1. FAMILIAL CHRONIC LYMPHOID DISORDERS Dr Estella Matutes Murcia, November 2006

2. 1887+19531884+19961894+19681895+19841897+19281900+19801903+1968 190719091912+1912 19151917+198019251919+1994 CLL

3. Epidemiological studies (cohort and case control) Vertical transmission and “anticipation” Significantly higher incidence of asymptomatic MBL Evidence for a genetic predisposition

4. The main evidence derives from: Cohort studies – risk 2.4-5.7 (Gunz, 1975; Giles, 1984; Goldgar, 1994) Case control studies – risk 2.3-4.3 (Linet, 1989; Pattern, 1991; Cartwright, 1987) Relatives of CLL patients have a six-fold increase in risk Familial risks of CLL

5. Videbaek’s pedigree 14 revisited (1947-2004)* (1947-2004)* Original family = 55 members Current pedigree = 221 descendents 10 diagnosed with CLL; 1 T-cell lymphoma 18 non-haematological cancers (5 breast) Relative risk for B-cell LPD = 7.9 (p < 0.001) This family provides further support for an inherited predisposition to CLL *Jønsson, Houlston, Catovsky et al (Leukemia, 19, 1025, 2005)

6. CaseFirst-degree relative with Familial RR (95%CI) (95%CI) CLLCLL7.5 (3.6-15.6) (3.6-15.6) CLLNHL1.5 (1.0-2.2) (1.0-2.2) CLLHL2.4 (1.1-5.1) (1.1-5.1) NHLNHL2.9 (1.0-8.5) (1.0-8.5) HLCLL2.1 (1.2-3.8) (1.2-3.8) Goldin et al., (2004) Blood 104:1850; Goldin et al., (2004) Cancer100; 1902 Goldin et al., (2004) Cancer Epid Bio Prev 13:1415 Familial risks of B-cell LPDs Evidence of pleiotropism

7. Family 037 Family 039 Family 005 Family 094

8. Anticipation in Familial CLL Yuille (1998) Goldin (1999) Wiernik (2001) Yuille (1998) Goldin (1999) Wiernik (2001) # families 10 13 10 # families 10 13 10 Mean age 74 68 72 Mean age 74 68 72 Mean age 52 51 51 Mean age 52 51 51 A large epidemiological study showed no evidence of anticipation in CLL & NHL: Daugherty et al,Cancer Epidemiol Biomarkers Prev. (2005) 14:1245

9. Monoclonal B-cell lymphocytosis (MBL) Diagnostic criteria recently reportedDiagnostic criteria recently reported (Marti et al, BJH 130:325, 2005) (Marti et al, BJH 130:325, 2005) Flow cytometry can detect ‘sub-clinical’ MBL in normal relatives of F-CLL and provides the possibility of extending the number of affecteds in linkage familiesFlow cytometry can detect ‘sub-clinical’ MBL in normal relatives of F-CLL and provides the possibility of extending the number of affecteds in linkage families MBL is found in 3.5% of normal adults by flow cytometryMBL is found in 3.5% of normal adults by flow cytometry (Rawstron et al, Blood 100:2289 & 100:635, 2002)

10. Incidence of MBL in Familial CLL Rawstrom et al (2002) 0% 0% 5% 5% 10% 15% 20% 25% <5050-5960-6970+FamilialControl years CD79b CD20 CD5

11. Age group General population Normal relatives from CLL families Relative Risk (95% C.I.) P-value Fishers exact test All ages 33/1242 (2.7%) 8/65 (12.3%) 3.9 (2.0 - 7.6) 0.001 16 - 40 1/365 (0.3%) 2/17 (11.8%) 16.9 (6.6 – 43.3) 0.005 40 - 60 10/457 (2.1%) 3/30 (10.0%) 4.1 (1.4 - 11.9) 0.037 60 - 90 22/420 (5.2%) 3/18 (16.7%) 3.5 (1.1 - 11.2) 0.067 MBL in F-CLL: young adults show the highest relative risk* *Tute, Yuille, Rawstron et al (2006) Leukemia 20:728

12. Familial CLL No differences from sporadic CLL in: Age, M:F ratio, incidence of Zap-70+ *Age, M:F ratio, incidence of Zap-70+ * IgVH usage and frequency of somatic mutation *IgVH usage and frequency of somatic mutation * ATM mutationsATM mutations Frequency of 6q21, 11q23, 13q14 and p53 deletions or trisomy 12Frequency of 6q21, 11q23, 13q14 and p53 deletions or trisomy 12 * Rassenti et al (2003) Blood 102:670a A study from the USA CLL Research Consortium

13. Strategies for identifying CLL predisposition genes 1: Linkage analysis of families to identify moderate-high penetrance alleles 2: Association studies of SNPs to identify low penetrance alleles 3: Screening familial cases for mutations in candidate genes

14. UK Familial CLL study Families collected to date 456 families documented (339 with 2 or more CLL cases)456 families documented (339 with 2 or more CLL cases) 401 of these we have at least 1 sample from the family401 of these we have at least 1 sample from the family 87 families have at least 1 case of CLL and 1 or more cases of LPD87 families have at least 1 case of CLL and 1 or more cases of LPD 33 families with 2 or more NHL/HL cases33 families with 2 or more NHL/HL cases

15. Linkage analysis in Familial CLL A high density single nucleotide polymorphism (SNP) - based genomewide linkage search was undertaken on 115 CLL families by our group using the Affymetrix Mapping 10K Array (11,555 markers)

16. Sample set used for SNP linkage analysis:Sample set used for SNP linkage analysis: 115 CLL/CLL-LPD families 115 CLL/CLL-LPD families 80 families with 2 affecteds 80 families with 2 affecteds 28 families with 3 affecteds 5 families with 4 affecteds 5 families with 4 affecteds 2 families with 5+ affecteds 2 families with 5+ affecteds Median age at diagnosis of CLL 61 yearsMedian age at diagnosis of CLL 61 years Linkage analysis in Familial CLL Sellick et al, Am J Hum Genetics (2005) 77:420-9

17. Familial CLL – linkage analysis Chromosomal Region Non- parametric Dominant model Recessive model Max NPL p Max HLOD α α 5q22-232.010.0221.020.291.350.20 6p222.250.0121.050.291.490.22 10q252.120.0170.940.281.280.22 11p113.140.00081.850.412.780.32 14q322.030.0211.180.340.910.19 Sellick et al, Am J Hum Genet, 77, 420 (2005)

18. Linkage analysis: future work Genotyping an additional 40 familiesGenotyping an additional 40 families Screening family members for MBL statusScreening family members for MBL status Currently undertaking mutation screening of genes mapping to linked regions e.g. the 11p11 locus: SPI1 and MADDCurrently undertaking mutation screening of genes mapping to linked regions e.g. the 11p11 locus: SPI1 and MADD

19. Pathogenesis of Familial CLL High-penetrance mutationsHigh-penetrance mutations [Genome-wide linkage analysis] OR Polygenic model of low penetrance allelesPolygenic model of low penetrance alleles [Association studies in ethnically matched cases and controls comparing the frequency of polymorphic genotypes]

20. SUMMARY Studies are preliminary and “on going” but this requires international collaboration, economical imput, application of new technologies and patient’s and relatives “willing”Studies are preliminary and “on going” but this requires international collaboration, economical imput, application of new technologies and patient’s and relatives “willing” At present it is premature to set up a program of counselling as a predisposing gene(s) has not been identified although patients and relatives are aware of the inherited susceptibilityAt present it is premature to set up a program of counselling as a predisposing gene(s) has not been identified although patients and relatives are aware of the inherited susceptibility