Chronic lymphocytic leukemia (CLL) immunoglobulin repertoire is biased. Furthermore, subsets of closely homologous (“stereotyped”) complementarity-determining region 3 (CDR3) sequences were recently described in CLL patients. In the present study, we evaluated the frequency and characteristics of these homologous subsets in a cohort of 916 CLL patients. We report that 201 cases (21.9%) expressed IGHV genes which belonged to one of 48 different subsets of sequences with stereotyped heavy chain (H) CDR3, of which only ten have been reported previously. Within each stereotyped HCDR3 subset, the IG sequences might show the usage of identical or different IGHV genes. In the latter case, the IGHV genes most often belonged to the same IGHV subgroup or clan or carried homologous HCDR1. Each subset included up to 20 cases. A similar proportion of HCDR3 restriction (80/462 cases; 17.3%) was found among public-database CLL sequences; comparison to 6430 non-CLL public database IGHV-D-J sequences showed that this is a “CLL-related” feature. In our series, the chance of belonging to a subset was even (p<0.001) higher for unmutated IGHV sequences (35%); furthermore, it exceeded 30% in cases using selected IGHV genes (e.g., IGHV3-21/1-69/1-2/1-3/4-39/3-48). Database and literature searches revealed that 64/916 CLL cases belonging to seven different subsets displayed HCDR3 homology with various autoantibodies, including rheumatoid factors and anti-cardiolipin antibodies. In our series, CLL cases with selected stereotyped IGs were also found to share unique biological and clinical features. In particular, cases expressing stereotyped IGHV4-34/IGKV2-30 B cell receptors (BCRs) were of significantly younger age and followed a strikingly indolent disease, whereas those expressing, IGHV3-21/IGLV3-21 BCRs experienced an aggressive disease, regardless of IGHV mutation status. Furthermore, among patients expressing unmutated IGHV1-69 genes, we identified a subset (IGHV1-69/IGHD3-10/IGHJ6) with higher overall survival (OS) compared to another subset (IGHV1-69/IGHD2-2/IGHJ6) with significantly shorter OS (log Rank test=0.05). In conclusion, the unique, “CLL-biased” molecular features of stereotyped HCDR3 sequences suggest a role for antigen not only in driving the cell of origin but also in determining the clinical features and outcome for at least some CLL patients. Considering the clinical-biological associations with certain subsets, it is conceivable that future therapeutic decisions should be based not only on mutational status of IGHV genes but also on individual HCDR3 characteristics.

Patients with chronic lymphocytic leukemia (CLL) may be more susceptible to Coronavirus disease 2019 (COVID-19) due to age, disease, and treatment-related immunosuppression. We aimed to assess risk factors of outcome and elucidate the impact of CLL-directed treatments on the course of COVID-19. We conducted a retrospective, international study, collectively including 941 patients with CLL and confirmed COVID-19. Data from the beginning of the pandemic until March 16, 2021, were collected from 91 centers. The risk factors of case fatality rate (CFR), disease severity, and overall survival (OS) were investigated. OS analysis was restricted to patients with severe COVID-19 (definition: hospitalization with need of oxygen or admission into an intensive care unit). CFR in patients with severe COVID-19 was 38.4%. OS was inferior for patients in all treatment categories compared to untreated (p < 0.001). Untreated patients had a lower risk of death (HR = 0.54, 95% CI:0.41–0.72). The risk of death was higher for older patients and those suffering from cardiac failure (HR = 1.03, 95% CI:1.02–1.04; HR = 1.79, 95% CI:1.04–3.07, respectively). Age, CLL-directed treatment, and cardiac failure were significant risk factors of OS. Untreated patients had a better chance of survival than those on treatment or recently treated.

Immunoglobulin gene sequence analysis is widely utilized for prognostication in chronic lymphocytic leukemia (CLL) and the definition of standardized procedures has allowed reliable and reproducible results. Occasionally, a straightforward interpretation of the sequences is not possible because of the so-called 'problematic sequences' that do not fit the 'classic' interpretation and pose scientific questions at the cross-road between hematology and immunology. Thanks to a dedicated effort within the European Research Initiative on CLL (ERIC), we have now the possibility to present such cases, offer a scientific explanation and propose recommendations in terms of prognostication.

The somatic hypermutation (SHM) status of the clonotypic immunoglobulin heavy variable (IGHV) gene is a critical biomarker for assessing the prognosis of patients with chronic lymphocytic leukemia (CLL). Importantly, independent studies have documented that IGHV SHM status is also a predictor of responses to therapy, including both chemoimmunotherapy (CIT) and novel, targeted agents. Moreover, immunogenetic analysis in CLL has revealed that different patients may express (quasi)identical, stereotyped B cell receptor immunoglobulin (BcR IG) and are classified into subsets based on this common feature. Patients in certain stereotyped subsets display consistent biology, clinical presentation, and outcome that are distinct from other patients, even with concordant IGHV gene SHM status. All of the above highlights the relevance of immunogenetic analysis in CLL, which is considered a cornerstone for accurate risk stratification and clinical decision making. Recommendations for robust immunogenetic analysis exist thanks to dedicated efforts by ERIC, the European Research Initiative on CLL, covering all test phases, from the pre-analytical and analytical to the post-analytical, pertaining to the analysis, interpretation, and reporting of the findings. That said, these recommendations apply to Sanger sequencing, which is increasingly being superseded by next generation sequencing (NGS), further underscoring the need for an update. Here, we present an overview of the clinical utility of immunogenetics in CLL and update our analytical recommendations with the aim to assist in the refined management of patients with CLL.