The absence of mutations in the IgV genes, together with the presence of ZAP-70 and CD38, are the most reliable negative prognostic markers for chronic lymphocytic leukemia (CLL) patients. Several lines of evidence indicate that CD38 may be not only a diagnostic marker but also a key element in the pathogenetic network in CLL. First, CD38 is a receptor that induces proliferation and increases survival of CLL cells. Second, CD38 signals start upon interaction with the CD31 ligand expressed by stromal and nurselike cells. Third, CD38/CD31 contacts upregulate CD100, a semaphorin involved in sustaining CLL growth. Fourth, evidence that nurselike cells express high levels of CD31 and plexin-B1, the high-affinity ligand for CD100, offers indirect confirmation for this model of receptor cross-talk.
IntroductionChronic lymphocytic leukemia (CLL) is defined as a proliferation of B lymphocytes that express surface CD19 or CD20, CD5, CD23, and low levels of immunoglobulin (Ig), CD79, and CD22. 1 CLL is a heterogeneous disease: some patients experience a slowly progressive clinical course but most will eventually enter an advanced phase and require recurrent treatment. A significant number of CLL patients show an active form of the disease from the early stages, characterized by refractoriness to treatment, infectious and autoimmune complications, and a relatively rapid fatal outcome. 2 Unlike most other B-lymphoproliferative disorders, little is known about the pathogenesis of CLL. The main challenge lies in determining the cellular origin of the disease and, consequently, the degree of immunocompetence of CLL cells. However, no common key cytogenetic abnormalities have been identified that might otherwise offer pathogenetic clues. 3,4 Heterogeneity in the clinical behavior of CLL makes it difficult to identify which patients will benefit most from earlier or more aggressive treatment and those who should be treated with more conservative and less toxic approaches. Clinical researchers have long sought to identify a marker (or markers) for use as a prognostic tool. 5 The earliest staging systems for CLL relied on disease burden parameters. The Rai and Binet systems were the first to determine a correlation between survival and different measures of disease burden. 6,7 Histologic patterns of bone marrow (BM) involvement have also been used as a valid adjunct. 8 However, these classifications fail to distinguish patients who will eventually progress to an aggressive form of the disease from those who have a more stable form. Likewise, lymphocyte doubling time (LDT), which is calculated by determining the number of months it takes the absolute lymphocyte count to double, shares the same drawback. Although it offers meaningful evidence about disease kinetics 9 and is therefore widely used as a measure of disease aggressiveness, treatment decisions based solely on LDT may come too late for patients who eventually prove to have aggressive forms of the disease.During the past 15 years, several soluble molecules have been used a...