Chronic lymphocytic leukemia (CLL) is characterized by the clonal expansion of CD5(+)CD23(+) B cells in blood, marrow, and second lymphoid tissues. Gene-expression profiling and phenotypic studies suggest that CLL is probably derived from CD5(+) B cells similar to those found in the blood of healthy adults. Next-generation sequencing has revealed recurrent genetic lesions that are implicated in CLL pathogenesis and/or disease progression. The biology of CLL is entwined with its microenvironment, in which accessory cells can promote leukemia cell growth and/or survival. Recently, much attention has been focused on the CLL B cell receptor (BCR) and on chemokine receptors that enable CLL cells to home to lymphoid tissues and to establish the leukemia microenvironment. Agents that can interfere with BCR signaling or chemokine-receptor signaling, or that target surface antigens selectively expressed on CLL cells, promise to have significant therapeutic benefit in patients with this disease.

Despite a prevailing view that advances in cancer therapy will come through selective targeting of enzymes encoded by mutated oncogenes responsible for the neoplastic phenotype, recent advances in the treatment of patients with chronic lymphocytic leukemia (CLL) have instead exploited knowledge of its biology. Indeed, CLL cells depend on interactions with cells and soluble factors present in the tumor microenvironment for proliferation and survival. B-cell receptor signaling and chemokine-receptor signaling play prominent roles. Elucidation of these signaling pathways has defined physiologic targets for drugs, such as ibrutinib, which inhibit Bruton tyrosine kinase and are therapeutically effective. The characteristic high-level expression of BCL2 in CLL that can enhance leukemia-cell survival has now become an Achilles heel targeted by clinically effective drugs such as venetoclax. Here we discuss advances in such targeted therapy and highlight other disease attributes, such as the distinctive expression of ROR1, which may be targeted for clinical benefit, alone or in combination with other targeted therapies.

[This corrects the article DOI: 10.1155/2017/5295286.].

Wnt5a is involved in activating several noncanonical Wnt signaling pathways, which can inhibit or activate canonical Wnt/β-catenin signaling pathway in a receptor context-dependent manner. Wnt5a signaling is critical for regulating normal developmental processes, including stem cell self-renewal, proliferation, differentiation, migration, adhesion, and polarity. Moreover, the aberrant activation or inhibition of Wnt5a signaling is emerging as an important event in cancer progression, exerting both oncogenic and tumor suppressive effects. Recent studies show the involvement of Wnt5a signaling in regulating normal and cancer stem cell self-renewal, cancer cell proliferation, migration, and invasion. In this article, we review recent findings regarding the molecular mechanisms and roles of Wnt5a signaling in stem cells in embryogenesis and in the normal or neoplastic breast or ovary, highlighting that Wnt5a may have different effects on target cells depending on the surface receptors expressed by the target cell.

Hodgkin lymphoma variant of Richter’s transformation (HvRT) is a rare complication for patients with chronic lymphocytic leukemia (CLL), with an overall poor prognosis. We present the first known case series of patients with HvRT treated with the combination of brentuximab vedotin, doxorubicin, vinblastine, and dacarbazine (A + AVD). In our series of 4 patients, two patients treated with A + AVD for HvRT had durable remissions of 40 and 42 months, while two patients had disease progression and ultimately died. Continued investigation into the optimal management for patients with HvRT is still needed.

Chimeric antigen receptor T cells (CAR T cells) have resulted in dramatic treatment responses for patients with hematologic malignancies, resulting in improved survival for patients with intractable disease. The first patient treated with CD19 directed CAR T cell therapy had chronic lymphocytic leukemia (CLL) and achieved a complete remission. Subsequent clinical trials have focused largely on patients with other B-cell hematologic malignancies, owing to the fact that CAR T cell therapy for patients with CLL has met with challenges. More recent clinical trials have demonstrated CAR T cell therapy can be well tolerated and effective for patients with CLL, making it a potential treatment option for patients with this disease. In this article we review the background on CAR T cells for the treatment of patients with CLL, focusing on the unique obstacles that patients with CLL present for the development of adoptive T cell therapy, and the novel approaches currently under development to overcome these hurdles.

Signaling pathways such as CXCR4/CXCL12 can regulate migration and trafficking of chronic lymphocytic leukemia (CLL) cells from the blood to lymphoid tissues, where they receive growth/survival signals from accessory cells within the lymphoid-tissue microenvironment. This requires extravasation of CLL cells that is contingent upon the leukemia-cells' ability to degrade the extracellular matrix via matrix metallopeptidases (MMP), such as MMP9, which is a type IV collagenase. We find that CLL cells that express high-levels of the receptor tyrosine kinase-like orphan receptor 1 (ROR1 Hi) express high-levels of MMP9 relative to that of CLL cells with low-level expression of ROR1 (ROR1 Low). However, short-term culture of ROR1 Hi CLL cells in serum-free medium causes attenuation in MMP9 expression, which can be counteracted by addition of exogenous Wnt5a, which is a non-canonical Wnt factor and ligand for ROR1 that is expressed at significantly higher levels in the plasma of patients with CLL than that of healthy adults. We found that stimulation of serum-starved CLL cells with Wnt5a enhance expression and release of MMP9 into the culture media. Such effects of Wnt5a could be inhibited by zilovertamab (also known as UC-961, or previously known as cirmtuzumab; 20 µg/ml), a humanized mAb highly-specific for ROR1 that can block CLL-cell ROR1-signaling (Choi et al., Cell Stem Cell, 22:951, 2018), indicating that MMP9 may be regulated in part by Wnt5a-induced ROR1-signaling. To test this hypothesis, we used the CLL-cell derived cell line, MEC1, which expresses endogenous Wnt5a, but lacks expression of ROR1, and MEC1-Wnt5a -/- cells in which we deleted functional genes encoding Wnt5a via CRISPR-Cas9. Stable transfection of MEC1 or MEC1-Wnt5a -/- cells with an expression vector encoding ROR1 generated MEC1-ROR1 and MEC1-Wnt5a -/--ROR1 that each expressed high-levels of surface ROR1, as assessed via flow cytometry. We found that MEC1-ROR1 cells had significantly higher expression levels of MMP9 and greater capacity to invade Boyden -Chamber Matrigel than MEC1 cells or MEC1-Wnt5a -/- or MEC1-Wnt5a -/--ROR1 cells. Noting the gene encoding MMP9 possesses a promoter that may be induced by activation of NF-kB, we examined for NF-kB-p65 and found MEC1-ROR1 cells had significantly higher activation of NF-kB-p65 than MEC1 cells or MEC1-Wnt5a -/- or MEC1-Wnt5a -/--ROR1 cells. Similarly, serum-starved ROR1 + CLL cells also expressed activated NF-kB-p65 when treated with Wnt5a, an effect that also could be inhibited by zilovertamab. Consistent with this model, we found that an inhibitor (CAS 545380-34-5, 20 nM) of NF-kB also could block Wnt5a induced expression of MMP9 in ROR1 + CLL cells. We examined whether such effects also could be observed for zanubrutinib, a covalent inhibitor of BTK that recently was approved for treatment of patients with CLL. We found that zanubrutinib (0.5 µM) could not inhibit Wnt5a-induced activation of NF-kB-p65 or expression of MMP9 in ROR1 + CLL cells. We also use the Boyden -Chamber Matrigel Invasion Assay to study the response to CXCL12 without or with Wnt5a of primary CLL cells in vitro. We found that CLL could invade the Boyden -Chamber Matrigel in response to CXCL12 and the extent of such invasion was enhanced by Wnt5a. We also found that zanubrutinib (0.5 µM) could inhibit the CXCL12 induced capacity of CLL cells to invade Matrigel, however, this drug was unable to block Wnt5a enhanced invasiveness of CLL cells. Zilovertamab could inhibit Wnt5a enhanced invasiveness of CLL cells. Moreover, the combined treatment of zanubrutinib and zilovertamab had additive activity in inhibiting Matrigel invasiveness by CLL cells, supporting potential evaluation of the combined use of zilovertamab and zanubrutinib in the treatment of patients with CLL.

Background: For patients with Richter's Syndrome (RS), a durable response is rarely achieved with standard therapies. Significant efforts have focused on the development of novel treatments with reduced toxicity. We describe our experience using the novel combination of obinutuzumab, high-dose methylprednisolone (HDMP) and lenalidomide (len) in patients with RS. Patients and Methods: Eligible patients included adults with biopsy-proven RS. Patients received obinutuzumab 1000 mg × 8 doses. All patients received HDMP 1000 mg/m² on days 1-5 of cycles 1-4. Patients were administered len PO daily, starting at a dose of 5 mg. Starting on C2D1, the dose increased every 2 weeks in 5 mg increments to a maximum of 25 mg PO daily. Results: Seven patients were treated. The median dose of len was 10 mg and the median number of cycles of treatment completed was 2. The most common grade 3/4 adverse events were neutropenia (29%) and pulmonary embolism (29%). The overall response rate for the entire cohort was 43% (95% CI, 10-82%). All patients who achieved a response underwent consolidative autologous or allogeneic stem cell transplant and remain in remission to date. Conclusions: The combination of obinutuzumab, HDMP, and len is a well-tolerated, outpatient regimen that could serve as a bridge to transplantation, or as palliation for transplant-ineligible patients with RS.

Background: Venetoclax (Ven) is a BCL-2 inhibitor that produces deep responses with high rates of undetectable minimal residual disease (uMRD) for patients (pts) with chronic lymphocytic leukemia (CLL) (Al-Sawaf et al. 2020). Currently, ven is FDA approved as either monotherapy (mono) or in combination (combo) with rituximab (R) In patients with relapsed/refractory (R/R) CLL (Seymour et al. 2018). However, the optimal ven based treatment (tx) for pts with R/R CLL either as mono, or in combo with anti-CD20 monoclonal antibody (mab), or bruton tyrosine kinase inhibitor (BTKi) is uncertain. We performed a single institution retrospective analysis of pts with R/R CLL treated with ven based regimens evaluating efficacy of different ven based txs. Methods: 98 pts with R/R CLL treated between the years of 2012 and 2023 were evaluated. Ven based treatment consisted of ven mono or in combo with R, obinutuzumab (G), or ibrutinib (BTKi) with standard ven dose ramp up to a maximum dose of 400mg daily. R and G were administered per FDA standard dosing. Ibrutinib was administered as 420mg daily, as either fixed or continuous duration tx. Response assessment was performed using iwCLL criteria. Minimal residual disease (MRD) was assessed by multi-parametric peripheral blood flow cytometry with a sensitivity of 10 -4. Time-to-event analyses were performed with the Kaplan-Meier method, with log-rank test used to assess statistically significant differences between variables. Hazard ratios (HR) were calculated by use of Cox proportional modelling. Results: The pts had a median age of 68 years (range; 46-89). Rai stage at time of tx initiation with ven: I 14.2%; II 36.3%; III 8.8%; Stage IV 40.7%. The median number of previous txs was 4 (range; 1-14). Pts harbored the following cytogenetic abnormalities: del(13q) 50.5%; del(11q) 18.5%; trisomy 12 15.5%; normal 15.5%; del(17p)/TP53 mutation 24.7%; and complex in 33%. Seventy percent of pts harbored an unmutated immunoglobulin heavy chain. 25.5% of pts had genomic complexity, with ≥ 5 gene mutations. 43.9% of pts were treated with ven mono; 19.4% were treated with venR; 25.5% of pts were treated with venG; and 11.2% of pts were treated with ven + BTKi. The median number of months of ven based tx was 16.3 (range; 0.9-118.6). 14.3% of pts currently remain on ven. 60.8% of pts had progression after ven based tx; with 62.2% requiring additional tx. 15.3% of pts developed Richter's Transformation. The best overall response for the cohort was: CR 67%; PR 24.5%; SD 1.1%; and PD 7.4%. The best MRD response for the whole cohort was uMRD 76.8%; low MRD 19.5; and high MRD 3.6%. uMRD as best MRD response occurred in 66.7% of ven mono; 82.4% of venR; 86.4% of venG; and 70% of ven + BTKi treated pts. With a median follow-up of 52 months (mo), the median progression-free survival (PFS) for the whole cohort was 67.8 mo. Ven combo had superior PFS to ven mono; median PFS 76.6 vs 58.9 mo (p = 0.04; HR 0.5037; 95% CI 0.2583 - 0.9635). Among the combination treatment approaches, there was a trend for improved PFS for venG compared to ven mono; median PFS not reached (NR) vs 58.9 mo (p = 0.08; HR 0.4385; 95% CI 0.1608 - 1.0240). Similarly, there was also a trend to improved PFS for ven + BTKi compared to ven mono; median PFS NR vs 58.9 mo (p = 0.07; HR 0.2895; 95% CI 0.0462 - 0.9950). Both the presence of del17p/TP53 mutation; and the presence of MRD (+MRD) 12 months after stopping ven based tx were associated with inferior PFS. The median PFS for pts without del17p/TP53 mutation vs with del17p/TP53 mutation was 118 vs 39.7 mo (p < 0.0001; HR 0.2242; 95% CI 0.0533 - 0.8366). Median PFS for pts with uMRD vs +MRD 12 months after ven was NR vs 42.8 mo (p = 0.0001; HR 0.0689; 95% CI 0.0037 - 0.3810). Conclusions : In a high-risk population of pts with R/R CLL, we found that ven based tx leads to durable remissions, with high rates of uMRD. Combo approaches with the addition of either an anti-CD20mab or BTKi led to improved PFS. While venR is the current FDA approved combo regimen for pts with R/R CLL, we found that there was a trend for improved PFS with either venG or ven + BTKi compared to ven mono. Both the presence of a del17p/TP53 mutation and the presence of MRD 12 months after stopping ven based tx significantly adversely affected PFS. However, pts who maintained uMRD 12 months after completing ven, had exceptionally durable long-term remission. This has possible implications for employing MRD adapted txs for pts with CLL.