A herpes virus isn't just for Christmas; you have it for life. This is particularly true for cytomegalo virus (CMV) which about 85% of us get during the course of a lifetime. In order to stop it causing an illness we produce a lot of T cells to keep it under control. In older people these CMV-specific T cells comprise a sizable proportion of all of our T cells. In CLL an even larger proportion of our T cells are specifically programmed to fight CMV. In the issue of Blood for October 21st 2010, Paul Moss and his group from Birmingham, UK, have looked in detail of the effects of this accumulation.
They studied the CMV-specific CD4+ T-cell response in 45 patients and 35 age matched control subjects and demonstrated that it was markedly expanded in the patient group, averaging 11% of the CD4+ pool compared with 4.7% in controls. The magnitude of the CMV-specific CD4+ immune response increased with disease stage and was particularly high in patients who received chemotherapy. Within this group, the CMV-specific response comprised over 46% of the CD4+ T-cell repertoire in some patients. Serial analysis revealed that CMV-specific immunity increased during treatment with chemotherapy and remained stable thereafter.
Perhaps more important was the fact that overall survival was reduced by nearly 4 years in CMV-seropositive patients, and although this did not reach statistical significance larger series of patients might confirm this finding and this would be a worry that ought to be remedied.
Many studies of T-cells in patients with CLL and have shown abnormalities in the numbers and phenotype of CD4 and CD8 T cells, including inversion of the normal CD4:8 ratio and the accumulation of terminally differentiated effector T cells with relative absence of naive precursors. It has been suggested that these abnormalities contribute to the immunosuppression of B-CLL which I have written about and indicate the presence of a tumor-specific CD4+ T-cell response, though I have always doubted that this is so.
Rather than being an anti-tumor response, the rise in T cells has been postulated as being an anti-CMV response. Initial infection with CMV is associated with a vigorous CMV-specific immune response, which typically comprises over 2% of the CD8+ T-cell repertoire. In states of immunosuppression this value is often increased and is felt to represent cellular response to subclinical viral reactivation occurring during the immunosuppression. It has been shown that the CMV-specific CD8+ T-cell response is similarly increased in patients with CLL and the phenotype of CMV-specific cells was that of late differentiated effector cells. Much less has been known about the activity of the CD4+ CMV-specific T-cell response in either healthy donors or in patient groups.
The CD3+ T-cell count was increased by over 2 fold in CLL patients compared with controls. Furthermore, CMV seropositivity was associated with an increased CD3+ cell count in both the patients CMV seropositive 2648/mL vs CMV seronegative 2225/mL (P = 0.042) and the control group CMV seropositive 1100/mL vs CMV seronegative 792/mL, (P = 0.02). The CD4+ T-cell count was also increased in CLL patients (1139/mL vs 1262/mL) in comparison to the control group (467/mL vs 566/mL) but although the counts were higher in CMV pos patients and controls this did not reach statistical significance. In the patient group, the mean CD8+ T-cell count in CMV-seropositive donors was 1460/mL compared with 1070/mL in the CMV-seronegative group (P = .019). In the control group, the corresponding values were 541/mL and 175/mL, respectively (P < .001).
It is of interest that patients with CLL had increased T-cell counts compared with the control group, irrespective of CMV serostatus. The reasons for this are unknown but could reflect an increased immune component against other infectious agents or a possibly a tumor-specific immune response.
The CMV-specific CD4+ T-cell response was found to be significantly increased in CLL patients whether measured by expression of either IFN, TNF, or IL-2. The absolute number of CMV-specific CD4+ T cells was increased 3.5 fold in CLL patients compared with the control group (83 900/mL vs 24 100/mL for IFN, 79 300/mL vs 26 900/mL for TNF; and 23 200/mL vs 7850/mL for IL-2).
A significant increase in the frequency of CMV-specific CD4+ T cells was seen in patients at Binet stages B and C compared with patients at stage A of the disease. The mean value in patients with advanced disease was 15.2% of the CD4+ pool compared with 8.2% in patients at stage A disease (P = .03).
The CMV-specific CD4+ T cells response was greater in patients who had been treated. Despite the potentially immune suppressive effects of chemotherapy, the mean number of CMV-specific CD4+ T cells was increased in treated patients at 138 000/mL, 116 000/mL, and 39 200/mL for IFN, TNF, and IL-2 responses, respectively, compared with 55 900/mL, 42 400/mL, and 6270/mL in untreated patients (P = .047, P = .045, and P = .015 respectively). In two patients treated with respectively chlorambucil and fludarabine, the CMV-specific CD4+ T cells rose with treatment and then remained stable for a period. Interestingly, the rate of this increase was dependent on the nature of the treatment, and the half-life of T-cell expansion was measured at 40 days during fludarabine treatment and 120 days during chlorambucil treatment. They were not able to detect CMV reactivation by PCR within these patients, which indicates that viral replication is effectively controlled in CLL patients undergoing chemotherapy with fludarabine or chlorambucil.
The CMV-specific CD4+ T cells showed an effector memory phenotype of CD45RO+CD27–CD28–CD57+ expression. They observed that 9.5% of CD4+ T cells showed a CD28–CD57+ phenotype in CMV-seropositive patients compared with <1% in the uninfected group
Compared to the CMV positive controls, there was reduced expression of the important costimulatory and survival molecules CD27 and CD28, as well as CD45RA and CCR7, which are observed on naive and/or central memory cells, respectively. In contrast, the expression of CD57 and CD45RO, both of which are expressed on late differentiated effector memory cells, was increased in CMV-seropositive patients. These findings show that although CMV modulates the CD4+ T-cell repertoire in healthy donors, these effects are much more marked in the CLL patient group, which reflects the great increase in the absolute CMV-specific CD4+ T-cell count.
Comparison of the clinical features of the CLL cohort in relation to CMV serostatus showed that major infectious episodes were more commonly observed within the CMV-seropositive cohort. Features such as an increase in memory or CD57+ T cells have been associated with clinical complications of CLL. Serious infections such as pneumonia and shingles were seen only in the CMV-seropositive patients, and as the relative usage of fludarabine was comparable in both groups, this might suggest that CMV infection increases the degree of immune suppression within patients. Those patients who were seronegative for CMV demonstrated an increased survival compared with CMV-seropositive patients, with a median survival estimated of 157 months compared with 112 months. However, although the hazard ratio was 0.67 (95% CI: 0.25 to 1.81), indicating an observed 33% reduction in the risk of death for CMV-seronegative patients, this effect did not reach statistical significance due to the small cohort size (P = .42).
Friday, February 04, 2011
fludarabine v cladribine
A new look at Cladribine has been published in Blood. It is perhaps a neglected drug, being very similar to fludarabine, which is usually preferred. I first heard about it from Gunner Julliussen who was obtaining it cheaply from Poland. I gather someone there was manufacturing it as a cottage industry. More recently it has been championed by Dr Robak from Poland. Although similar to fludarabine it has an extra activity in that it is able to alter the mitochondrial membrane potential, which produces caspase-dependent apoptosis in a TP53 independent way. However, There seem to be only 4 fludarabine-refractory patients who have responded to cladribine and 2 cladribine-refractory patients who have responded to fludarabine.
There is a head-to-head comparison between cladribine and fludarabine as front-line therapies for CLL, which showed a significantly longer progression-free survival for cladribine (25 v 10 months), but that seems a very short pfs for fludarabine (more jiggery-pokery from the pharmaceutical companies?).
There is one study which suggests that cladribine does better fludarabine in del 17p cases, but the fludarabine patients in the comparison were of a more advanced stage and the p value was only 0.112.
The major side effect of cladribine is cytopenia, which can be severe and persistent. CD4 lymphopenia is a problem as it is with fludarabine, requiring PCP prophylaxis. Secondary MDS occurs in 1.6% of patients treated with cladribine. The combination of cladribine and an alkylating agent increased the risk of lung cancer. Autoimmunity is no commoner than with chlorambucil. Rare toxicities reported include, Stevens-Johnson syndrome, stroke, tumor lysis syndrome and Transfusions associated GVHD.
All in all cladribine is very similar to fludarabine and the only reason for using it in preference to fludarabine would be if it were substantially cheaper.
There is a head-to-head comparison between cladribine and fludarabine as front-line therapies for CLL, which showed a significantly longer progression-free survival for cladribine (25 v 10 months), but that seems a very short pfs for fludarabine (more jiggery-pokery from the pharmaceutical companies?).
There is one study which suggests that cladribine does better fludarabine in del 17p cases, but the fludarabine patients in the comparison were of a more advanced stage and the p value was only 0.112.
The major side effect of cladribine is cytopenia, which can be severe and persistent. CD4 lymphopenia is a problem as it is with fludarabine, requiring PCP prophylaxis. Secondary MDS occurs in 1.6% of patients treated with cladribine. The combination of cladribine and an alkylating agent increased the risk of lung cancer. Autoimmunity is no commoner than with chlorambucil. Rare toxicities reported include, Stevens-Johnson syndrome, stroke, tumor lysis syndrome and Transfusions associated GVHD.
All in all cladribine is very similar to fludarabine and the only reason for using it in preference to fludarabine would be if it were substantially cheaper.
Picking up on Richter's Syndrome
What makes a CLL patient more prone to develop Richter's syndrome? This is an important question since early recognition and treatment are the keys to better outcomes in this dreaded complication.
A paper from Davide Rossi's group in Novara, Italy helps to address this question. A variant of the LRP4 gene affects the risk of chronic lymphocytic leukaemia transformation to Richter syndrome. Silvia Rasi, Valeria Spina, Alessio Bruscaggin, Tiziana Vaisitti, Claudio Tripodo, Francesco Forconi, Lorenzo De Paoli, Marco Fangazio, Elisa Sozzi, Emanuele Cencini, Luca Laurenti, Roberto Marasca, Carlo Visco, Zijun Y. Xu-Monette, Valter Gattei, Ken H. Young, Fabio Malavasi, Silvia Deaglio, Gianluca Gaidano, Davide Rossi British Journal of Haematology
Volume 152, Issue 3, pages 284–294, February 2011
Chief among markers for Richter's transformation is the use of the IGHV 4-39 gene, especially with a stereotyped HCDR3, and another reason why everybody with active CLL should have their V genes sequenced. A single neucleotide polymorphism (SNP) of the CD38 gene (rs6449182) has also been implicated in the development of Richter's disease, as has a TP53 deletion or mutation, or indeed the use of unmutated V genes. Rossi's group have looked at LRP4, a member of the low-density lipoprotein receptor family that acts as an antagonist of the Wnt/beta-Catenin signaling pathway. In particular they have surveyed the use of an SNP (rs2306029) in 331 cases of CLL, 21 (6.3%) of which developed Richter's syndrome.
In a multivariate analysis, the hazard ration for transformation for the use of V4-39 with the stereotyped HCDR3 was 6.13 (all of the cases transformed within 6 years), for the stereotyped HCDR3 without V4-39 it was 4.45 (38% transformed by 12 years) and for the LRP4 SNP it was 3.21 (9.5% transformed by 2and a half years). Although the CD38 polymorphism carried a significant risk in the univariant analysis, this was lost in the multivariant analysis. When the LRP4 SNP was found with the stereotyped HDR3 but without V4-39 usage, the hazard ration was 14.13 (62% transformed by 12 years).
To confirm that this was not simply a chance finding, they have validated their work in an entirely separate CLL population.
A paper from Davide Rossi's group in Novara, Italy helps to address this question. A variant of the LRP4 gene affects the risk of chronic lymphocytic leukaemia transformation to Richter syndrome. Silvia Rasi, Valeria Spina, Alessio Bruscaggin, Tiziana Vaisitti, Claudio Tripodo, Francesco Forconi, Lorenzo De Paoli, Marco Fangazio, Elisa Sozzi, Emanuele Cencini, Luca Laurenti, Roberto Marasca, Carlo Visco, Zijun Y. Xu-Monette, Valter Gattei, Ken H. Young, Fabio Malavasi, Silvia Deaglio, Gianluca Gaidano, Davide Rossi British Journal of Haematology
Volume 152, Issue 3, pages 284–294, February 2011
Chief among markers for Richter's transformation is the use of the IGHV 4-39 gene, especially with a stereotyped HCDR3, and another reason why everybody with active CLL should have their V genes sequenced. A single neucleotide polymorphism (SNP) of the CD38 gene (rs6449182) has also been implicated in the development of Richter's disease, as has a TP53 deletion or mutation, or indeed the use of unmutated V genes. Rossi's group have looked at LRP4, a member of the low-density lipoprotein receptor family that acts as an antagonist of the Wnt/beta-Catenin signaling pathway. In particular they have surveyed the use of an SNP (rs2306029) in 331 cases of CLL, 21 (6.3%) of which developed Richter's syndrome.
In a multivariate analysis, the hazard ration for transformation for the use of V4-39 with the stereotyped HCDR3 was 6.13 (all of the cases transformed within 6 years), for the stereotyped HCDR3 without V4-39 it was 4.45 (38% transformed by 12 years) and for the LRP4 SNP it was 3.21 (9.5% transformed by 2and a half years). Although the CD38 polymorphism carried a significant risk in the univariant analysis, this was lost in the multivariant analysis. When the LRP4 SNP was found with the stereotyped HDR3 but without V4-39 usage, the hazard ration was 14.13 (62% transformed by 12 years).
To confirm that this was not simply a chance finding, they have validated their work in an entirely separate CLL population.
clinical trials
I have been away from my desk for most of the week following my 17th course of chemotherapy. The day before the treatment I had a gruelling three hour session with two other CLL experts in a conference call reviewing cases from a clinical trial. WE are still using the 1996 Guidelines to judge the quality of remissions. It is extraordinarily difficult to make a judgment in these cases. In certain areas the Guidelines are imprecise and sometimes the local investigator has omitted a vital piece of evidence. Given that this is a multi-center study with Middle-European investigators as well as American ones, multiculturism raises it's ugly head and some of the language translations are comical. We sometimes refer to the 2008 Guidelines, but although they resolve some questions, they still leave vacuums where we get the wrong answer, even though our answer is correct.
When judging a new agent in a clinical trial, surely the right question is, "Has the treatment done the patient any good?" It is possible to achieve MRD negativity without benefiting the patient.
When judging a new agent in a clinical trial, surely the right question is, "Has the treatment done the patient any good?" It is possible to achieve MRD negativity without benefiting the patient.
Monday, January 31, 2011
NHS reforms
The NHS is undergoing yet another reorganization. The split between purchaser and provider is being maintained, but rather than the purchaser being a medical manager led Primary Care Trust, in future Consortia of General Practitioners will determine which services are purchased and there will be more open competition among providers. The role of NICE will be diminished to merely offering advice.
There is a good deal of trepidation about the changes. Hospital doctors fear that GPs will not understand what secondary care providers might be offering; that they might go for a cheaper option without understanding why it is so cheap (ie it doesn't work); that they might repatriate services to GP practices inappropriately (eg near patient blood testing which is much more expensive than testing in laboratories with large machines and it is poorly quality controled, though superficially it does offer some attractive qualities like instant access, it is like comparing a Polaroid picture with a professional photographer).
I came across a good example of how things can go wrong. A Primary Care Trust decided to purchase GP blood tests from a different hospital from the one that patients were likely to be referred to for treatment. One result was that patients arrived for treatment with no blood test results on the hospital computer so that everything had to be repeated, but worse than this, the GPs would ring up the lab where the patient was registered to ask for advice on the recent blood test. Of course the hematologist had not seen the recent blood test an could not give an opinion. On the other hand, the haematologist at the hospital where the blood test was performed, could not help; he did not know the patient and in any case the contract was for blood tests, not their interpretation - that's why they were cheaper.
GP's are worried that they have no management training and may not be up to the job, but undoubtedly they will employ some of the displaced managers from the PCTs. Patients are worried that we will be back to post code prescribing. am worried that GPs will purchase complimentary medicine rather than cancer chemotherapy.
In the BMJ of January 29th, Des Spence, a left wing GP and regular columnist, voices his opinion on the changes. He admits that the previous government pushed up labor costs and reduced productivity, but he fears that the private sector will find this an easy way in to the NHS. The private sector, he says is not based on competition, but greed. He is scathing about the effect of competition in the USA. Healthcare costs are twice as expensive as in the UK and 50 million citizens have restricted access to care. Medicare and Medicaid together spend almost as great a proportion of a much larger GDP as the whole of the NHS does of the smaller British GDP, and when you add in the VA and CDC the proportion is greater. He also claims that the US system is more bureaucratic and that 'competition' has produced the world's most expensive drugs. He says that the US system is defined by overinvestigation, overdiagnosis and overtreatment. Mere activity is no measure of quality.
There is a good deal of trepidation about the changes. Hospital doctors fear that GPs will not understand what secondary care providers might be offering; that they might go for a cheaper option without understanding why it is so cheap (ie it doesn't work); that they might repatriate services to GP practices inappropriately (eg near patient blood testing which is much more expensive than testing in laboratories with large machines and it is poorly quality controled, though superficially it does offer some attractive qualities like instant access, it is like comparing a Polaroid picture with a professional photographer).
I came across a good example of how things can go wrong. A Primary Care Trust decided to purchase GP blood tests from a different hospital from the one that patients were likely to be referred to for treatment. One result was that patients arrived for treatment with no blood test results on the hospital computer so that everything had to be repeated, but worse than this, the GPs would ring up the lab where the patient was registered to ask for advice on the recent blood test. Of course the hematologist had not seen the recent blood test an could not give an opinion. On the other hand, the haematologist at the hospital where the blood test was performed, could not help; he did not know the patient and in any case the contract was for blood tests, not their interpretation - that's why they were cheaper.
GP's are worried that they have no management training and may not be up to the job, but undoubtedly they will employ some of the displaced managers from the PCTs. Patients are worried that we will be back to post code prescribing. am worried that GPs will purchase complimentary medicine rather than cancer chemotherapy.
In the BMJ of January 29th, Des Spence, a left wing GP and regular columnist, voices his opinion on the changes. He admits that the previous government pushed up labor costs and reduced productivity, but he fears that the private sector will find this an easy way in to the NHS. The private sector, he says is not based on competition, but greed. He is scathing about the effect of competition in the USA. Healthcare costs are twice as expensive as in the UK and 50 million citizens have restricted access to care. Medicare and Medicaid together spend almost as great a proportion of a much larger GDP as the whole of the NHS does of the smaller British GDP, and when you add in the VA and CDC the proportion is greater. He also claims that the US system is more bureaucratic and that 'competition' has produced the world's most expensive drugs. He says that the US system is defined by overinvestigation, overdiagnosis and overtreatment. Mere activity is no measure of quality.
Saturday, January 29, 2011
Government by referendum
Some people believe that every political decision should be decided by referendum. A good example why this is nonsense has just occurred in Switzerland. I quote from New Scientist:
SWITZERLAND has bowed to popular pressure and decreed that state-backed health insurance must pay for five types of “complementary medicine” between now and 2017, pending an investigation of their efficacy. In 2009, 67 per cent of the Swiss electorate voted, under the country's system of deciding issues by referendum, for five complementary therapies to be covered by health insurance. They are homeopathy, herbal and traditional Chinese treatments, neural therapy and anthroposophic medicine – which, among other techniques, uses mistletoe to treat cancer.
In December, however, the government's scientific panel advised that this would be illegal, as the law requires insurance to pay only for treatments that meet objective measures of efficacy, and these techniques do not. “The only solution was to pay for the five methods temporarily, but linked to an evidence-based evaluation,” says Ignazio Cassis, a member of the Swiss federal parliament and vice-chair of the Swiss Medical Association. “This isn't science, it's Swiss politics.”
The evaluation will be based on a report on existing studies of the techniques. This will be prepared by Swiss complementary practitioners and then reviewed by an independent body, possibly the UK's National Institute for Health and Clinical Excellence.
SWITZERLAND has bowed to popular pressure and decreed that state-backed health insurance must pay for five types of “complementary medicine” between now and 2017, pending an investigation of their efficacy. In 2009, 67 per cent of the Swiss electorate voted, under the country's system of deciding issues by referendum, for five complementary therapies to be covered by health insurance. They are homeopathy, herbal and traditional Chinese treatments, neural therapy and anthroposophic medicine – which, among other techniques, uses mistletoe to treat cancer.
In December, however, the government's scientific panel advised that this would be illegal, as the law requires insurance to pay only for treatments that meet objective measures of efficacy, and these techniques do not. “The only solution was to pay for the five methods temporarily, but linked to an evidence-based evaluation,” says Ignazio Cassis, a member of the Swiss federal parliament and vice-chair of the Swiss Medical Association. “This isn't science, it's Swiss politics.”
The evaluation will be based on a report on existing studies of the techniques. This will be prepared by Swiss complementary practitioners and then reviewed by an independent body, possibly the UK's National Institute for Health and Clinical Excellence.
Friday, January 28, 2011
T-depleted transplants - the UK experience
The point about RIC transplants is that they use the transplanted immune system to attack the host's leukemia. This graft-versus-leukemia (GVL) effect is difficult to separate from the graft-versus-host-disease (GVHD) that usually accompanies it. As we saw yesterday with the report of the German study chronic GVHD is very common and it can be very debilitating; so much so that I have had patients who have committed suicide rather than continue with it. I remember a teenager with ALL whose GVHD made him look like an old man of 80+. He drowned himself.
One way of attempting to prevent GVHD is to deplete the T cells from the graft, but this carries the risk of graft failure and relapse because some T cells are necessary for the graft to survive and in getting rid of the T cells you are apt to abolish GVL withe the GVHD. The German study seemed to have suffered from both problems, though the number of T-depleted transplants was small and the figures were not reliable.
In the October 21st issue of Blood Steve MacKinnon and his colleagues from teh Royal Free Hospital presented the results of a study in which he titrated the dose of alemtuzumab used to T-deplete. Most people use 100mg of alemtuzumab (5 days of 20mg/d infused into the recipient before the transplant) and this is the experience of MacKinnon and of the German group I wrote about yesterday. Previous British experience has been that the incidence of grade 2 to 4 acute GVHD has been 2% to 20% and with chronic GVHD has been 0% to 13%. The disadvantage of this approach has been slower immune reconstitution and therefore more frequent infections and possibly a lesser GVL effect.
In this study they have titrated down the dose of alemtuzumab. In four cohorts they used 60mg, 40mg, 30mg, or 20mg. 106 patients were transplanted - a mixture of AML, CLL, myeloma, NHL and Hodgkin's disease. There were 15 patients with CLL. All the donors were HLA matched siblings. The conditioning regimen was 5 days of fludarabine 30mg/sq m/d and one day of melphalan 140 ng/sq m. This is probably slightly more intense than the fludarabine/cyclophosphamide regimen used by the Germans.
There was a marked difference between those who received 20mg of alemtuzumab and those who received more than 20mg. The follwing differences were statistically significant. Grade 2-4 acute GVHD, 16% v 5%; extensive chronic GVHD 24% v 9%.
The two year progression-free survival was 60% and overall survival 73%. Full donor chimerism was 81% at 2 years. The non-relapse mortality was 15% at 2 years.
The use of alemtuzumab allows DLI to be used to eliminate mixed chimerism and therefore abort early relapse, without too great a risk of GVHD. Selected T cells may also be infused to protect against re-activated CMV infections and possibly other viral infections.
In future T-depleted transplants in the UK will be with 30mg rather than 100mg of alemtuzumab. It has to be recognized that this study was in a number of different diseases and teh CD52 positive tumors like CLL and NHL would adsorb more alemtuzumab than the myelod tumors, but even so 30mg seems to be enough.
One way of attempting to prevent GVHD is to deplete the T cells from the graft, but this carries the risk of graft failure and relapse because some T cells are necessary for the graft to survive and in getting rid of the T cells you are apt to abolish GVL withe the GVHD. The German study seemed to have suffered from both problems, though the number of T-depleted transplants was small and the figures were not reliable.
In the October 21st issue of Blood Steve MacKinnon and his colleagues from teh Royal Free Hospital presented the results of a study in which he titrated the dose of alemtuzumab used to T-deplete. Most people use 100mg of alemtuzumab (5 days of 20mg/d infused into the recipient before the transplant) and this is the experience of MacKinnon and of the German group I wrote about yesterday. Previous British experience has been that the incidence of grade 2 to 4 acute GVHD has been 2% to 20% and with chronic GVHD has been 0% to 13%. The disadvantage of this approach has been slower immune reconstitution and therefore more frequent infections and possibly a lesser GVL effect.
In this study they have titrated down the dose of alemtuzumab. In four cohorts they used 60mg, 40mg, 30mg, or 20mg. 106 patients were transplanted - a mixture of AML, CLL, myeloma, NHL and Hodgkin's disease. There were 15 patients with CLL. All the donors were HLA matched siblings. The conditioning regimen was 5 days of fludarabine 30mg/sq m/d and one day of melphalan 140 ng/sq m. This is probably slightly more intense than the fludarabine/cyclophosphamide regimen used by the Germans.
There was a marked difference between those who received 20mg of alemtuzumab and those who received more than 20mg. The follwing differences were statistically significant. Grade 2-4 acute GVHD, 16% v 5%; extensive chronic GVHD 24% v 9%.
The two year progression-free survival was 60% and overall survival 73%. Full donor chimerism was 81% at 2 years. The non-relapse mortality was 15% at 2 years.
The use of alemtuzumab allows DLI to be used to eliminate mixed chimerism and therefore abort early relapse, without too great a risk of GVHD. Selected T cells may also be infused to protect against re-activated CMV infections and possibly other viral infections.
In future T-depleted transplants in the UK will be with 30mg rather than 100mg of alemtuzumab. It has to be recognized that this study was in a number of different diseases and teh CD52 positive tumors like CLL and NHL would adsorb more alemtuzumab than the myelod tumors, but even so 30mg seems to be enough.
Song from scripture
Song based on Philippians 1:27
Holy Spirit, take control,
Subjugate my rebel will;
Help me live the Jesus way,
All the Gospel truths instil.
Never flinching from the fight;
Ever living in the light.
Holy Spirit, take control,
Make this congregation one.
Evil forces creep around;
Give us victory in the Son
Who has risen from the grave,
All His chosen souls to save.
Holy Spirit, take control,
Subjugate my rebel will;
Help me live the Jesus way,
All the Gospel truths instil.
Never flinching from the fight;
Ever living in the light.
Holy Spirit, take control,
Make this congregation one.
Evil forces creep around;
Give us victory in the Son
Who has risen from the grave,
All His chosen souls to save.
Thursday, January 27, 2011
RIC allografting in CLL
A long time ago I promised to review the German experience with reduced intensity conditioning allograft in CLL which was published in the October 7th 2010 issue of Blood.
They treated 113 patients from 16 centers. The patients were poor-risk, defined as refractory to or relapsed within 12 months of treatment with a fludarabine containing regimen, or relapse after autologous SCT or progressive disease in the presence of either del 11q or del 17p and/or unmutated IGHV genes or use of V3-21. Patients were aged between 18 and 65 with an ECOG score of 1 or better, normal organ function. Patients with Richter's syndrome were excluded. Related and unrelated donors were matched at 6 loci (more recently 10 loci are preferred).
Conditioning was Fludarabine 30mg/sq m for 5 days and cyclophosphamide 500mg/sq m for 5 days. With unrelated donors ATG 10 mg/kg/d was given for 4 days. The donor source was peripheral blood harvests generated by G-CSF stimulation. For a limited period (June 2002 to November 2005 an alternative conditioning regimen was used, FC + 2Gy TBI on day -9 and alemtuzumab 20mg/d for 5 days. After November 2005 an intensified conditioning regimen was introduced for refractory patients consisting of fludarabine 30 mg/sq m.d for 5 days, busulfan 4mg/kg/d for 3 days, cyclophosphamide 30 mg/kg/d for 2 days. GVHD prophylaxis was with cyclosporin A. Some patients received short courses of methotrexate or mycophenolat mofetil. DLI was admoinistered no earlier than 4 weeks after complete withdrawal of cyclosporin A in case of incomplete donor chimerism or MRD.
13 patients had to be excluded from analysis because of ineligibility. 10 patients did not receive a transplant (1 progressive disease, 3 Richter's transformation, 2 refusal, 4 no donor found).
Of the remaining 90, 24 had uncontrolled refractory disease at time of SCT. Of the 90, del 17p was found in 13, and del 11q in 26. 40% had sibling donors the rest volunteer donors. 65 patients had FC conditioning, 12 FCB and 12 the alemtuzumab-containing regimen.
Neutrophil and platelet recovery occurred in 85/86 with data available and complete donor chimerism was achieved in 66/80 and incomplete chimerism in a further 6. 7 failed to engraft and one had graft failure after partial chimerism - these failures only occurred with the FC and Alemtuzumab regimens. 6/7 had some degree of mismatch and 2 had marrow rather than peripheral blood grafts. 7/8 had autologous recovery and one was salvaged with a 2nd transplant. No patient died of the conditioning which caused a median time in hospital of 22 days (range 0-150 days). There were 2 unrelated deaths in the first 3 months.
Clinically significant GVHD occurred in 45% either after primary transplant or after DLI but grade 3 or 4 GVHD was seen in only 14%. Chronic and extensive GVHD was 73% at 2 years. 65% of those who were alive at 1 year were still on systemic immunosuppression.
33 of the 90 patients died; 16 of progressive disease, 4 of acute GVHD, 5 of chronic GVHD, 5 of infection, 1 of transplantation-associated microangiopathy and 2 of unknown causes. Non-relapse mortality at 4 years was 23% and overall survival at 4 years was 65%. Of the 10 patients who did not get a transplant 7 had died (5 from progressive CLL and 2 from off-protocol allograft)
A CR after allograft was achieved in 73% though 11% of these were already in CR at the time of allograft. A further 21% achieved a PR. At 4 years the relapse rate was 40%. Taking account of the 17 relapse-free mortality cases, the single secondary malignancy and the 8 non-engraftments, the event free survival at 4 years was 42%.
There were some MRD measurements in some of the patients. In those who had data available 39/52 were event-free at 1 year and 27/52 were MRD negative. There were 2 relapses and one non-relapse death among the 27 who were MRD negative at 12 months. 2 others became MRD +ve on follow up. Patients who had a clear GVL effect had the worst GVHD effect. 15 patients required DLI and 5 became MRD negative following this.
So what factors can predict a good or poor outcome? First of all, this study confirms that allografting is an effective treatment for del 17p patients. But having uncontrolled disease at the time of transplant definitely affected outcome adversely. This suggests that once teh criteria for allograft are met it is foolhardy to delay until the disease bulk increases so that no other hope is left. Some patients elect to do just that. Better to grasp your courage and take the chance.
Because matching was only available at 6 rather than 10 loci, many of the grafts would today be considered partially mismatched. This gave the opportunity to assess whether this made a difference. It didn't. This ought to encourage patients to go ahead with an allograft even though a fully matched donor is not available.
There was a high rate of chronic GVHD. One way of avoiding this is to T-deplete the graft. The attempt to do this with alemtuzumab in this study was unsuccessful with shorter event-free and overall survivals. However the authors feel the small numbers involved and the non-randomized allocation of patients to receive T-cell depletion, by no means rule alemtuzumab out of court. I shall have more to say about this later.
In summary, this is the most complete study of RIC transplants in CLL yet published. 60% of patients will be still alive at 4 years and it is the most effective way of treating TP53 deficient disease. However this 60% are not all cured and chronic GVHD is still a major hazard. Finally, if you are taking this option, don't leave it too late.
They treated 113 patients from 16 centers. The patients were poor-risk, defined as refractory to or relapsed within 12 months of treatment with a fludarabine containing regimen, or relapse after autologous SCT or progressive disease in the presence of either del 11q or del 17p and/or unmutated IGHV genes or use of V3-21. Patients were aged between 18 and 65 with an ECOG score of 1 or better, normal organ function. Patients with Richter's syndrome were excluded. Related and unrelated donors were matched at 6 loci (more recently 10 loci are preferred).
Conditioning was Fludarabine 30mg/sq m for 5 days and cyclophosphamide 500mg/sq m for 5 days. With unrelated donors ATG 10 mg/kg/d was given for 4 days. The donor source was peripheral blood harvests generated by G-CSF stimulation. For a limited period (June 2002 to November 2005 an alternative conditioning regimen was used, FC + 2Gy TBI on day -9 and alemtuzumab 20mg/d for 5 days. After November 2005 an intensified conditioning regimen was introduced for refractory patients consisting of fludarabine 30 mg/sq m.d for 5 days, busulfan 4mg/kg/d for 3 days, cyclophosphamide 30 mg/kg/d for 2 days. GVHD prophylaxis was with cyclosporin A. Some patients received short courses of methotrexate or mycophenolat mofetil. DLI was admoinistered no earlier than 4 weeks after complete withdrawal of cyclosporin A in case of incomplete donor chimerism or MRD.
13 patients had to be excluded from analysis because of ineligibility. 10 patients did not receive a transplant (1 progressive disease, 3 Richter's transformation, 2 refusal, 4 no donor found).
Of the remaining 90, 24 had uncontrolled refractory disease at time of SCT. Of the 90, del 17p was found in 13, and del 11q in 26. 40% had sibling donors the rest volunteer donors. 65 patients had FC conditioning, 12 FCB and 12 the alemtuzumab-containing regimen.
Neutrophil and platelet recovery occurred in 85/86 with data available and complete donor chimerism was achieved in 66/80 and incomplete chimerism in a further 6. 7 failed to engraft and one had graft failure after partial chimerism - these failures only occurred with the FC and Alemtuzumab regimens. 6/7 had some degree of mismatch and 2 had marrow rather than peripheral blood grafts. 7/8 had autologous recovery and one was salvaged with a 2nd transplant. No patient died of the conditioning which caused a median time in hospital of 22 days (range 0-150 days). There were 2 unrelated deaths in the first 3 months.
Clinically significant GVHD occurred in 45% either after primary transplant or after DLI but grade 3 or 4 GVHD was seen in only 14%. Chronic and extensive GVHD was 73% at 2 years. 65% of those who were alive at 1 year were still on systemic immunosuppression.
33 of the 90 patients died; 16 of progressive disease, 4 of acute GVHD, 5 of chronic GVHD, 5 of infection, 1 of transplantation-associated microangiopathy and 2 of unknown causes. Non-relapse mortality at 4 years was 23% and overall survival at 4 years was 65%. Of the 10 patients who did not get a transplant 7 had died (5 from progressive CLL and 2 from off-protocol allograft)
A CR after allograft was achieved in 73% though 11% of these were already in CR at the time of allograft. A further 21% achieved a PR. At 4 years the relapse rate was 40%. Taking account of the 17 relapse-free mortality cases, the single secondary malignancy and the 8 non-engraftments, the event free survival at 4 years was 42%.
There were some MRD measurements in some of the patients. In those who had data available 39/52 were event-free at 1 year and 27/52 were MRD negative. There were 2 relapses and one non-relapse death among the 27 who were MRD negative at 12 months. 2 others became MRD +ve on follow up. Patients who had a clear GVL effect had the worst GVHD effect. 15 patients required DLI and 5 became MRD negative following this.
So what factors can predict a good or poor outcome? First of all, this study confirms that allografting is an effective treatment for del 17p patients. But having uncontrolled disease at the time of transplant definitely affected outcome adversely. This suggests that once teh criteria for allograft are met it is foolhardy to delay until the disease bulk increases so that no other hope is left. Some patients elect to do just that. Better to grasp your courage and take the chance.
Because matching was only available at 6 rather than 10 loci, many of the grafts would today be considered partially mismatched. This gave the opportunity to assess whether this made a difference. It didn't. This ought to encourage patients to go ahead with an allograft even though a fully matched donor is not available.
There was a high rate of chronic GVHD. One way of avoiding this is to T-deplete the graft. The attempt to do this with alemtuzumab in this study was unsuccessful with shorter event-free and overall survivals. However the authors feel the small numbers involved and the non-randomized allocation of patients to receive T-cell depletion, by no means rule alemtuzumab out of court. I shall have more to say about this later.
In summary, this is the most complete study of RIC transplants in CLL yet published. 60% of patients will be still alive at 4 years and it is the most effective way of treating TP53 deficient disease. However this 60% are not all cured and chronic GVHD is still a major hazard. Finally, if you are taking this option, don't leave it too late.
ZAP-70 again
As readers know I am less than enthusiastic about ZAP-70 as a surrogate for IGHV mutations. I came across this conversation on the web which I find interesting.
John C. Byrd, MD:
There is a lot of hype about other biomarkers that were being used as surrogates because IgVH gene mutation status was initially harder to obtain. However, that has changed, and now many good commercial and clinical labs at CLL centers are able to obtain these findings. Other tests, like the 70-kDa zeta-associated protein (ZAP-70), I find very challenging to use in my CLL practice. Patients will bring results from 3 different tests that have 3 different answers. The ZAP-70 is clearly a valuable test in the research setting, but for the purposes of translation into real practice, it has not been easily reproducible across different laboratories.
Jennifer R. Brown, MD, PhD:
I have that exact problem. Frequently, ZAP-70 may be the only prognostic test patients come in with. They have not had cytogenetic analysis by FISH, nor do they know the mutational status of IgVH. They may have put a lot of stock in their ZAP-70 result even though, as you note, it may not be interpretable.
John C. Byrd, MD:
There is a lot of hype about other biomarkers that were being used as surrogates because IgVH gene mutation status was initially harder to obtain. However, that has changed, and now many good commercial and clinical labs at CLL centers are able to obtain these findings. Other tests, like the 70-kDa zeta-associated protein (ZAP-70), I find very challenging to use in my CLL practice. Patients will bring results from 3 different tests that have 3 different answers. The ZAP-70 is clearly a valuable test in the research setting, but for the purposes of translation into real practice, it has not been easily reproducible across different laboratories.
Jennifer R. Brown, MD, PhD:
I have that exact problem. Frequently, ZAP-70 may be the only prognostic test patients come in with. They have not had cytogenetic analysis by FISH, nor do they know the mutational status of IgVH. They may have put a lot of stock in their ZAP-70 result even though, as you note, it may not be interpretable.
Wednesday, January 26, 2011
PARP again
I have already written about PARP inhibitors here so this will be a follow up for some. A paper in the November 25th Blood tells of the pre-clinical basis of these new agents which are now in a clinical trial. The paper is from Tanya Stankovic from Birmingham and is a collaboration between several labs including my old lab.
The PARP inhibitor olaparib induces significant killing of ATM-deficient lymphoid tumor cells in vitro and in vivo
Victoria J. Weston, Ceri E. Oldreive, Anna Skowronska, David G. Oscier, Guy Pratt, Martin J. S. Dyer, Graeme Smith, Judy E. Powell, Zbigniew Rudzki, Pamela Kearns, Paul A. H. Moss, A. Malcolm R. Taylor, and Tatjana Stankovic. Blood. 2010; 116(22):4578-87.
This is of interest to those who are 11q23 deleted. The Ataxia Telangiectasia Mutated (ATM) gene is frequently inactivated by either deletion or mutation in lymphoid malignancies such as CLL, T-PLL, and mantle cell lymphoma (MCL) and is associated with defective apoptosis in response to alkylating agents and purine analogues.
ATM mutant cells exhibit impaired DNA double strand break repair. Poly (ADP-ribose) polymerase (PARP) inhibition that imposes the requirement for DNA double strand break repair should selectively sensitize ATM-deficient tumor cells to killing. They have investigated sensitivity to the PARP inhibitor, olaparib, in the test tube of 5 ATM mutant lymphoblastoid cell lines (LCL), an ATM mutant MCL cell line, an ATM knockdown PGA CLL cell line, and 9 ATM-deficient primary CLLs induced to cycle and observed differential killing compared with ATM wildtype counterparts.
Pharmacologic inhibition of ATM and ATM knockdown confirmed the effect was ATM dependent and mediated through mitotic catastrophe independently of apoptosis.
A non-obese diabetic/severe combined immunodeficient (NOD/SCID) murine xenograft model of an ATM mutant MCL cell line demonstrated significantly reduced tumor load and an increased survival of animals after olaparib treatment in vivo.
Addition of olaparib sensitized ATM null tumor cells to DNA-damaging agents.
They suggested that olaparib would be an appropriate agent for treating refractory ATM mutant lymphoid tumors.
Olaparib, here, targets only proliferating cells with ATM dysfunction, consistent with a cytotoxic mechanism involving the conversion of single-stranded DNA breaks into double stranded breaks during DNA replication that cannot be repaired efficiently in cells with a homologous repair (HR) defect. PARP inhibition did not lead to the same degree of cytotoxicity of ATM deficient tumor cells as BRCA mutant cells because the major role of ATM is in sensing the damage that is subsequently repaired by HR repair in which Rad51, BRCA2 and BRCA1 proteins play a major role. The response of ATM mutant lymphoid tumor cells to PARP inhibition is, therefore, comparable to, although not the same as, the scenario previously described for BRCA1/2 mutant breast carcinoma cells which has resulted in Phase I and ongoing Phase II clinical trials with orally administrated olaparib, providing evidence that this agent is well tolerated and exhibits clinical potency. Thus, the clear differential sensitivity of ATM mutant lymphoid cells to submicromolar concentrations of olaparib and the necessity to improve treatment for chemoresistant ATM mutant lymphoid tumors makes olaparib a compelling candidate for trials in these malignancies. Indeed, progressive tumors with especially active proliferation centers may provide the ideal
cellular scenario for targeting by olaparib with the aim of at least delaying disease progression.
It is possible that loss of a single ATM allele by 11q deletion does not affect ATM function and it is therefore conceivable that only 11q-deleted tumors that exhibit mutation in the remaining ATM allele and consequently lose ATM function will
respond differentially to treatment with olaparib. While olaparib monotherapy is an attractive proposition for treating these tumors, there is also the possibility of combining olaparib with chemotherapy agents.
Clinical trials of olaparib in CLL, T-PLL and MCL have begun in the UK.
The PARP inhibitor olaparib induces significant killing of ATM-deficient lymphoid tumor cells in vitro and in vivo
Victoria J. Weston, Ceri E. Oldreive, Anna Skowronska, David G. Oscier, Guy Pratt, Martin J. S. Dyer, Graeme Smith, Judy E. Powell, Zbigniew Rudzki, Pamela Kearns, Paul A. H. Moss, A. Malcolm R. Taylor, and Tatjana Stankovic. Blood. 2010; 116(22):4578-87.
This is of interest to those who are 11q23 deleted. The Ataxia Telangiectasia Mutated (ATM) gene is frequently inactivated by either deletion or mutation in lymphoid malignancies such as CLL, T-PLL, and mantle cell lymphoma (MCL) and is associated with defective apoptosis in response to alkylating agents and purine analogues.
ATM mutant cells exhibit impaired DNA double strand break repair. Poly (ADP-ribose) polymerase (PARP) inhibition that imposes the requirement for DNA double strand break repair should selectively sensitize ATM-deficient tumor cells to killing. They have investigated sensitivity to the PARP inhibitor, olaparib, in the test tube of 5 ATM mutant lymphoblastoid cell lines (LCL), an ATM mutant MCL cell line, an ATM knockdown PGA CLL cell line, and 9 ATM-deficient primary CLLs induced to cycle and observed differential killing compared with ATM wildtype counterparts.
Pharmacologic inhibition of ATM and ATM knockdown confirmed the effect was ATM dependent and mediated through mitotic catastrophe independently of apoptosis.
A non-obese diabetic/severe combined immunodeficient (NOD/SCID) murine xenograft model of an ATM mutant MCL cell line demonstrated significantly reduced tumor load and an increased survival of animals after olaparib treatment in vivo.
Addition of olaparib sensitized ATM null tumor cells to DNA-damaging agents.
They suggested that olaparib would be an appropriate agent for treating refractory ATM mutant lymphoid tumors.
Olaparib, here, targets only proliferating cells with ATM dysfunction, consistent with a cytotoxic mechanism involving the conversion of single-stranded DNA breaks into double stranded breaks during DNA replication that cannot be repaired efficiently in cells with a homologous repair (HR) defect. PARP inhibition did not lead to the same degree of cytotoxicity of ATM deficient tumor cells as BRCA mutant cells because the major role of ATM is in sensing the damage that is subsequently repaired by HR repair in which Rad51, BRCA2 and BRCA1 proteins play a major role. The response of ATM mutant lymphoid tumor cells to PARP inhibition is, therefore, comparable to, although not the same as, the scenario previously described for BRCA1/2 mutant breast carcinoma cells which has resulted in Phase I and ongoing Phase II clinical trials with orally administrated olaparib, providing evidence that this agent is well tolerated and exhibits clinical potency. Thus, the clear differential sensitivity of ATM mutant lymphoid cells to submicromolar concentrations of olaparib and the necessity to improve treatment for chemoresistant ATM mutant lymphoid tumors makes olaparib a compelling candidate for trials in these malignancies. Indeed, progressive tumors with especially active proliferation centers may provide the ideal
cellular scenario for targeting by olaparib with the aim of at least delaying disease progression.
It is possible that loss of a single ATM allele by 11q deletion does not affect ATM function and it is therefore conceivable that only 11q-deleted tumors that exhibit mutation in the remaining ATM allele and consequently lose ATM function will
respond differentially to treatment with olaparib. While olaparib monotherapy is an attractive proposition for treating these tumors, there is also the possibility of combining olaparib with chemotherapy agents.
Clinical trials of olaparib in CLL, T-PLL and MCL have begun in the UK.
Poem based on Philippians 1:27
Let your living be worthy of the Gospel of Christ
Standing firm in the Spirit with one mind
Whoever observes you or however enticed
Let your aims and ambitions be aligned.
Never flinching or shrinking from those who oppose
With your unity and courage thus displayed
Victory is yours in the one who arose
And who all your indebtedness has paid.
Standing firm in the Spirit with one mind
Whoever observes you or however enticed
Let your aims and ambitions be aligned.
Never flinching or shrinking from those who oppose
With your unity and courage thus displayed
Victory is yours in the one who arose
And who all your indebtedness has paid.
The causes of CLL extended
The incidence of CLL in Taiwan is increasing. The incidence of CLL has always been recognized as 10 times as great among Caucasians compared to that of East Asians. However, a paper in Blood
The incidence of chronic lymphocytic leukemia in Taiwan, 1986-2005: a distinct increasing trend with birth-cohort effect
Shang-Ju Wu, Shang-Yi Huang, Chien-Ting Lin, Yu-Jr Lin, Chee-Jen Chang and Hwei-Fang Tien Blood. 2010;116:4430-4435
reports a drastically increasing trend. The epidemiologic data of CLL for Taiwanese and Caucasian Americans during 1986 to 2005 were obtained from the Taiwan SEER database. The age-adjusted incidence rate of CLL for Taiwanese was continuously increasing during the 20-year period while that for Caucasian Americans remained
steady. A much stronger birth cohort effect was identified for Taiwanese but not for Caucasian Americans. This effect corresponded to the westernization of lifestyle in Taiwan since 1960. They concluded that, in addition to the ethnic difference of incidence, there is distinct increasing incidence trend of CLL in Taiwan. The strong birth-cohort effect underlying this increasing trend indicates that lifestyles and environmental factors may play a role in the development of CLL for Taiwanese.
The incidence of chronic lymphocytic leukemia in Taiwan, 1986-2005: a distinct increasing trend with birth-cohort effect
Shang-Ju Wu, Shang-Yi Huang, Chien-Ting Lin, Yu-Jr Lin, Chee-Jen Chang and Hwei-Fang Tien Blood. 2010;116:4430-4435
reports a drastically increasing trend. The epidemiologic data of CLL for Taiwanese and Caucasian Americans during 1986 to 2005 were obtained from the Taiwan SEER database. The age-adjusted incidence rate of CLL for Taiwanese was continuously increasing during the 20-year period while that for Caucasian Americans remained
steady. A much stronger birth cohort effect was identified for Taiwanese but not for Caucasian Americans. This effect corresponded to the westernization of lifestyle in Taiwan since 1960. They concluded that, in addition to the ethnic difference of incidence, there is distinct increasing incidence trend of CLL in Taiwan. The strong birth-cohort effect underlying this increasing trend indicates that lifestyles and environmental factors may play a role in the development of CLL for Taiwanese.
CD14 raised in CLL
It has long been known that CLL cells need help to be able to survive. Several studies have shown that it is what goes on in the tissues rather than the blood that provides the drive for CLL cells to multiply and resist apoptosis. A number of different cells have been implicated including 'nurse' cells described by Tom Kipps group and T cells according to Sylbia Deaglio's group in Italy.
I have been going back through old copies of Blood before disposing of them and I came across this article in the issue from November 18th last year. Soluble CD14 is a novel monocyte-derived survival factor for chronic lymphocytic leukemia cells, which is induced by CLL cells in vitro and present at abnormally high levels in vivo by Martina Seiffert, Angela Schulz, Sibylle Ohl, Hartmut Dohner, Stephan Stilgenbauer, and Peter Lichter. Ulm, Germany
The bottom line is that monocytes help in the survival of CLL cells by secreting soluble CD14, which induces nuclear factor kappa B activation in these cells, and that CLL cells actively shape their microenvironment by inducing CD14 secretion in accessory monocytes.
CD14 is a cell-surface receptor present on monocytes and macrophages, and to a lesser extent on neutrophils and dendritic cells. By binding bacterial Lipopolysaccharide (LPS), CD14 helps in the activation of Toll-like receptor (TLR)-4 signaling, which subsequently results in the activity of NF kappa B, AP1, and IRF3 transcription factors. Although LPS is considered its main ligand, CD14 also recognizes other pathogen associated molecules. A soluble form of CD14 is present in body fluids, like blood, saliva or breast milk, where it is involved in innate immunity by conferring its signaling activity to cells that do not express CD14. By adding recombinant soluble CD14 to CLL cells in culture, they observed increased CLL cell viability. Consistent with this they found that stimulation of CLL cells with soluble CD14 resulted in an augmented activity of the NF Kappa B components, p50 and p65, which are known to be constitutively active in primary CLL cells and are associated with their survival.
It is known that soluble CD14 is raised in patients with CLL and that it parallels the B-cell count.
Another possible target for treatment?
I have been going back through old copies of Blood before disposing of them and I came across this article in the issue from November 18th last year. Soluble CD14 is a novel monocyte-derived survival factor for chronic lymphocytic leukemia cells, which is induced by CLL cells in vitro and present at abnormally high levels in vivo by Martina Seiffert, Angela Schulz, Sibylle Ohl, Hartmut Dohner, Stephan Stilgenbauer, and Peter Lichter. Ulm, Germany
The bottom line is that monocytes help in the survival of CLL cells by secreting soluble CD14, which induces nuclear factor kappa B activation in these cells, and that CLL cells actively shape their microenvironment by inducing CD14 secretion in accessory monocytes.
CD14 is a cell-surface receptor present on monocytes and macrophages, and to a lesser extent on neutrophils and dendritic cells. By binding bacterial Lipopolysaccharide (LPS), CD14 helps in the activation of Toll-like receptor (TLR)-4 signaling, which subsequently results in the activity of NF kappa B, AP1, and IRF3 transcription factors. Although LPS is considered its main ligand, CD14 also recognizes other pathogen associated molecules. A soluble form of CD14 is present in body fluids, like blood, saliva or breast milk, where it is involved in innate immunity by conferring its signaling activity to cells that do not express CD14. By adding recombinant soluble CD14 to CLL cells in culture, they observed increased CLL cell viability. Consistent with this they found that stimulation of CLL cells with soluble CD14 resulted in an augmented activity of the NF Kappa B components, p50 and p65, which are known to be constitutively active in primary CLL cells and are associated with their survival.
It is known that soluble CD14 is raised in patients with CLL and that it parallels the B-cell count.
Another possible target for treatment?
Bentham v Kant. Moral philosophy part 2
I am enjoying the course on moral philosophy being broadcast by the BBC and led by Michael Sandel.
Yesterday he contrasted the utilitarianism of Jeremy Bentham with the categorical imperative of Immanuel Kant.
Bentham believed in the greatest happiness for the greatest number. In many ways many of us would go along with that until it comes to the hard questions.
One example: a trolley bus is careering down a hill out of control. The brakes have failed and five workers on the tracks below are bound to be killed. But there is a siding to the right with only one worker on it. The driver can still steer. Should he steer to the right and kill one to save the five? Most people take this choice, but when the same question is put in a way that involves a direct act of murder most would hold back.
There are 5 patients waiting for a transplant. Two need kidneys, one a liver, one a heart/lung and the fifth a pancreas. There are no donors and they are all going to die. But in the next room a fit young man with the right blood group has come in for a check-up. He is taking an afternoon nap. The surgeon has a bright idea, "I could nip in and take the required organs from him. True I would lose one life, but I would save five."
There would be no support for this action - even from the relatives of the potential recipients.
Kant saw the flaws in utilitarianism and propounded his own ideas. Human dignity trumps mere numbers. He talked about categorical imperatives, principles that are intrinsically valid, good in and of themselves. One of these imperatives is the idea of human rights or human dignity.
But it is easy to put hard cases to the committed Kantian. For example torture would be absolutely forbidden according to Kant. But supposing there is a bomb on a plane which will explode and kill 500 people. The man who put the bomb on the plane has been caught but refuses to tell where it is. Does anybody believe it would be wrong to waterboard the bomber to save the lives of the 500? Kantians do. Politicians avoid the question by calling the idea hypothetical, saying that such situations don't occur in real life. But they do.
A recent German case illustrates the dilemma. A young child was kidnapped. The kidnapper was caught and the ransom retrieved, but he refused to say where the child was. The police chief threatened him with torture and he caved in and gave the location of the child. He admitted that he had killed the child shortly after the kidnapping. He was prosecuted for murder and received a life sentence. But, and here's the rub, the police chief was prosecuted for violating the kidnapper's human rights. You or I might think that the murderer had forfeited his human rights in this case, but under the German Constitution, the rights of all its citizens are sacrosanct.
I believe that after the Third Reich so violated the human rights of 6 million Jews, the German conscience so pricked that they felt it necessary to incorporate this principle of their favorite philosopher in law. So many European countries were complicit in the persecution of Jewry that they raised no objection to this guiding principle throughout Europe and the last Labour government in the UK incorporated the European Convention on Human Rights into UK law.
In the UK we have managed without a written constitution for thousands of years and the German experience shows the wisdom of that. The sorts of dilemmas that Sandel has highlighted demonstrate the futility of laying down absolute principles. In the 2000+ years since Socrates the greatest minds have disagreed about these questions of moral philosophy - how are we supposed to resolve them? Each case must be judged on its merits. Sometime the law is an ass and a wise judge will recognize that.
One of Kant's categorical imperatives concerns lying which he says is always wrong. So you have a RAF pilot hidden in your hayloft. The Gestapo calls and asks you if you have seen one and Kant would say you have to betray the pilot because it is wrong to lie. I would say that the Gestapo officer has forfeited his right to be told the truth.
The same applies to imprisoned murderers who have been denied the right to vote in general elections. By their actions they have forfeited some of their human rights. Not according to the European Court which holds the UK is in contempt for its policy.
Yesterday he contrasted the utilitarianism of Jeremy Bentham with the categorical imperative of Immanuel Kant.
Bentham believed in the greatest happiness for the greatest number. In many ways many of us would go along with that until it comes to the hard questions.
One example: a trolley bus is careering down a hill out of control. The brakes have failed and five workers on the tracks below are bound to be killed. But there is a siding to the right with only one worker on it. The driver can still steer. Should he steer to the right and kill one to save the five? Most people take this choice, but when the same question is put in a way that involves a direct act of murder most would hold back.
There are 5 patients waiting for a transplant. Two need kidneys, one a liver, one a heart/lung and the fifth a pancreas. There are no donors and they are all going to die. But in the next room a fit young man with the right blood group has come in for a check-up. He is taking an afternoon nap. The surgeon has a bright idea, "I could nip in and take the required organs from him. True I would lose one life, but I would save five."
There would be no support for this action - even from the relatives of the potential recipients.
Kant saw the flaws in utilitarianism and propounded his own ideas. Human dignity trumps mere numbers. He talked about categorical imperatives, principles that are intrinsically valid, good in and of themselves. One of these imperatives is the idea of human rights or human dignity.
But it is easy to put hard cases to the committed Kantian. For example torture would be absolutely forbidden according to Kant. But supposing there is a bomb on a plane which will explode and kill 500 people. The man who put the bomb on the plane has been caught but refuses to tell where it is. Does anybody believe it would be wrong to waterboard the bomber to save the lives of the 500? Kantians do. Politicians avoid the question by calling the idea hypothetical, saying that such situations don't occur in real life. But they do.
A recent German case illustrates the dilemma. A young child was kidnapped. The kidnapper was caught and the ransom retrieved, but he refused to say where the child was. The police chief threatened him with torture and he caved in and gave the location of the child. He admitted that he had killed the child shortly after the kidnapping. He was prosecuted for murder and received a life sentence. But, and here's the rub, the police chief was prosecuted for violating the kidnapper's human rights. You or I might think that the murderer had forfeited his human rights in this case, but under the German Constitution, the rights of all its citizens are sacrosanct.
I believe that after the Third Reich so violated the human rights of 6 million Jews, the German conscience so pricked that they felt it necessary to incorporate this principle of their favorite philosopher in law. So many European countries were complicit in the persecution of Jewry that they raised no objection to this guiding principle throughout Europe and the last Labour government in the UK incorporated the European Convention on Human Rights into UK law.
In the UK we have managed without a written constitution for thousands of years and the German experience shows the wisdom of that. The sorts of dilemmas that Sandel has highlighted demonstrate the futility of laying down absolute principles. In the 2000+ years since Socrates the greatest minds have disagreed about these questions of moral philosophy - how are we supposed to resolve them? Each case must be judged on its merits. Sometime the law is an ass and a wise judge will recognize that.
One of Kant's categorical imperatives concerns lying which he says is always wrong. So you have a RAF pilot hidden in your hayloft. The Gestapo calls and asks you if you have seen one and Kant would say you have to betray the pilot because it is wrong to lie. I would say that the Gestapo officer has forfeited his right to be told the truth.
The same applies to imprisoned murderers who have been denied the right to vote in general elections. By their actions they have forfeited some of their human rights. Not according to the European Court which holds the UK is in contempt for its policy.
Tuesday, January 25, 2011
Fairness and the Big Society
I watched a debate on BBC4 last night about Fairness and the Big Society. It was conducted at the Royal Institution and moderated by Michael Sandel, the Harvard Professor.
The audience, being a BBC audience, was packed with left-wing students, which rather threw Sandel when they voted en masse against a communitarian solution to fairness - in reality they were voting against anything associated with the Tories.
However, some interesting points. A large number of people felt that fairness equated with equality. Well, it may do, but life is unfair. We are not all born equal, except in the sight of God. We are all born with natural talents. However hard I try I will never make a good carpenter or be able to play football for anything better than a pub team.
The question was posed as to whether it was fair that Wayne Rooney should make £11.2 million a year for playing football while a care worker has to make do on £12,000 a year. The point was made that there is a market out there for footballers and players are paid what the market will bear. It's all a question of supply and demand. Very few people can do what Wayne Rooney can do and people are willing to pay and watch it. On the other hand hundreds of thousands can do a care workers job and if she doesn't like her job there is no shortage of people willing to fill her shoes.
Equality of opportunity is one thing that most agree on and interestingly an overwhelming majority of the audience felt that they were either doing better than their parents or expected to do so. Despite this the UK is supposed to have less social mobility than most other OECD countries even including the USA. Denmark is held up as the paragon of social mobility (though the standard rate of income tax there is 52%). Certainly class and the public school system have in the past been a barrier to social mobility, but there is a problem in abolishing privilege: social mobility involves some moving down as well as some moving up. People tend to be reluctant to let their children suffer. It is noticeable that among left-wing politicians, just as much as among those on the right that nepotism abounds. Most successful actors are left-wing. Take the Redgraves. They have been called Trotskyites, yet if you are a Redgrave family member you find it easy to be a thespian. Inherited talent or nepotism? When you see Harley street doctors making it easy for their sons to follow them in the profession, ask the same question.
There is a hint of left-wing envy and snobbery about the whole debate. We live in an unfair world, because we are not all born equal and unequal things happen to us. To suggest that everybody ought to go to university just because that is what the rich do is nonsense. They have even dumbed down university courses to make it possible. An academic education is appropriate for academics but not for carpenters. I am all for everybody being educated to the limits of their ability, but to pretend that that means living away from home for three years, attending lectures and reading books is plain silly. For most, an apprenticeship is more appropriate. That is nothing to look down on. My most revered scientist, Edward Jenner, was apprenticed to a barber surgeon from the age of 13.
I respect my gardener because he grows beautiful camellias for me, my window cleaner because he reaches the parts that I cannot, my odd-job man because he replaced my damaged locks, the girl on the supermarket check-out because she had a cheerful word and was patient with me while I packed my bags, my patients because they make me feel useful and the homeless men who come to our church for food and clothing because they are human beings made in the image of God.
"From each according to his ability; to each according to his needs" is a slogan of Karl Marx, which is all very well in theory but in real life, it cannot be enforced by compulsion and no-one adopts it voluntarily. St Paul wrote "He who will not work, neither shall he eat." But even societies that start out with such an ideal find themselves soft-hearted when it comes to denying a beggar despite warnings that the money will go to drug dealers.
Perhaps we have to accept that life is unfair and read every situation as it comes along in a pragmatic way. I can't imagine what I would do with £11.2 million a year but I would certainly find it difficult to manage on £12,000. Income tax at 52% would make me think of emigrating, no matter how good the health service.
There is a famous science fiction story which envisioned a society where everyone was made to be equal. The bright had to wear headphones that played weird noises in their ears to stop them concentrating. The strong had to wear 40 pound bags on their backs to handicap them. It was an equal society but unfair to the talented.
I should like to see a society where everyone was enabled to fulfill their talents in meaningful work and where people were valued as people. No-one can help being born blind or deaf and they shouldn't be disrespected because of it. They should be helped to make the most of what they have. Wayne Rooney was born with a certain agility and dexterousness. No doubt he is such a good footballer because he has applied himself to training and practice, though even with that application I could never play professional football. Nevertheless, much as I approve of his ability to capitalize on his talent I believe he has a responsibility to the society that has nurtured him. Sportsmen have a great rewards and opportunities; they should use their good fortune for the common good. It used to be called Noblesse Oblige.
The audience, being a BBC audience, was packed with left-wing students, which rather threw Sandel when they voted en masse against a communitarian solution to fairness - in reality they were voting against anything associated with the Tories.
However, some interesting points. A large number of people felt that fairness equated with equality. Well, it may do, but life is unfair. We are not all born equal, except in the sight of God. We are all born with natural talents. However hard I try I will never make a good carpenter or be able to play football for anything better than a pub team.
The question was posed as to whether it was fair that Wayne Rooney should make £11.2 million a year for playing football while a care worker has to make do on £12,000 a year. The point was made that there is a market out there for footballers and players are paid what the market will bear. It's all a question of supply and demand. Very few people can do what Wayne Rooney can do and people are willing to pay and watch it. On the other hand hundreds of thousands can do a care workers job and if she doesn't like her job there is no shortage of people willing to fill her shoes.
Equality of opportunity is one thing that most agree on and interestingly an overwhelming majority of the audience felt that they were either doing better than their parents or expected to do so. Despite this the UK is supposed to have less social mobility than most other OECD countries even including the USA. Denmark is held up as the paragon of social mobility (though the standard rate of income tax there is 52%). Certainly class and the public school system have in the past been a barrier to social mobility, but there is a problem in abolishing privilege: social mobility involves some moving down as well as some moving up. People tend to be reluctant to let their children suffer. It is noticeable that among left-wing politicians, just as much as among those on the right that nepotism abounds. Most successful actors are left-wing. Take the Redgraves. They have been called Trotskyites, yet if you are a Redgrave family member you find it easy to be a thespian. Inherited talent or nepotism? When you see Harley street doctors making it easy for their sons to follow them in the profession, ask the same question.
There is a hint of left-wing envy and snobbery about the whole debate. We live in an unfair world, because we are not all born equal and unequal things happen to us. To suggest that everybody ought to go to university just because that is what the rich do is nonsense. They have even dumbed down university courses to make it possible. An academic education is appropriate for academics but not for carpenters. I am all for everybody being educated to the limits of their ability, but to pretend that that means living away from home for three years, attending lectures and reading books is plain silly. For most, an apprenticeship is more appropriate. That is nothing to look down on. My most revered scientist, Edward Jenner, was apprenticed to a barber surgeon from the age of 13.
I respect my gardener because he grows beautiful camellias for me, my window cleaner because he reaches the parts that I cannot, my odd-job man because he replaced my damaged locks, the girl on the supermarket check-out because she had a cheerful word and was patient with me while I packed my bags, my patients because they make me feel useful and the homeless men who come to our church for food and clothing because they are human beings made in the image of God.
"From each according to his ability; to each according to his needs" is a slogan of Karl Marx, which is all very well in theory but in real life, it cannot be enforced by compulsion and no-one adopts it voluntarily. St Paul wrote "He who will not work, neither shall he eat." But even societies that start out with such an ideal find themselves soft-hearted when it comes to denying a beggar despite warnings that the money will go to drug dealers.
Perhaps we have to accept that life is unfair and read every situation as it comes along in a pragmatic way. I can't imagine what I would do with £11.2 million a year but I would certainly find it difficult to manage on £12,000. Income tax at 52% would make me think of emigrating, no matter how good the health service.
There is a famous science fiction story which envisioned a society where everyone was made to be equal. The bright had to wear headphones that played weird noises in their ears to stop them concentrating. The strong had to wear 40 pound bags on their backs to handicap them. It was an equal society but unfair to the talented.
I should like to see a society where everyone was enabled to fulfill their talents in meaningful work and where people were valued as people. No-one can help being born blind or deaf and they shouldn't be disrespected because of it. They should be helped to make the most of what they have. Wayne Rooney was born with a certain agility and dexterousness. No doubt he is such a good footballer because he has applied himself to training and practice, though even with that application I could never play professional football. Nevertheless, much as I approve of his ability to capitalize on his talent I believe he has a responsibility to the society that has nurtured him. Sportsmen have a great rewards and opportunities; they should use their good fortune for the common good. It used to be called Noblesse Oblige.
Monday, January 24, 2011
News of health and other matters
As you will see, I have just posted a blog I started last Wednesday. I have an unpleasant few days since last Wednesday, with pain and fatigue making it difficult for me to do anything other that lie there and stare at the wall. With more than a 5 week gap between treatments, I had forgotten what an unpleasant thing chemotherapy is.
Today I am feeling a whole lot better and am able to sit at my desk, though I still haven't started on setting up my train set.
My discomfort has coincided with a poor showing by England in the one-day cricket internationals. I have refrained from crowing over the test matches in which the Australians got a drubbing since I know that these things go-around and then come-around. Liverpool FC have replaced their manager with Kenny Dalglish, the Return of the King, they are calling it. He had a decent win on Saturday. New managers can make a huge psychological difference, but success in football matches depends on fine margins. Manchester United and Arsenal continue on their successful ways and Spurs continue in the top 5. Chelsea seem to be in trouble and must beat Bolton tonight if they are not to have lost hope. Manchester City remain a group of expensively purchased stars, but not yet a team.
We have had a spell of dry weather and some sunshine, but temperatures have remained just above freezing by day and just below at night.
Family have visited a bit, but viral infections have limited this. I am still struggling with a new 1000 piece jigsaw puzzle and with NT Wright's "Virtue Reborn". January is nearly over.
Today I am feeling a whole lot better and am able to sit at my desk, though I still haven't started on setting up my train set.
My discomfort has coincided with a poor showing by England in the one-day cricket internationals. I have refrained from crowing over the test matches in which the Australians got a drubbing since I know that these things go-around and then come-around. Liverpool FC have replaced their manager with Kenny Dalglish, the Return of the King, they are calling it. He had a decent win on Saturday. New managers can make a huge psychological difference, but success in football matches depends on fine margins. Manchester United and Arsenal continue on their successful ways and Spurs continue in the top 5. Chelsea seem to be in trouble and must beat Bolton tonight if they are not to have lost hope. Manchester City remain a group of expensively purchased stars, but not yet a team.
We have had a spell of dry weather and some sunshine, but temperatures have remained just above freezing by day and just below at night.
Family have visited a bit, but viral infections have limited this. I am still struggling with a new 1000 piece jigsaw puzzle and with NT Wright's "Virtue Reborn". January is nearly over.
Wednesday, January 19, 2011
Peonises, promises. Galatians 3:15-18
"There ought to be a law against that!" says David.
"I'm sorry but there isn't one." replies Richard.
"Then let's make one!" exclaims David.
"Well, we could, I suppose," explains Richard, "but we wouldn't be able to catch this lot because laws don't operate retrospectively."
This is what Paul is explaining. The Law can have nothing to do with Abraham because Abraham lived hundreds of years before Moses was given the Law. God made a promise to Abraham even before he left Haran and it is through this promise we are saved. "All people on earth will be blessed through you." Genesis 12:3. This covenant promise was made by God in an unconditional way. It did not depend on the behavior of Abraham or any of his descendants.
Paul takes an example from everyday life (Galatians 3:15). The example is a last will or testament. Once it is signed, sealed and delivered after a person's death, it cannot be altered. So long as the testamentor was of sound mind and the will was properly witnessed, the cats' home is going to benefit and not the long-lost cousin in Australia. God made a covenant with Abraham and God will deliver.
But this passage in Galatians has two major problems. The first is how Paul goes on about singular and plural 'seeds'. In English this doesn't make much sense to us, since 'seed' is a collective noun; it can mean one seed or many. The same is true for both Hebrew or Greek, the languages that Paul might have been referring to.
The second is the 430 years since the promise was given. On some accounts this seems to be an underestimate; some interpreters put the period as 645 years. I don't want to go into a great deal of detail about this; it seems to me to fall into Paul's category of arguing about meaningless genealogies, but I suspect that the answer to both questions lies in the fact that the promises were repeated in Genesis 22:18 to Abraham, in 26:4 to Isaac and 28:14 to Jacob. And with each repetition there is a choice between plural seeds and singular seed. It was to Isaac not Ishmael that the promise was given, and to Jacob not Esau and as a matter of fact to Judah and not the 11 other sons. Not to Levi, through whom the priesthood and Mosaic law derived; not even through Benjamin, from whom we have the writer of most of the New Testament and the greatest preacher ever. It is through Judah, that seed, that we have the Christ, the fulfillment of all prophesy and promises.
If the inheritance depends on the law; it no longer depends on a promise. What sort of a promise is it that it takes the law to enforce it? God in his grace gave the inheritance to Abraham through a promise. Our salvation depends on a promise.
As a father, I have often fallen down on my promises. Life encroaches and one forgets. But this was a promise from God. The all-seeing, all-powerful God. He does not renege; he does not forget. Our salvation is all of grace; none of works. We bring nothing to the party except our sins - and these to be washed away.
"I'm sorry but there isn't one." replies Richard.
"Then let's make one!" exclaims David.
"Well, we could, I suppose," explains Richard, "but we wouldn't be able to catch this lot because laws don't operate retrospectively."
This is what Paul is explaining. The Law can have nothing to do with Abraham because Abraham lived hundreds of years before Moses was given the Law. God made a promise to Abraham even before he left Haran and it is through this promise we are saved. "All people on earth will be blessed through you." Genesis 12:3. This covenant promise was made by God in an unconditional way. It did not depend on the behavior of Abraham or any of his descendants.
Paul takes an example from everyday life (Galatians 3:15). The example is a last will or testament. Once it is signed, sealed and delivered after a person's death, it cannot be altered. So long as the testamentor was of sound mind and the will was properly witnessed, the cats' home is going to benefit and not the long-lost cousin in Australia. God made a covenant with Abraham and God will deliver.
But this passage in Galatians has two major problems. The first is how Paul goes on about singular and plural 'seeds'. In English this doesn't make much sense to us, since 'seed' is a collective noun; it can mean one seed or many. The same is true for both Hebrew or Greek, the languages that Paul might have been referring to.
The second is the 430 years since the promise was given. On some accounts this seems to be an underestimate; some interpreters put the period as 645 years. I don't want to go into a great deal of detail about this; it seems to me to fall into Paul's category of arguing about meaningless genealogies, but I suspect that the answer to both questions lies in the fact that the promises were repeated in Genesis 22:18 to Abraham, in 26:4 to Isaac and 28:14 to Jacob. And with each repetition there is a choice between plural seeds and singular seed. It was to Isaac not Ishmael that the promise was given, and to Jacob not Esau and as a matter of fact to Judah and not the 11 other sons. Not to Levi, through whom the priesthood and Mosaic law derived; not even through Benjamin, from whom we have the writer of most of the New Testament and the greatest preacher ever. It is through Judah, that seed, that we have the Christ, the fulfillment of all prophesy and promises.
If the inheritance depends on the law; it no longer depends on a promise. What sort of a promise is it that it takes the law to enforce it? God in his grace gave the inheritance to Abraham through a promise. Our salvation depends on a promise.
As a father, I have often fallen down on my promises. Life encroaches and one forgets. But this was a promise from God. The all-seeing, all-powerful God. He does not renege; he does not forget. Our salvation is all of grace; none of works. We bring nothing to the party except our sins - and these to be washed away.
Monday, January 17, 2011
Autoimmunity and CLL
Emili Montserrat's group in Barcelona has just published its experience with autoimmune phenomena in CLL over the past 28 years Blood 2010, 116:4771-6. Among 961 patients with CLL seen in that time, autoimmune cytopenias were confirmed in 70 ((7%). 49 had AIHA, 20 ITP and one had both at presentation though a further three with ITP later developed AIHA. In 3 patients the autoimmune thrombocytopenia preceded the diagnosis of CLL and in a further 19 the diagnosis was simultaneous. In 35 (50%) the autoimmunity occured during or soon (immediately up to 10 months) after therapy (8/204 after fludarabine, 12/231 after chlorambucil).
Autoimmunity was associated with advanced clinical stage, high lymphocyte count and short lymphocyte doubling time. Among more modern prognostic factors, beta-2 M, CD38and ZAP-70 were associated with autoimmunity but too few patients had IGHV mutations or cytogenetics done to make a correlation with these. There were no significant differences between overall survivals of those with and without autoimmune phenomena.
Neither Binet nor Rai staging takes account of the effect of autoimmunity. Thus patients with ITP are automatically assigned to Rai stage 4 or Binet stage C. I have always though this nonsensical and Montserrat agrees with me. He differentiates between Binet stage C (immune) and C (infiltrative). They compared 19 patients with stage C (immune) with 54 patients with stage C (infiltrative) The groups were demographically similar except that the infiltrative group had higher beta-2M levels and more marrow infiltration. There was a major difference in survival between the two groups with the immune patients having an average survival of 7.4 years and the infiltrative patients having an average survival of 3.7 years.
The reason for this difference was the relative response to steroids with immune patients being downstaged to stage A in 84% of cases and the infiltrative patients being downstaged to stage A in only 16% of cases. The ITP cases did slightly better than the AIHA with 100% downstaged compared to 75%. The development of an autoimmune disease during the course of the CLL did not significantly affect prognosis, though for patients with early stage A average survival was 9 years compared to that of stage A patients who did not develop autoimmune phenomena who survived on average for 10 years. Median survival for stage A were 10.2 years, for stage B 5.6 years, stage C immune 7.4 years and stage C infiltrative 3.7 years.
Agreeing with what was found in LRFCLL4 the prevalence of AIHA after chlorambucil and after fludarabine was similar at 5% and 4% respectively.
The same group have also published a systematic review of the subject in Haematologica and I quote extensively from it.
Among the additional points they make are that the monoclonal B cell lymphocytosis (MBL) is markedly more common in patients with supposed idiopathic AIHA or ITP than in matched controls which emphasizes the importance of excluding CLL and other chronic lymphoproliferative diseases in patients with AIHA and ITP.
In the early 1990s we published our concern that treatment with purine analogs (particularly fludarabine) was associated with a higher frequency of autoimmune cytopenia (Myint H et al, Br J Haematol 1995;91:341-4) and several other authors agreed. This was thought to be related to prolonged suppression of CD4+CD25+FOXP3+ regulatory T cells (Tregs) which has been shown to lead to autoimmune disease, and Tregs are highly sensitive to fludarabine. The cases reported were mainly in patients who had been heavily pre-treated with purine analogs. As a result of these observations, there has been agreement that purine analogs should be avoided in
patients with a history of autoimmune cytopenia, particularly if related to purine-analog therapy.
More recent trials in patients treated with first line therapy have suggested that the risk for developing autoimmune cytopenia after purine analog exposure is not greater than with other agents though cases may be more severe. In the UK LRFCLL4 trial no differences were observed in the percentage of patients becoming DAT positive after therapy (14% chlorambucil, 13% fludarabine, and 10% fludarabine plus cyclophosphamide), but the incidence of AIHA was significantly lower in patients treated with fludarabine plus cyclophosphamide (5%) than in those allocated to receive chlorambucil (12%) or fludarabine alone (11%) (p<0.01). This suggests that the addition of cyclophosphamide to fludarabine might have a “protective” effect on the appearance of AIHA. An earlier smaller study from MDACC supports this low incidence of AIHA in patients treated with fludarabine, cyclophosphamide and rituximab. The most recent data come from the German CLL 8 trial of patients with CLL requiring treatment and without clinically apparent autoimmune cytopenia. When treated with fludarabine and cyclophosphamide with or without rituximab, the rate of AIHA was <1%. Taken together these results demonstrate that the risk of AIHA is not higher following regimes in which fludarabine and cyclophosphamide (with or without rituximab) are given together in comparison to the risk seen after older therapies for CLL.
Treatment of patients with CLL and autoimmune cytopenia is largely based on
expert opinion and depends on whether the patient’s CLL requires treatment at the same time. In those patients with immune cytopenia in the context of quiescent CLL, the treatment is the same as idiopathic AIHA initially with corticosteroids, and then in patients who fail to respond or relapse quickly, alternative immunosuppression such as ciclosporine, mycophenylate or azathioprine, or sometimes splenectomy. There are case reports of the use of combinations of rituximab with or without immunosuppression with good effect; alemtuzumab has also been successfully used. Intravenous immunoglobulin can be useful where a rapid response is needed though as a single agent it will not give lasting effects. The new thrombopoietin receptor agonists may be effective in CLL associated ITP as they are in primary ITP. Despite the fact that the problem is destruction rather tha failure to produce blood elements, supportive care should include blood product transfusion as clinically indicated. Folic acid in AIHA and local efforts to control bleeding in ITP may also be required. Failure of autoimmune cytopenia to respond to conventional treatment is considered an indication for anti-CLL therapy.
Given the concerns about therapy-triggered AIHA, there has been recent interest in the most appropriate treatment for patients with active CLL and immune cytopenia or a positive DAT Monotherapy with fludarabine is not appropriate, either in terms of risk of AIHA or efficacy in treatment of CLL. The studiesquoted in this article suggest that treatment with FC with or without rituximab does not provoke an excess of AIHA sompared to previous treatments, and that patients with a previous history of AIHA or a positive DAT might be safely treated with such regimens. Indeed, optimal treatment of CLL may be the most efficient way to treat associated cytopenias. However, patients with active AIHA or ITP are still excluded from clinical trials, and given ongoing concerns about using fludarabine in
this situation, alternative regimens which do not feature fludarabine such as R-CVP and R-CD have also been explored.
ITP in CLL is difficult to diagnose and its incidence may be underestimated. There is no specific test and thrombocytopenia in CLL is more commonly due to splenomegaly and bone marrow failure secondary to infiltration by disease. Thrombocytopenia in a patient with CLL can be considered immune mediated when there is a sudden profound fall in platelets (>50% fall to a platelet count <100 x 109/L) in the absence of splenomegaly, infection or chemotherapy and with plentiful megakaryocytes in the bone marrow. In advanced disease, anemia usually occurs before thrombocytopenia, so isolated thrombocytopenia is more likely to be immune in origin. However, ITP with a gradual rather than sudden decline in platelet count is seen more commonly in adults than classic acute ITP of childhood, and can provide particular diagnostic difficulties. Response of thrombocytopenia to steroids may be the diagnostic test.
Autoimmunity was associated with advanced clinical stage, high lymphocyte count and short lymphocyte doubling time. Among more modern prognostic factors, beta-2 M, CD38and ZAP-70 were associated with autoimmunity but too few patients had IGHV mutations or cytogenetics done to make a correlation with these. There were no significant differences between overall survivals of those with and without autoimmune phenomena.
Neither Binet nor Rai staging takes account of the effect of autoimmunity. Thus patients with ITP are automatically assigned to Rai stage 4 or Binet stage C. I have always though this nonsensical and Montserrat agrees with me. He differentiates between Binet stage C (immune) and C (infiltrative). They compared 19 patients with stage C (immune) with 54 patients with stage C (infiltrative) The groups were demographically similar except that the infiltrative group had higher beta-2M levels and more marrow infiltration. There was a major difference in survival between the two groups with the immune patients having an average survival of 7.4 years and the infiltrative patients having an average survival of 3.7 years.
The reason for this difference was the relative response to steroids with immune patients being downstaged to stage A in 84% of cases and the infiltrative patients being downstaged to stage A in only 16% of cases. The ITP cases did slightly better than the AIHA with 100% downstaged compared to 75%. The development of an autoimmune disease during the course of the CLL did not significantly affect prognosis, though for patients with early stage A average survival was 9 years compared to that of stage A patients who did not develop autoimmune phenomena who survived on average for 10 years. Median survival for stage A were 10.2 years, for stage B 5.6 years, stage C immune 7.4 years and stage C infiltrative 3.7 years.
Agreeing with what was found in LRFCLL4 the prevalence of AIHA after chlorambucil and after fludarabine was similar at 5% and 4% respectively.
The same group have also published a systematic review of the subject in Haematologica and I quote extensively from it.
Among the additional points they make are that the monoclonal B cell lymphocytosis (MBL) is markedly more common in patients with supposed idiopathic AIHA or ITP than in matched controls which emphasizes the importance of excluding CLL and other chronic lymphoproliferative diseases in patients with AIHA and ITP.
In the early 1990s we published our concern that treatment with purine analogs (particularly fludarabine) was associated with a higher frequency of autoimmune cytopenia (Myint H et al, Br J Haematol 1995;91:341-4) and several other authors agreed. This was thought to be related to prolonged suppression of CD4+CD25+FOXP3+ regulatory T cells (Tregs) which has been shown to lead to autoimmune disease, and Tregs are highly sensitive to fludarabine. The cases reported were mainly in patients who had been heavily pre-treated with purine analogs. As a result of these observations, there has been agreement that purine analogs should be avoided in
patients with a history of autoimmune cytopenia, particularly if related to purine-analog therapy.
More recent trials in patients treated with first line therapy have suggested that the risk for developing autoimmune cytopenia after purine analog exposure is not greater than with other agents though cases may be more severe. In the UK LRFCLL4 trial no differences were observed in the percentage of patients becoming DAT positive after therapy (14% chlorambucil, 13% fludarabine, and 10% fludarabine plus cyclophosphamide), but the incidence of AIHA was significantly lower in patients treated with fludarabine plus cyclophosphamide (5%) than in those allocated to receive chlorambucil (12%) or fludarabine alone (11%) (p<0.01). This suggests that the addition of cyclophosphamide to fludarabine might have a “protective” effect on the appearance of AIHA. An earlier smaller study from MDACC supports this low incidence of AIHA in patients treated with fludarabine, cyclophosphamide and rituximab. The most recent data come from the German CLL 8 trial of patients with CLL requiring treatment and without clinically apparent autoimmune cytopenia. When treated with fludarabine and cyclophosphamide with or without rituximab, the rate of AIHA was <1%. Taken together these results demonstrate that the risk of AIHA is not higher following regimes in which fludarabine and cyclophosphamide (with or without rituximab) are given together in comparison to the risk seen after older therapies for CLL.
Treatment of patients with CLL and autoimmune cytopenia is largely based on
expert opinion and depends on whether the patient’s CLL requires treatment at the same time. In those patients with immune cytopenia in the context of quiescent CLL, the treatment is the same as idiopathic AIHA initially with corticosteroids, and then in patients who fail to respond or relapse quickly, alternative immunosuppression such as ciclosporine, mycophenylate or azathioprine, or sometimes splenectomy. There are case reports of the use of combinations of rituximab with or without immunosuppression with good effect; alemtuzumab has also been successfully used. Intravenous immunoglobulin can be useful where a rapid response is needed though as a single agent it will not give lasting effects. The new thrombopoietin receptor agonists may be effective in CLL associated ITP as they are in primary ITP. Despite the fact that the problem is destruction rather tha failure to produce blood elements, supportive care should include blood product transfusion as clinically indicated. Folic acid in AIHA and local efforts to control bleeding in ITP may also be required. Failure of autoimmune cytopenia to respond to conventional treatment is considered an indication for anti-CLL therapy.
Given the concerns about therapy-triggered AIHA, there has been recent interest in the most appropriate treatment for patients with active CLL and immune cytopenia or a positive DAT Monotherapy with fludarabine is not appropriate, either in terms of risk of AIHA or efficacy in treatment of CLL. The studiesquoted in this article suggest that treatment with FC with or without rituximab does not provoke an excess of AIHA sompared to previous treatments, and that patients with a previous history of AIHA or a positive DAT might be safely treated with such regimens. Indeed, optimal treatment of CLL may be the most efficient way to treat associated cytopenias. However, patients with active AIHA or ITP are still excluded from clinical trials, and given ongoing concerns about using fludarabine in
this situation, alternative regimens which do not feature fludarabine such as R-CVP and R-CD have also been explored.
ITP in CLL is difficult to diagnose and its incidence may be underestimated. There is no specific test and thrombocytopenia in CLL is more commonly due to splenomegaly and bone marrow failure secondary to infiltration by disease. Thrombocytopenia in a patient with CLL can be considered immune mediated when there is a sudden profound fall in platelets (>50% fall to a platelet count <100 x 109/L) in the absence of splenomegaly, infection or chemotherapy and with plentiful megakaryocytes in the bone marrow. In advanced disease, anemia usually occurs before thrombocytopenia, so isolated thrombocytopenia is more likely to be immune in origin. However, ITP with a gradual rather than sudden decline in platelet count is seen more commonly in adults than classic acute ITP of childhood, and can provide particular diagnostic difficulties. Response of thrombocytopenia to steroids may be the diagnostic test.
Sunday, January 16, 2011
More on Stereotypy
ASH 2010 abstract 43 summarizes a collaboration between 16 different laboratories in which a total of 7596 patients with CLL who had had their V genes sequenced were compared, looking for evidence of stereotypy. They have assembled three times as many cases as ever published before (around a thousand of them came from my old lab). Stereotypy was found in 2308 (30.4%) cases. 218 sequences were placed in the V3-21 cluster, the first one to be recognized and the most common. The second most common with 184 sequences, was different in that it was not confined to a single V gene type. This is typical of an immune response; what is important is that the antibody combining site or B cell receptor (BCR) is configured to combine with an antigen.. This cluster utilizes different IGHV genes of Clan I (ie IGHV1-2, 1-3, 1-8, 1-18, 5-a, 7-4-1) but the same three amino acids (glutamine-tryptophan-leucine) at a vital point of the CDR3 (positions 108-110) which constitutes the BCR.
As more sequences have been studied, more stereotypes have been recognized. In some cases there are only two members of a cluster – but then there should be no cases with identical sequences for the antibody combining site unless something bizarre was going on, so even two with the same sequence is suspicious.
The question then has to be asked whether if enough cases were sequenced, would every CLL belong to one cluster of stereotypes or another. To that, the answer is no. As more cases are sequenced the rate of increase in stereotypes found diminishes and the authors think it won’t exceed more than 1 in 3 cases. Do stereotyped and non-stereotyped cases differ qualitatively? Probably not. Most stereotyped cases are unmutated and it will probably possible to recognize patterns of behaviour for these and even to devise targeted treatments. Most of the mutated subtypes are not stereotyped and most will not require targeted treatment.
As more sequences have been studied, more stereotypes have been recognized. In some cases there are only two members of a cluster – but then there should be no cases with identical sequences for the antibody combining site unless something bizarre was going on, so even two with the same sequence is suspicious.
The question then has to be asked whether if enough cases were sequenced, would every CLL belong to one cluster of stereotypes or another. To that, the answer is no. As more cases are sequenced the rate of increase in stereotypes found diminishes and the authors think it won’t exceed more than 1 in 3 cases. Do stereotyped and non-stereotyped cases differ qualitatively? Probably not. Most stereotyped cases are unmutated and it will probably possible to recognize patterns of behaviour for these and even to devise targeted treatments. Most of the mutated subtypes are not stereotyped and most will not require targeted treatment.
Subscribe to:
Posts (Atom)