genomic aberrations and survival in chronic lymphocytic leukemia, N Engl J Med 343 (2000), pp. 1910–1916.

20 T Hamblin, Chronic lymphocytic leukaemia: one disease or two?, Ann Hematol 81 (2002), pp. 299–303.

21 HG Drexler, WG Dirks, Y Matsuo and RA MacLeod, False leukemia-lymphoma cell lines: an update on over 500 cell lines, Leukemia 17 (2003), pp. 416–426.

22 R Bichi, SA Shinton and ES Martin et al., Human chronic lymphocytic leukemia modeled in mouse by targeted TCL1 expression, Proc Natl Acad Sci USA 99 (2002), pp. 6955–6960.

TP53: is it such a big deal?

Everyone knows that p53 abnormalities bode ill for patients with CLL. Generally such leukemias are resistant to fludarabine, cyclophosphamide, chlorambucil, penatastatin, cladribine, and rituximab. Although responsive to high dose steroids and Campath and sometimes to Revlimid, most patients with this abnormality have very short survivals. The data on this come from randomized clinical trials like LRF CLL4. However, not all patients need treatment and these trials lack representation from unreated patients. So I have examined my database for patients with del 17p (the chromosomal abnormality that most commonly causes p53 deletion. Have a look at these graphs:





What they tell us is that patients with mutated IgVH genes who also have del 17p usually don't require treatment, just like other patients with mutated IgVH genes.

Epidemiology of CLL

The incidence of chronic lymphocytic leukaemia varies with the age and sex structure of the population. Analysis of the Surveillance, Epidemiology, and End Results (SEER) database notes the US incidence as being 3·5 per 100 000 per year (men 5·0, women 2·5).[1] In the Leukaemia Research Fund data collection study, researchers gathered data from individual haematologists responsible for laboratories covering about a third of the population of England and Wales and reported an incidence of chronic lymphocytic leukaemia in the UK of 6·15 per 100 000 per year, although this value concealed a variation between 1·3 and 13·7 per 100 000 per year in different health districts, dependent largely on how interested the local haematologist was in the disease.[2] Since, in our experience, more than three-quarters of patients with chronic lymphocytic leukaemia are discovered because of an incidental blood count, the exact prevalence of the disease depends clearly on how assiduous is the case finding.

Chronic lymphocytic leukaemia is rare in people younger than 50 years, but after this age a fairly rapid rise in incidence takes place. According to SEER data, the median age for diagnosis of the disease is 70 years for men and 74 years for women, and median age at death is 76 years and 81 years, respectively. White American individuals have a slightly higher incidence than those of African-American origin (3·9 vs 2·8 per 100 000 per year), but in American people of Chinese, Japanese, and Filipino extraction, incidence is about five times lower, even in those who have adopted a fully American lifestyle.[3] Early data put the incidence of chronic lymphocytic leukaemia in Jewish people at twice that of non-Jewish North American individuals.[4]

Chronic lymphocytic leukaemia can arise in families.[5] and [6] First-degree relatives of patients with the disease are three times more likely to have chronic lymphocytic leukaemia or another lymphoid neoplasm than the general population.[7] With a four-colour flow-cytometric assay, Rawstron and colleagues [8] noted that 3·5% of healthy individuals older than 40 years had a population of monoclonal lymphocytes in their blood, with the immunophenotypic characteristics of chronic lymphocytic leukaemia cells, at concentrations lower than 3·5×109/L; in first-degree relatives of patients with familial chronic lymphocytic leukaemia, the prevalence of such cells is between 13·5% and 18%.[9] and [10] The relation between subclinical chronic lymphocytic leukaemia and full-blown disease is a matter of intense investigation in several laboratories.

No consistent evidence is available to link chronic lymphocytic leukaemia with environmental exposure to either radiation or chemicals, except in the case of agricultural workers and herbicides. On Jan 23, 2003, the US National Academy of Sciences' Institute of Medicine published a report concluding that there is “sufficient evidence of an association between exposure to Agent Orange, a herbicide used in Viet Nam, and the development of chronic lymphocytic leukaemia”. [11] Although ionising radiation has traditionally been absolved from causing chronic lymphocytic leukaemia, recent studies have suggested that this may be unwarranted.[12]

References
1 National Cancer Institute, SEER cancer statistics review 1975–2001 http://seer.cancer.gov/csr/1975_2001/

2 RA Cartwright, SM Bernard and CC Bird et al., Chronic lymphocytic leukaemia: case control epidemiological study in Yorkshire, Br J Haematol 56 (1987), pp. 79–82.

3 NS Weiss, Geographical variation in the incidence of the leukemias and the lymphomas, Natl Cancer Inst Monogr 53 (1978), p. 139.

4 B MacMahon and EK Koller, Ethnic differences in the incidences of leukemia, Blood 12 (1957), pp. 1–10.

5 MS Linet, ML Van Natta and R Brookmeyer et al., Familial cancer history and chronic lymphocytic leukemia: a case-control study, Am J Epidemiol 130 (1989), pp. 655–664.

6 GS Sellick, D Catovsky and RS Houlston, Familial chronic lymphocytic leukemia, Semin Oncol 33 (2006), pp. 195–201.

7 J Cuttner, Increased incidence of hematologic malignancies in first degree relatives of patients with chronic lymphocytic leukemia, Cancer Invest 10 (1992), pp. 103–109.

8 AC Rawstron, MJ Green and A Kuzmicki et al., Monoclonal B lymphocytes with the characteristics of “indolent” chronic lymphocytic leukemia are present in 3·5% of adults with normal blood counts, Blood 100 (2002), pp. 635–639.

9 AC Rawstron, MR Yuille, J Fuller, M Cullen, B Kennedy and SJ Richards, Inherited predisposition to CLL is detectable as subclinical monoclonal B-lymphocyte expansion, Blood 100 (2002), pp. 2289–2290.

10 GE Marti, P Carter and F Abbasi et al., B-cell monoclonal lymphocytosis and B-cell abnormalities in the setting of familial B-cell chronic lymphocytic leukemia, Cytometry B Clin Cytom 52 (2003), pp. 1–12.

11 Committee to review the health effects in Vietnam veterans of exposure to herbicides (fourth biennial update), Veterans and Agent Orange: 2002, National Academic Press, Washington, DC (2003), pp. 373–377.

12 TJ Hamblin, Have we been wrong about ionizing radiation and chronic lymphocytic leukemia?, Leuk Res 32 (2008), pp. 523–525.

Obama

"If Barack gets past the primary," said the Rev. Jeremiah Wright to the New York Times in April of last year, "he might have to publicly distance himself from me. I said it to Barack personally, and he said yeah, that might have to happen."

Calculating or what?