{"id":1033,"date":"2017-04-07T21:19:53","date_gmt":"2017-04-07T19:19:53","guid":{"rendered":"http:\/\/www.newslab.sk\/2017\/04\/07\/molekulova-analyza-prognosticky-vyznamnych-markerov-chronickej-lymfocytovej-leukemie\/"},"modified":"2017-10-03T09:25:16","modified_gmt":"2017-10-03T07:25:16","slug":"molecular-analysis-of-prognostically-significant-markers-of-chronic-lymphocytic-leukemia","status":"publish","type":"post","link":"https:\/\/www.newslab.sk\/en\/molecular-analysis-of-prognostically-significant-markers-of-chronic-lymphocytic-leukemia\/","title":{"rendered":"Molecular analysis of prognostically significant markers of chronic lymphocytic leukemia"},"content":{"rendered":"<pre><span style=\"color: #ff0000;\"><strong>*All tables, charts, graphs and pictures that are featured in this article can be found in the .pdf\u00a0\r\nattachment at the end of the paper.<\/strong><\/span><\/pre>\n<p>&nbsp;<\/p>\n<p><strong>\u00davod<\/strong><\/p>\n<p>Chronick\u00e1 \u00a0lymfocytov\u00e1 leuk\u00e9mia (CLL) je lymfoproliferat\u00edvne ochorenie charakterizovan\u00e9 akumul\u00e1ciou zrel\u00fdch monoklon\u00e1lnych B-lymfocytov \u00a0v perif\u00e9rnej krvi, kostnej dreni a \u00a0lymfatick\u00fdch \u00a0tkaniv\u00e1ch. \u00a0Je naj\u010dastej\u0161ou \u00a0leuk\u00e9miou dospel\u00fdch z\u00e1padn\u00e9ho sveta a postihuje najm\u00e4 \u00a0pacientov star\u0161\u00edch \u00a0ako 50 rokov. Pri CLL bola pozorovan\u00e1 zna\u010dn\u00e1 diverzita v morfol\u00f3gii, imunofenotype, cytogenetike a molekulov\u00fdch znakoch buniek, \u00a0ktor\u00e1 \u00a0vy\u00fas\u0165uje \u00a0do\u00a0 variabiln\u00e9ho klinick\u00e9ho priebehu a odpovede na \u00a0lie\u010dbu. Pribli\u017ene jedna \u00a0tretina pacientov pre\u017e\u00edva dlh\u0161ie ako 20 rokov po diagnostikovan\u00ed ochorenia \u00a0a nevy\u017eaduje terapiu, u niektor\u00fdch pacientov, naopak, ochorenie rap\u00eddne progreduje a je spojen\u00e9 s \u010fal\u0161\u00edmi komplik\u00e1ciami(1).<\/p>\n<p>Vzh\u013eadom \u00a0na \u00a0klinick\u00fa \u00a0heterogenitu \u00a0CLL bolo \u00a0potrebn\u00e9 n\u00e1js\u0165 vhodn\u00e9 \u00a0parametre na stratifik\u00e1ciu pacientov do prognostick\u00fdch skup\u00edn \u00a0s cie\u013eom \u00a0u\u013eah\u010di\u0165 v\u00fdber vhodnej lie\u010debnej strat\u00e9gie od \u00a0\u201ewatch-and-wait\u201c \u00a0po \u00a0alog\u00e9nnu transplant\u00e1ciu kme\u0148ov\u00fdch buniek. V s\u00fa\u010dasnosti je ur\u010denie rizikov\u00e9ho profilu CLL zalo\u017een\u00e9 na identifik\u00e1cii tzv. nov\u00fdch prognostick\u00fdch faktorov, medzi \u00a0ktor\u00e9 \u00a0patria \u00a0aj chromoz\u00f3mov\u00e9 aber\u00e1cie a muta\u010dn\u00fd \u00a0stav \u00a0g\u00e9nu \u00a0<em>IGHV<\/em>. Tieto\u00a0 faktory \u00a0s\u00fa \u00a0nez\u00e1visl\u00e9 od klinick\u00e9ho \u00a0\u0161t\u00e1dia a umo\u017e\u0148uj\u00fa predikova\u0165 \u00a0progn\u00f3zu ochorenia u\u017e v \u010dase diagn\u00f3zy. Znalos\u0165 genotypu CLL buniek \u00a0je z\u00e1kladom individu\u00e1lneho pr\u00edstupu ku ka\u017ed\u00e9mu pacientovi a ovplyv\u0148uje terapeutick\u00fd postup(2).<\/p>\n<p>&nbsp;<\/p>\n<p><strong><em>Chromoz\u00f3mov\u00e9 aber<\/em><\/strong><strong><em>\u00e1cie<\/em><\/strong><\/p>\n<p>Napriek \u00a0relat\u00edvnej\u00a0 \u00a0gen\u00f3movej \u00a0stabilite \u00a0CLL buniek\u00a0 \u00a0sa a\u017e \u00a0u 80 % pacientov vyskytuj\u00fa \u00a0chromoz\u00f3mov\u00e9 aber\u00e1cie(3).<\/p>\n<p>Naj\u010dastej\u0161\u00edmi chromoz\u00f3mov\u00fdmi abnormalitami s prognostick\u00fdm \u00a0charakterom s\u00fa \u00a0parci\u00e1lne del\u00e9cie 13q14, 11q22-23 a 17p13, \u00a0menej \u00a0frekventovan\u00e1 je triz\u00f3mia chromoz\u00f3mu 12. Del\u00e9cia \u00a013q14 \u00a0predstavuje naj\u010dastej\u0161iu cytogenetick\u00fa aber\u00e1ciu pri CLL. Samostatn\u00e1 del13q14 je charakterizovan\u00e1 ben\u00edgnym priebehom ochorenia, v pr\u00edpade kombin\u00e1cie s inou aber\u00e1ciou sa jej pozit\u00edvny\u00a0 prognostick\u00fd v\u00fdznam \u00a0str\u00e1ca. Triz\u00f3mia 12 je naj\u010dastej\u0161ou CLL aber\u00e1ciou, pri ktorej doch\u00e1dza k amplifik\u00e1cii genetick\u00e9ho materi\u00e1lu. V niektor\u00fdch pr\u00edpadoch ide len o duplik\u00e1ciu \u00a0segmentu medzi 12q13 \u00a0a 12q21.2(4). Del\u00e9cia \u00a011q22-23 je asociovan\u00e1 s hor\u0161ou progn\u00f3zou, preto\u017ee nar\u00fa\u0161a expresiu g\u00e9nu <em>ATM <\/em>(ataxia teleangiectasia mutated), sp\u00f4sobuje deregul\u00e1ciu bunkov\u00e9ho cyklu a vedie k akumul\u00e1cii mal\u00edgnych B-lymfocytov n\u00e1chyln\u00fdch na vznik pr\u00eddavn\u00fdch genetick\u00fdch aber\u00e1ci\u00ed. Del\u00e9cia 17p13 \u00a0je asociovan\u00e1 s ve\u013emi agres\u00edvnym priebehom ochorenia a so slabou odpove\u010fou na terapiu v d\u00f4sledku deregul\u00e1cie expresie <em>TP53<\/em>(3). Pr\u00edtomnos\u0165 aber\u00e1ci\u00ed <em>TP53 <\/em>zara\u010fuje pacienta do \u201eultra high-risk\u201c CLL skupiny. Zriedka sa vyskytuje samostatne, zvy\u010dajne je asociovan\u00e1 s \u010fal\u0161\u00edmi aber\u00e1ciami(5).<\/p>\n<p>&nbsp;<\/p>\n<p><strong><em>Somatick\u00e9 <\/em><\/strong><strong><em>mut\u00e1cie \u00a0IGHV<\/em><\/strong><\/p>\n<p>Nez\u00e1visl\u00fdm prognosticky v\u00fdznamn\u00fdm markerom CLL je stanovenie muta\u010dn\u00e9ho statusu <em>IGHV, <\/em>ktor\u00fd k\u00f3duje variabiln\u00fa oblas\u0165 \u0165a\u017ek\u00e9ho re\u0165azca imunoglobul\u00ednov. V roku 1999 Damle a kolekt\u00edv uverejnili publik\u00e1ciu, kde vysvet\u013euj\u00fa heterogenitu, ktor\u00e1 bola v praxi pozorovan\u00e1 u pacientov s CLL. Pod\u013ea muta\u010dn\u00e9ho stavu \u00a0<em>IGHV <\/em>rozdelili pacientov na dve skupiny. Pacienti s rozdielom v nukleotidovej sekvencii oproti \u00a0z\u00e1rodo\u010dnej l\u00ednii &gt; 2 %, t. j. mutovan\u00fdm stavom <em>IGHV <\/em>g\u00e9nu (<em>M-IGHV<\/em>), s\u00fa\u00a0charakteristick\u00ed miernej\u0161\u00edm priebehom ochorenia. Tento stav je pova\u017eovan\u00fd za prognosticky priazniv\u00fd a definuje \u00a0potenci\u00e1lne \u00a0indolentn\u00fa formu \u00a0CLL. U pacientov s rozdielom oproti z\u00e1rodo\u010dnej l\u00ednii \u2264 2 %, t. j. nemutovan\u00fdm stavom <em>IGHV <\/em>g\u00e9nu (<em>UM-IGHV<\/em>), tento stav koreluje \u00a0s hor\u0161ou progn\u00f3zou a krat\u0161\u00edm pre\u017e\u00edvan\u00edm. Pacienti \u00a0s <em>UM-IGHV <\/em>s\u00fa n\u00e1chyln\u00ed \u00a0na \u00a0v\u00fdvin cytogenetick\u00fdch abnormal\u00edt alebo \u00a0na tzv. Richterovu \u00a0trans- form\u00e1ciu (transform\u00e1cia CLL na\u00a0 vy\u0161\u0161\u00ed stupe\u0148 malignity)(6). Okrem rozdielov v d\u013a\u017eke pre\u017e\u00edvania boli medzi t\u00fdmito dvoma skupinami pacientov pozorovan\u00e9 rozdiely v pr\u00edtomnosti nepriazniv\u00fdch \u00a0cytogenetick\u00fdch abnormal\u00edt. Nepriazniv\u00e9 aber\u00e1cie (del11q22-23, del17p13) sa objavuj\u00fa \u00a0\u010dastej\u0161ie u pacientov s <em>UM-IGHV<\/em>, priazniv\u00e1 aber\u00e1cia (samostatn\u00e1 del13q14) je \u010dastej\u0161ie asociovan\u00e1 s <em>M-IGHV<\/em>(7). T\u00e1to nevyv\u00e1\u017een\u00e1 distrib\u00facia \u00a0len zd\u00f4raz\u0148uje rozdielne biologick\u00e9 pozadie CLL podskup\u00edn \u00a0s mutovan\u00fdm a nemutovan\u00fdm <em>IGHV<\/em>, ale len \u010diasto\u010dne vysvet\u013euje ich rozdielny klinick\u00fd priebeh(8).<\/p>\n<p>&nbsp;<\/p>\n<p><strong>Materi\u00e1l a metodika<\/strong><\/p>\n<p><strong><em>S\u00fabor pacientov<\/em><\/strong><\/p>\n<p>Za obdobie 8\/2015 \u2013 2\/2016 sme vy\u0161etrili 200 pacientov s podozren\u00edm na\u00a0 CLL. S\u00fabor \u00a0pacientov pozost\u00e1val zo 109 mu\u017eov a z 91 \u017eien. Pacienti boli v \u010dase diagn\u00f3zy vo veku 34 \u2013 89 rokov. Na molekulov\u00fa anal\u00fdzu sme pou\u017e\u00edvali perif\u00e9rnu krv alebo \u00a0kostn\u00fa dre\u0148, ktor\u00e9 boli odobrat\u00e9 do sk\u00famaviek s EDTA a z\u00e1rove\u0148 do sk\u00famaviek TEMPUS. Vzorky DNA na anal\u00fdzu MLPA boli izolovan\u00e9 kitom Magnesia 16 Genomic\u00a0 DNA Whole Blood Kit (Anatolia Geneworks). Vzorky RNA na anal\u00fdzu <em>IG<\/em><em>HV <\/em>muta\u010dn\u00e9ho statusu boli izolovan\u00e9 pomocou kitu Tempus Spin RNA Isolation Kit (ThermoFisher Scientific).<\/p>\n<p>&nbsp;<\/p>\n<p><strong><em>IGH Somatic Hypermutation <\/em><\/strong><strong><em>Assa<\/em><\/strong><strong><em>y<\/em><\/strong><\/p>\n<p>Princ\u00edpom met\u00f3dy je fragmentov\u00e1 anal\u00fdza, \u00a0pomocou ktorej sme identifikovali \u00a0prestavby g\u00e9nu \u00a0<em>IGH <\/em>(g\u00e9n pre \u0165a\u017ek\u00fd re\u0165azec imunoglobul\u00ednu), a Sangerovo sekvenovanie, ktor\u00fdm sme zis\u0165ovali muta\u010dn\u00fd status g\u00e9nu <em>IGHV. <\/em>Pou\u017e\u00edvali sme IGH Somatic Hypermutation Assay \u00a0v2.0 \u2013 Gel Detection kit (Invivoscribe), \u00a0IGH Somatic Hypermutation Assay v2.0 \u2013 ABI Fluorescence Detection kit (Invivoscribe) a BigDye Termina- tor v3.1 Cycle Sequencing Kit (ThermoFisher Scientific). PCR produkty boli separovan\u00e9 pomocou genetick\u00e9ho analyz\u00e1tora ABI 3500 Series \u00a0Genetic Analyzer (ThermoFisher Scientific). Fragmentov\u00fa anal\u00fdzu sme vyhodnotili v softv\u00e9ri GeneMapper Software 5 (ThermoFisher Scientific), \u00a0na hodnotenie sekvenovania sme pou\u017eili softv\u00e9r Sequencing Analysis \u00a0Software v6.0 (ThermoFisher Scientific). Po \u00a0anal\u00fdze sme sekvencie vzoriek porovnali so sekvenciami <em>IGHV <\/em>g\u00e9nu z\u00e1rodo\u010dnej l\u00ednie B-lymfocytov pomocou datab\u00e1zy IMGT\/V-QUEST.<\/p>\n<p>&nbsp;<\/p>\n<p><strong><em>ML<\/em><\/strong><strong><em>P<\/em><\/strong><strong><em>A <\/em><\/strong><strong><em>(Multiple<\/em><\/strong><strong><em>x ligation-dependent probe amplification) <\/em><\/strong><\/p>\n<p>Chromoz\u00f3mov\u00e9 aber\u00e1cie sme detegovali u pacientov met\u00f3dou MLPA, ktorej \u00a0princ\u00edpom je hybridiz\u00e1cia \u0161pecifick\u00fdch pr\u00f3b na cie\u013eov\u00e9 sekvencie DNA. Pou\u017e\u00edvali sme kit SALSA ML- PA P040 \u00a0CLL probemix kit (MRC-Holland) obsahuj\u00faci sondy pre nieko\u013eko chromoz\u00f3mov\u00fdch oblast\u00ed, \u00a0ktor\u00e9 \u00a0maj\u00fa \u00a0u pacientov s CLL diagnosticky alebo \u00a0prognosticky v\u00fdznamn\u00fa \u00falohu:<\/p>\n<p>11q22-23, chromoz\u00f3m 12, 13q a 17p.\u00a0 PCR produkty \u00a0boli separovan\u00e9 pomocou genetick\u00e9ho analyz\u00e1tora ABI 3500 Series Genetic \u00a0Analyzer (ThermoFisher Scientific), v\u00fdsledky sme vyhodnotili v softv\u00e9ri \u00a0Coffalyser. Net Software (MRC-Holland).<\/p>\n<p>&nbsp;<\/p>\n<p><strong><em>\u0160tatistick\u00e1 anal\u00fdza<\/em><\/strong><\/p>\n<p>Na vyhodnotenie frekvenci\u00ed muta\u010dn\u00e9ho statusu <em>IGHV <\/em>a interpret\u00e1ciu vz\u0165ahu medzi v\u00fdskytom chromoz\u00f3mov\u00fdch aber\u00e1ci\u00ed a muta\u010dn\u00fdm stavom <em>IGHV <\/em>sme pou\u017eili \u03c7\u00b2 test.<\/p>\n<p>&nbsp;<\/p>\n<p><strong>V<\/strong><strong>\u00fdsledky<\/strong><\/p>\n<p><strong><em>Stanovenie <\/em><\/strong><strong><em>IGHV <\/em><\/strong><strong><em>segmentu <\/em><\/strong><strong><em>a muta\u010dn\u00e9ho statusu<\/em><\/strong><\/p>\n<p>Met\u00f3dou fragmentovej anal\u00fdzy \u00a0sme v celom \u00a0s\u00fabore pacientov stanovili klonalitu \u00a0popul\u00e1cie B-lymfocytov. U 150 (75 %) pacientov sme preuk\u00e1zali monoklon\u00e1lnu popul\u00e1ciu typick\u00fa pre\u00a0 CLL <strong><em>(obr\u00e1zok 1 (A))<\/em><\/strong>, u zvy\u0161n\u00fdch \u00a050 (25 %) pacientov sme detegovali r\u00f4zne \u00a0typy in\u00fdch popul\u00e1ci\u00ed \u00a0<strong><em>(obr\u00e1zok\u00a0<\/em><\/strong><strong><em>1 (B))<\/em><\/strong>. Po stanoven\u00ed klonality sme do \u010fal\u0161ieho skr\u00edningu \u00a0zaradili 154 (77 %) pacientov, u ktor\u00fdch bolo mo\u017en\u00e9 ur\u010di\u0165 <em>IGHV <\/em>segment a jeho muta\u010dn\u00fd status. Naj\u010dastej\u0161ie sa vyskytuj\u00facim segmentom v s\u00fabore pacientov bol <em>IGHV1-69 <\/em>pr\u00edtomn\u00fd u 22 (14,29 %) pacientov, a to v\u00fdhradne \u00a0v nemutovanom stave. Druh\u00fdm naj\u010dastej\u0161ie sa vyskytuj\u00facim \u00a0segmentom bol <em>IG<\/em><em>&#8211; <\/em><em>HV3-30 <\/em>u 18 (11,69 %) pacientov. V\u0161etky ostatn\u00e9 segmenty mali v s\u00fabore zast\u00fapenie menej \u00a0ako 10 %. Z t\u00fdchto \u00a0mali najvy\u0161\u0161iu frekvenciu segmenty <em>IGHV3-21<\/em>, <em>IGHV3-7 <\/em>a <em>IGHV4-34<\/em>, ktor\u00e9 boli vo v\u00e4\u010d\u0161ine pr\u00edpadov mutovan\u00e9. U jedn\u00e9ho pacienta s biklon\u00e1lnou popul\u00e1ciou B-lymfocytov bolo mo\u017en\u00e9 stanovi\u0165 v\u00fdsledok \u00a0pre oba klony: segment <em>IGHV1-69 <\/em>v nemutovanom stave a segment <em>IGHV4-59 <\/em>v mutovanom stave.<\/p>\n<p>&nbsp;<\/p>\n<p><strong><em>Detekcia chromoz\u00f3mov\u00fdch aber\u00e1ci\u00ed<\/em><\/strong><\/p>\n<p>U pacientov sa chromoz\u00f3mov\u00e9 aber\u00e1cie vyskytovali samostatne aj v r\u00f4znych kombin\u00e1ci\u00e1ch. U 79 (39,5 %) pacientov sme nedetegovali \u00a0\u017eiadnu \u00a0aber\u00e1ciu. Najv\u00e4\u010d\u0161iu frekvenciu v\u00fdskytu sme zaznamenali pri del13q14, a to celkovo u 85 (42,5 %) pacientov. \u00a0Del\u00e9cia \u00a0sa naj\u010dastej\u0161ie vyskytovala samostatne, a to v 58 (68,24 %) pr\u00edpadoch. Druhou najfrekventovanej\u0161ou aber\u00e1ciou bola del11q22-23, ktor\u00fa sme detegovali u 27 (13,5 %) pacientov. Parci\u00e1lnu triz\u00f3miu \u00a012 <strong><em>(obr\u00e1zok \u00a02) <\/em><\/strong>sme zaznamenali u 23 (11,5 %) pacientov. Najmenej po\u010detnou zo sledovan\u00fdch aber\u00e1ci\u00ed bola del17p13 detegovan\u00e1 u 10 (5 %) pacientov. V 3 (1,5 %) pr\u00edpadoch sme pozorovali pr\u00edtomnos\u0165 3 aber\u00e1ci\u00ed s\u00fa\u010dasne. U 7 (3,5 %) pacientov bol v\u00fdsledok neinformat\u00edvny.<\/p>\n<p>&nbsp;<\/p>\n<p><strong>Diskusia<\/strong><\/p>\n<p>Klinick\u00fd obraz \u00a0CLL vyzna\u010duj\u00faci sa stabiln\u00fdm priebehom ochorenia \u00a0bez \u00a0potreby lie\u010debnej \u00a0intervencie alebo, \u00a0naopak, s vysokou \u00a0po\u010detnos\u0165ou \u00a0relapsov vy\u017eaduj\u00facich opakovan\u00fa terapiu je preuk\u00e1zate\u013ene ovplyvnen\u00fd \u00a0v\u00fdskytom \u00a0genetick\u00fdch zmien v bunk\u00e1ch CLL. Hoci \u017eiadna konkr\u00e9tna genetick\u00e1 abnormalita nebola identifikovan\u00e1 ako pr\u00ed\u010dina \u00a0vzniku CLL, ochorenie je charakteristick\u00e9 pr\u00edtomnos\u0165ou molekulovogenetick\u00fdch markerov, na z\u00e1klade ktor\u00fdch je mo\u017en\u00e1 stratifik\u00e1cia pacientov do prognostick\u00fdch skup\u00edn a individu\u00e1lny terapeutick\u00fd pr\u00edstup.<\/p>\n<p>Polyklonalita popul\u00e1cie \u00a0B-lymfocytov \u00a0u zdrav\u00e9ho jedinca \u00a0je d\u00f4sledkom r\u00f4znorodej d\u013a\u017eky preskupen\u00fdch g\u00e9nov <em>IGHV<\/em>. U pacienta s CLL je t\u00e1to \u00a0r\u00f4znorodos\u0165 z ve\u013ekej \u010dasti naru\u0161en\u00e1, preto \u00a0je pre CLL typick\u00e1 monoklon\u00e1lna popul\u00e1cia, pri ktorej jeden klon \u00faplne potla\u010dil ostatn\u00e9 klony. Pr\u00edtomnos\u0165\u00a0takejto popul\u00e1cie sme dok\u00e1zali u 75 % pacientov. Polyklon\u00e1lnu popul\u00e1ciu sme identifikovali \u00a0u 16 % pacientov, u ktor\u00fdch nebolo \u00a0mo\u017en\u00e9 potvrdi\u0165 diagn\u00f3zu CLL. V tak\u00fdchto pr\u00edpadoch je nutn\u00e9 \u00a0kritick\u00e9 pos\u00fadenie n\u00e1lezu \u00a0a s odstupom \u010dasu realizova\u0165 \u00a0dodato\u010dn\u00e9 vy\u0161etrenia na\u00a0 stanovenie definit\u00edvnej diagn\u00f3zy. U 3 % pacientov sme dok\u00e1zali polyklon\u00e1lnu popul\u00e1ciu, v ktorej mal jeden klon v\u00fdrazn\u00e9 zast\u00fapenie, a u jedn\u00e9ho pacienta sme zistili dva preva\u017euj\u00face klony. Pr\u00edtomnos\u0165 polyklon\u00e1lnej \u00a0popul\u00e1cie, v ktorej p\u00f4vodne minoritn\u00fd klon z\u00edskal rastov\u00fa v\u00fdhodu, sme pova\u017eovali za znak subklon\u00e1lnej selekcie. U tak\u00fdchto pacientov je d\u00f4le\u017eit\u00e1 strat\u00e9gia \u201ewatch-and-wait\u201c, teda \u00a0pacienta d\u00f4kladne sledova\u0165 a \u010dasom vy\u0161etrenia zopakova\u0165 na detekciu progresu ochorenia.<\/p>\n<p>U 5 % pacientov sme detegovali biklon\u00e1lnu \u00a0popul\u00e1ciu. Tak\u00e9to pr\u00edpady s\u00fa zriedkav\u00e9 a nie ve\u013emi dobre charakterizovan\u00e9. Bolo navrhnut\u00fdch nieko\u013eko pr\u00ed\u010din, kedy u pacienta s CLL m\u00f4\u017ee by\u0165 detegovate\u013en\u00e1 viac ako jedna <em>IGH <\/em>prestavba. Bunky CLL m\u00f4\u017eu \u00a0exprimova\u0165 \u00a0dva r\u00f4zne \u00a0receptory BCR (B cell receptor), a teda sekretova\u0165 dva typy protil\u00e1tok. Tak\u00e9to \u00a0bunky ozna\u010dujeme ako dvojn\u00e1sobne produkt\u00edvne (HCDP, heavy chain \u00a0double productive)(9). Druhou z mo\u017enost\u00ed je, \u017ee pacienti maj\u00fa dve <em>IGH <\/em>prestavby detegovate\u013en\u00e9 pomocou PCR, ale iba jedna \u00a0je produkt\u00edvna \u00a0a translatovan\u00e1 do imunoglobul\u00ednu(10). \u010eal\u0161\u00edm mo\u017en\u00fdm vysvetlen\u00edm biklon\u00e1lneho modelu je, \u017ee v krvi pacienta s\u00fa naozaj pr\u00edtomn\u00e9 dva mal\u00edgne klony so samostatn\u00fdm p\u00f4vodom, pri\u010dom \u00a0ka\u017ed\u00fd exprimuje \u00a0in\u00fd imunoglobul\u00edn. V tomto pr\u00edpade ide o prav\u00fa biklon\u00e1lnu \u00a0leuk\u00e9miu(11). Vysok\u00fd v\u00fdskyt atypick\u00fdch \u00a0modelov pouk\u00e1zal na d\u00f4le\u017eitos\u0165 vy\u0161etrenia klonality n\u00e1dorovej popul\u00e1cie u CLL suspektn\u00fdch pacientov.<\/p>\n<p>Somatick\u00e9 mut\u00e1cie g\u00e9nu \u00a0<em>IGHV <\/em>s\u00fa pr\u00edtomn\u00e9 asi v polovici pr\u00edpadov \u00a0CLL(8). Nemutovan\u00e9 CLL bunky pravdepodobne poch\u00e1dzaj\u00fa z B-lymfocytov, ktor\u00e9 podst\u00fapili antig\u00e9nov\u00fa stimul\u00e1ciu a\u017e po mal\u00edgnej transform\u00e1cii. Zachov\u00e1vaj\u00fa si reaktivitu na antig\u00e9n, d\u00f4sledkom \u010doho \u00a0je ich vysok\u00e1 prolifera\u010dn\u00e1 aktivita. Naopak, \u00a0mutovan\u00e9 bunky CLL pre\u0161li mal\u00edgnou transform\u00e1ciou a\u017e\u00a0 po stimul\u00e1cii antig\u00e9nom, nemaj\u00fa zachovan\u00fa sign\u00e1lnu kapacitu BCR receptora a progn\u00f3za je priaznivej\u0161ia (12). <em>IGHV <\/em>segment a muta\u010dn\u00fd status bolo mo\u017en\u00e9 ur\u010di\u0165 u 77 % pacientov. U jedn\u00e9ho pacienta s biklon\u00e1lnou popul\u00e1ciou bolo mo\u017en\u00e9 stanovi\u0165 \u00a0dva v\u00fdsledky, celkovo \u00a0sme teda \u00a0analyzovali 154 pacientov, ale 155 segmentov <strong><em>(graf 1)<\/em><\/strong>. A\u017e 52,26 % segmentov nevykazovalo somatick\u00fa hypermut\u00e1ciu, 47,74 % segmentov bolo v mutovanom stave. V porovnan\u00ed so svetov\u00fdmi \u0161t\u00fadiami bola frekvencia mutovan\u00fdch a nemutovan\u00fdch <em>IGHV <\/em>g\u00e9nov rovnak\u00e1 ako v popul\u00e1cii \u00a0Spojen\u00fdch \u0161t\u00e1tov (53 % <em>UM-IGHV<\/em>, 47 % <em>M-IGHV<\/em>)(13). Celkovo sme zaznamenali 29 ty- pov segmentov, pri\u010dom a\u017e 14 typov patrilo do g\u00e9novej rodiny <em>IGHV3<\/em>. Z celkov\u00e9ho po\u010dtu \u00a0155 identifikovan\u00fdch g\u00e9nov \u00a0tvorili segmenty tejto g\u00e9novej \u00a0rodiny a\u017e 52,26 % pr\u00edpadov. \u00a0<em>IGHV3 <\/em>je vo v\u0161eobecnosti najroz\u0161\u00edrenej\u0161ou g\u00e9novou rodinou, \u010do potvrdzuj\u00fa viacer\u00e9 \u00a0eur\u00f3pske i svetov\u00e9 \u0161t\u00fadie.<\/p>\n<p>Naj\u010dastej\u0161ie \u00a0sa\u00a0 vyskytuj\u00facim segmentom \u00a0v s\u00fabore bol <em>IGHV1-69 <\/em>pr\u00edtomn\u00fd \u00a0u 14,29 % pacientov a vyskytoval \u00a0sa v\u00fdhradne v nemutovanom stave. Ve\u013emi podobn\u00e1 frekvencia bola \u00a0reportovan\u00e1 v popul\u00e1cii \u0160v\u00e9dska, kde \u00a0bol \u00a0tento segment tie\u017e \u00a0najfrekventovanej\u0161\u00ed a rovnako \u00a0sa vyskytoval \u00a0v\u00fdhradne v nemutovanom stave(14). Druh\u00fdm naj\u010dastej\u0161\u00edm g\u00e9nom bol <em>IGHV3-30 <\/em>zaznamenan\u00fd u 11,69 % pacientov, z toho u 61,11 % pr\u00edpadov \u00a0mutovan\u00fd. Segment bol tie\u017e \u010dasto reportovan\u00fd v oblasti Stredozemn\u00e9ho mora(15). <em>IGHV3-30 <\/em>je vo v\u00e4\u010d\u0161ine oblast\u00ed asociovan\u00fd s mutovan\u00fdm stavom. Pr\u00edtomnos\u0165 segmentu <em>IGHV3-21 <\/em>sme stanovili \u00a0u 7,79 % pr\u00edpadov. Preferen\u010dne sa vyskytoval \u00a0mutovan\u00fd, a to u 58,33 \u00a0% pacientov. <em>IGHV3-21 <\/em>je asociovan\u00fd s hor\u0161ou progn\u00f3zou bez oh\u013eadu \u00a0na muta\u010dn\u00fd status(16). \u00a0Najvy\u0161\u0161ia prevalencia g\u00e9nu bola publikovan\u00e1 \u00a0v \u0160kandin\u00e1vii \u00a0(11,2 \u00a0%), kde \u00a0sa vyskytoval preva\u017ene v mutovanom stave(14). Naopak, \u00a0v popul\u00e1ci\u00e1ch ju\u017enej Eur\u00f3py (Franc\u00fazsko, Gr\u00e9cko, Taliansko, \u0160panielsko) je v\u00fdskyt <em>IGHV3-21 <\/em>zna\u010dne ni\u017e\u0161\u00ed (2,9 %) a ni\u017e\u0161ia \u00a0je aj pr\u00edtomnos\u0165 somatickej hypermut\u00e1cie(15). Rozdiely vo v\u00fdskyte jednotliv\u00fdch g\u00e9nov \u00a0<em>IGHV <\/em>pravdepodobne reflektuj\u00fa \u00a0nielen vari\u00e1cie \u00a0v genetickom pozad\u00ed CLL, ale \u00a0aj leukemick\u00fa variabilitu dependentn\u00fa od geografickej polohy(17). Tieto rozdiely \u00a0tie\u017e \u00a0m\u00f4\u017eu znamena\u0165, \u017ee prestavby <em>IGH <\/em>g\u00e9nu k\u00f3duj\u00fa \u0161pecifick\u00fd epitop, na ktor\u00fd sa via\u017ee \u00a0nezn\u00e1my antig\u00e9n a stimuluje prolifer\u00e1ciu B-lymfocytov(14).<\/p>\n<p>Napriek \u00a0relat\u00edvnej \u00a0gen\u00f3movej stabilite buniek \u00a0CLL sa a\u017e u 80 % pacientov vyskytuj\u00fa \u00a0chromoz\u00f3mov\u00e9 aber\u00e1cie. Vo v\u0161eobecnosti maj\u00fa \u00a0pacienti s del17p13 a del11q22-23 hor\u0161iu progn\u00f3zu a krat\u0161ie pre\u017e\u00edvanie, preto\u017ee nar\u00fa\u0161aj\u00fa expresiu tumor-supresorov\u00fdch g\u00e9nov <em>TP53 <\/em>a <em>ATM<\/em>. Pr\u00edtomnos\u0165 del13q14 m\u00e1 pri samostatnom v\u00fdskyte priazniv\u00fd prognostick\u00fd charakter a prognostick\u00fd v\u00fdznam \u00a0triz\u00f3mie \u00a012 je sporn\u00fd(3). Pr\u00edtomnos\u0165 aber\u00e1ci\u00ed sme dok\u00e1zali u 57 % pacientov. U 39,5 % pacientov sme nedetegovali \u017eiadnu abnormalitu a v 3,5 % pr\u00edpadov \u00a0nebolo \u00a0mo\u017en\u00e9 v\u00fdsledky vyhodnoti\u0165. Ak by sme vyhodnotili len 168 pacientov, u ktor\u00fdch sme potvrdili plne vyvinut\u00fa CLL (pr\u00edpady \u00a0s monoklon\u00e1lnou popul\u00e1ciou) alebo vyv\u00edjaj\u00facu sa CLL (pr\u00edpady \u00a0s atypick\u00fdm \u00a0modelom popul\u00e1cie), pr\u00edtomnos\u0165 \u00a0aber\u00e1cie by sme detegovali u 64,88 \u00a0% pacientov. Dan\u00e9\u00a0 v\u00fdsledky \u00a0neboli \u00a0v s\u00falade s publikovan\u00fdmi \u00fadajmi in\u00fdch \u0161t\u00fadi\u00ed, ale boli zna\u010dne ni\u017e\u0161ie. Nemeck\u00e9 \u0161t\u00fadie uv\u00e1dzaj\u00fa frekvenciu \u00a0chromoz\u00f3mov\u00fdch abnormal\u00edt 82 \u2013 85,2 %(3,18), frekvencia \u00a0vo Ve\u013ekej Brit\u00e1nii je 69 %(19) \u00a0a v USA 72,5 %(20). Uveden\u00fd rozdiel mohol \u00a0by\u0165 ovplyvnen\u00fd viacer\u00fdmi faktormi, napr. kompoz\u00edciou a ve\u013ekos\u0165ou s\u00faboru, rozdielmi v indika\u010dn\u00fdch krit\u00e9ri\u00e1ch \u010di metodick\u00fdmi rozdielmi.<\/p>\n<p>U 12,5 % pacientov sme neidentifikovali \u017eiadnu \u00a0aber\u00e1ciu a s\u00fa\u010dasne sme pozorovali polyklon\u00e1lny model popul\u00e1cie. Tak\u00edto pacienti nevykazuj\u00fa \u017eiadne z\u00e1kladn\u00e9 molekulovogenetick\u00e9 \u00a0znaky \u00a0rozv\u00edjaj\u00faceho sa ochorenia CLL. Norm\u00e1lny \u00a0karyotyp sme pozorovali aj v 24 % pr\u00edpadov \u00a0s monoklon\u00e1lnou popul\u00e1ciou, \u010do je priazniv\u00fd prognostick\u00fd znak. \u00a0U pacientov s atypick\u00fdm \u00a0modelom popul\u00e1cie (polyklon\u00e1lna s jedn\u00fdm alebo dvoma preva\u017euj\u00facimi klonmi, biklon\u00e1lna, triklon\u00e1lna,) sme nezaznamenali asoci\u00e1ciu so \u017eiadnou \u0161pecifickou aber\u00e1ciou.<\/p>\n<p>Najv\u00e4\u010d\u0161iu frekvenciu v\u00fdskytu sme zaznamenali pri del13q14, a to celkovo \u00a0u 42,5 \u00a0% pacientov. Del\u00e9cia \u00a0sa naj\u010dastej\u0161ie vyskytovala samostatne, a to u 68,24\u00a0 % pacientov. Prevalencia a samostatn\u00fd v\u00fdskyt boli najviac \u00a0podobn\u00e9 stavu v USA (62 %)(20). Pre pacientov predstavuje samostatn\u00fd v\u00fdskyt tejto \u00a0aber\u00e1cie priazniv\u00fa \u00a0progn\u00f3zu. U 31,76 \u00a0% pacientov bola pozorovan\u00e1 spolu s niektorou \u010fal\u0161ou aber\u00e1ciou a jej priazniv\u00fd prognostick\u00fd v\u00fdznam sa str\u00e1cal. Del13q14 bola jedinou aber\u00e1ciou, ktor\u00fa sme dok\u00e1zali u pacientov s polyklonalitou B-lymfocytov. Vysvetlen\u00edm \u00a0tohto \u00a0faktu m\u00f4\u017ee \u00a0by\u0165, \u017ee del\u00e9cia postihuje g\u00e9ny <em>MIR15A <\/em>a <em>MIR161 <\/em>k\u00f3duj\u00face miRNA, ktor\u00fdch \u00falohou je negat\u00edvna regul\u00e1cia g\u00e9nu <em>BCL2 <\/em>(B cell lymphoma 2) na posttranskrip\u010dnej \u00farovni. Pri del\u00e9cii t\u00fdchto g\u00e9nov doch\u00e1dza k zv\u00fd\u0161enej expresii \u00a0antiapoptotick\u00e9ho prote\u00ednu Bcl2, \u010do m\u00f4\u017ee sp\u00f4sobova\u0165 perzistentn\u00fa lymfocyt\u00f3zu aj u pacientov s polyklon\u00e1lnou popul\u00e1ciou. Druhou najfrekventovanej\u0161ou aber\u00e1ciou bola del11q22-23, ktor\u00fa \u00a0sme detegovali u 13,5 % pacientov. Prevalencia del\u00e9cie bola podobn\u00e1 Nemecku (12 %)(18). Bunky CLL s del11q22-23 s\u00fa\u00a0 n\u00e1chylnej\u0161ie na vznik \u010fal\u0161\u00edch genetick\u00fdch aber\u00e1ci\u00ed(5). Pr\u00edtomnos\u0165 parci\u00e1lnej triz\u00f3mie \u00a012 sme zaznamenali u 11,5 % pacientov a jej v\u00fdskyt bol v s\u00falade s frekvenciou u nemeck\u00fdch pacientov (13,6 %)(18). Triz\u00f3mia 12 je pova\u017eovan\u00e1 za marker s intermedi\u00e1rnou prognostickou hodnotou(3). Najmenej \u00a0po\u010detn\u00e1 zo sledovan\u00fdch aber\u00e1ci\u00ed bola \u00a0del17p13, detegovan\u00e1 u 5 % pacientov. V\u00fdskyt del\u00e9cie sa zhoduje s britskou \u00a0(6 %)(19) \u00a0a nemeckou popul\u00e1ciou (7 %)(18). Bez oh\u013eadu na pr\u00edtomnos\u0165 inej aber\u00e1cie je asociovan\u00e1 s ve\u013emi agres\u00edvnym priebehom ochorenia, preto\u017ee nar\u00fa\u0161a expresiu g\u00e9nu \u00a0<em>TP53<\/em>(3). U 1,5 % pacientov sme zaznamenali pr\u00edtomnos\u0165 3 aber\u00e1ci\u00ed s\u00fa\u010dasne, \u010do je indik\u00e1torom agres\u00edvneho priebehu ochorenia. Ni\u017e\u0161iu frekvenciu chromoz\u00f3mov\u00fdch abnormal\u00edt v porovnan\u00ed so zahrani\u010dn\u00fdmi \u0161t\u00fadiami pripisujeme ich zachyteniu v ran\u00fdch \u0161t\u00e1di\u00e1ch ochorenia. Nepr\u00edtomnos\u0165 aber\u00e1cie sa v\u0161ak m\u00f4\u017ee \u00a0\u010dasom \u00a0zmeni\u0165 v d\u00f4sledku klon\u00e1lnej evol\u00facie buniek CLL.<\/p>\n<p>V s\u00fabore pacientov sme tie\u017e sledovali vz\u00e1jomn\u00fd vz\u0165ah muta\u010dn\u00e9ho statusu <em>IGHV <\/em>s v\u00fdskytom chromoz\u00f3mov\u00fdch aber\u00e1ci\u00ed <strong><em>(graf 2)<\/em><\/strong>. Zo 79 pacientov negat\u00edvnych na chromoz\u00f3mov\u00e9 aber\u00e1cie sme v 32,91 % pr\u00edpadov \u00a0stanovili nemutovan\u00fd stav <em>IGHV, <\/em>u 27,85 % pacientov stav mutovan\u00fd. U 39,24 % negat\u00edvnych\u00a0 pacientov s polyklon\u00e1lnou, biklon\u00e1lnou a triklon\u00e1lnou popul\u00e1ciou sme muta\u010dn\u00fd status neur\u010dovali. Vzh\u013eadom \u00a0na rovnomern\u00e9 percentu\u00e1lne zast\u00fapenie \u00a0jednotliv\u00fdch kateg\u00f3ri\u00ed sme neidentifikovali \u017eiaden preferen\u010dn\u00fd muta\u010dn\u00fd status. Del13q14 \u00a0bola \u00a0preva\u017ene, t. j. u 51,76 \u00a0% pr\u00edpadov, asociovan\u00e1 s <em>M-IGHV. <\/em>U t\u00fdchto \u00a0pacientov bola \u00a0jedinou \u00a0detegovanou aber\u00e1ciou, \u010do potvrdzuje jej priazniv\u00fd prognostick\u00fd v\u00fdznam. U 34,12 % pacientov sa vyskytovala v spojen\u00ed s <em>UM-IGHV<\/em>, pri\u010dom bola u nich okrem del13q14 pozorovan\u00e1 e\u0161te aspo\u0148 jedna aber\u00e1cia. Vz\u0165ah chromoz\u00f3mov\u00fdch aber\u00e1ci\u00ed s muta\u010dn\u00fdm statusom potvrdil korel\u00e1ciu prognosticky priaznivej aber\u00e1cie, samostatnej del13q14, s mutovan\u00fdm stavom <em>IGHV. <\/em>Triz\u00f3miu 12 sme pozorovali v asoci\u00e1cii s <em>UM-IGHV <\/em>u 52,17 % pacientov, v 34,79 \u00a0% pr\u00edpadov bola \u00a0asociovan\u00e1 s <em>M-IGHV<\/em>. Preferen\u010dn\u00fd \u00a0status v\u0161ak \u00a0nebolo mo\u017en\u00e9 ur\u010di\u0165, preto\u017ee rozdiel \u00a0vo frekvenci\u00e1ch nebol preukazn\u00fd (<em>P <\/em>= 0,0706), \u010do nazna\u010duje intermedi\u00e1rnu prognostick\u00fa hodnotu. Del11q22-23 sa vyskytovala v\u00fdhradne u pacientov s <em>UM-IGHV <\/em>a nikdy sa nevyskytovala u pacientov s typickou polyklonalitou. Dosiahnut\u00e9 v\u00fdsledky potvrdili negat\u00edvny prognostick\u00fd v\u00fdznam \u00a0del11q22-23. Del\u00e9ciu 17p13 \u00a0s najmenej priaznivou progn\u00f3zou sme v 70 % pr\u00edpadov pozorovali s <em>UM-IGHV, <\/em>\u010do potvrdzuje ich korel\u00e1ciu. Muta\u010dn\u00fd status tie\u017e s\u00favisel \u00a0s po\u010dtom chromoz\u00f3mov\u00fdch abnormal\u00edt. \u00a0U 28 pacientov sme detegovali pr\u00edtomnos\u0165 dvoch a viacer\u00fdch aber\u00e1ci\u00ed, \u00a0z toho 67,88 % pr\u00edpadov \u00a0bolo asociovan\u00fdch s nepriazniv\u00fdm nemutovan\u00fdm stavom <em>IGHV. <\/em>Pozorovan\u00fd vz\u0165ah chromoz\u00f3mov\u00fdch aber\u00e1ci\u00ed s muta\u010dn\u00fdm statusom potvrdil prognostick\u00fa korel\u00e1ciu a v\u00fdsledky boli v s\u00falade so \u0161t\u00fadiami z Nemecka(18) \u010di Ve\u013ekej Brit\u00e1nie(19).<\/p>\n<p>&nbsp;<\/p>\n<p><strong>Z\u00e1ver<\/strong><\/p>\n<p>V s\u00fa\u010dasnosti je hlavn\u00fdm vedeck\u00fdm cie\u013eom anal\u00fdzy prognostick\u00fdch markerov n\u00e1js\u0165 genetick\u00e9 vysvetlenie klinickej heterogenity CLL. Molekulovogenetick\u00e9 parametre, ako je muta\u010dn\u00fd \u00a0status <em>IGHV <\/em>a chromoz\u00f3mov\u00e9 aber\u00e1cie, boli \u00faspe\u0161ne zaveden\u00e9 do klinickej praxe. \u00a0V predlo\u017eenej \u0161t\u00fadii sme preuk\u00e1zali, \u017ee stav t\u00fdchto parametrov v slovenskej popul\u00e1cii je intermedi\u00e1rny, \u00a0preto\u017ee so \u00a0\u017eiadnou zo zahrani\u010dn\u00fdch \u0161t\u00fadi\u00ed sa nezhodoval \u00faplne. Nazna\u010duje to nielen genetick\u00e9 pozadie ochorenia, ale\u00a0 aj existenciu environment\u00e1lneho antig\u00e9nov\u00e9ho tlaku \u00a0na \u00a0selekciu \u00a0B-lymfocytov. \u00a0V\u00fdsledkom \u00a0spr\u00e1vnej detekcie a interpret\u00e1cie prognostick\u00fdch faktorov je skor\u00e1 stratifik\u00e1cia pacientov do prognostick\u00fdch skup\u00edn \u00a0pre vo\u013ebu vhodnej terapeutickej strat\u00e9gie a n\u00e1sledn\u00e9 zlep\u0161enie klinickej starostlivosti.<\/p>\n<p>&nbsp;<\/p>\n<p><strong><em>P<\/em><\/strong><strong><em>o\u010fako<\/em><\/strong><strong><em>v<\/em><\/strong><strong><em>anie<\/em><\/strong><\/p>\n<p><em>Moja v\u010faka patr\u00ed v\u0161etk\u00fdm kolegom, ktor\u00ed sa podie\u013eali na pr\u00edpra<\/em><em>v<\/em><em>e a vyhodnocovan\u00ed vzoriek pacientov vy\u0161etrovan\u00e9ho s\u00faboru.<\/em><\/p>\n<p><strong>Literat\u00fara<\/strong><br \/>\n1. Rodr\u00edguez D, Bretones G, Arango JR., et al. Molecular pathogenesis ofCLL and its evolution. International Journal of Hematology 2015; 101(3): 219-228.<br \/>\n2. Balh\u00e1rek T, Barthov\u00e1 M, Sz\u00e9pe P, et al. Koment\u00e1r k v\u00fdvoju konceptu prognostick\u00fdch faktorov chronickej lymfocytovej leuk\u00e9mie: Cesta od prognostick\u00fdch faktorov k prediktorom lie\u010debnej odpovede. Klinick\u00e1 Onkologie<br \/>\n2009; 22(6): 254-263.<br \/>\n3. D\u00f6hner H, Stilgenbauer S, Benner A, et al. Genomic aberrations and survival in chronic lymphocytic leukemia. The New England Journal of Medicine 2000; 343(26): 1910-1916.<br \/>\n4. Cuneo A, Cavazzini F, Ciccone M, et al. Molecular cytogenetic lesions in chronic lymphocytic leukemia. Hematology Meeting Reports 2009; 3(3): 86-90.<br \/>\n5. Cop\u00e1kov\u00e1 L, Pia\u010dkov\u00e1 B, Leitnerov\u00e1 M. V\u00fdznam del\u00e9cie a mut\u00e1cie g\u00e9nu TP53 a \u010fal\u0161\u00edch prognostick\u00fdch markerov u pacientov s CLL. Onkol\u00f3gia 2014; 9(2): 100-103.<br \/>\n6. Damle RN, Wasil T, Fais F, et al. Ig V gene mutation status and CD38 expression as novel prognostic indicators in chronic lymphocytic leukemia. Blood 1999; 94(6): 1840-1847.<br \/>\n7. Kr\u00f6ber A, Seiler T, Benner A, et al. V(H) mutation status, CD38 expression level, genomic aberrations, and survival in chronic lymphocytic leukemia. Blood 2002; 100(4): 1410-1416.<br \/>\n8. Rodr\u00edguez-Vicente AE, D\u00edaz MG, Hern\u00e1ndez-Rivas JM. Chronic lymphocytic leukemia: a clinical and molecular heterogenous disease. Cancer Genetics 2013; 206(3): 49-62.<br \/>\n9. Kalmanovich G, Mehr R. Models for antigen receptor gene rearrangement. iii. heavy and light chain allelic exclusion. The Journal of Immunology 2003; 170(1): 182-193.<br \/>\n10. Buc M. Imunol\u00f3gia. Bratislava: Veda 2001; 463 pp.<br \/>\n11. Chang H, Cerny J. Molecular characterization of chronic lymphocytic leukemia with two distinct cell populations: Evidence for separate clonal origins. American Journal of Clinical Pathology 2006; 126(1): 23-28.<br \/>\n12. Stevenson FK, Krysov S, Davies AJ, et al. B-cell receptor signaling in chronic lymphocytic leukemia. Blood 2011; 118(16): 4313-4320.<br \/>\n13. Rassenti LZ, Huynh L, Toy TL, et al. ZAP-70 compared with immunoglobulin heavy-chain gene mutation status as a predictor of disease progression in chronic lymphocytic leukemia. The New England Journal of Medicine 2004; 351(9): 893-901.<br \/>\n14. Tobin G, Thunberg U, Johnson A, et al. Somatically mutated IgVH3-21 genes characterize a new subset of chronic lymphocytic leukemia. Blood 2002; 99(6): 2262-2264.<br \/>\n15. Ghia P, Stamatopoulos K, Belessi C, et al. Geographic patterns and pathogenetic implications of IGHV gene usage in chronic lymphocytic leukemia: the lesson of the IGHV3-21 gene. Blood 2005; 105(4): 1678-1685.<br \/>\n16. Dal-Bo M, Del Giudice I, Bomben R, et al. B-cell receptor, clinical course and prognosis in chronic lymphocytic leukaemia: the growing saga of the IGHV3 subgroup gene usage. British Journal of Haematology 2011;<br \/>\n153(1): 3-14.<br \/>\n17. Ren\u00e9 C, Prat N, Thuizat A, et al. Comprehensive characterization of immunoglobulin gene rearrangements in patients with chronic lymphocytic leukaemia.<br \/>\nJournal of Cellular and Molecular Medicine 2014; 18(6): 979-990.<br \/>\n18. Haferlach C, Dicker F, Schnittger S, et al. Comprehensive genetic characterization of CLL: a study on 506 cases analysed with chromosome banding analysis, interphase FISH, IgVH status and immunophenotyping. Leukemia 2007; 21(12): 2442-2451.<br \/>\n19. Oscier DG, Gardiner AC, Mould SJ, et al. Multivariate analysis of prognostic factors in CLL: clinical stage, IGVH gene mutational status, and loss or mutation of the p53 gene are independent prognostic factors. Blood 2002; 100(4): 1177-84.<br \/>\n20. Nelson BP, Gupta R, Dewald GW, et al. Chronic lymphocytic leukemia FISH panel: impact on diagnosis. American Journal of Clinical Pathology 2007; 128(2): 323-332.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>*All tables, charts, graphs and pictures that are featured in this article can be found in the .pdf\u00a0 attachment at the end of the paper. &nbsp; \u00davod Chronick\u00e1 \u00a0lymfocytov\u00e1 leuk\u00e9mia (CLL) je lymfoproliferat\u00edvne ochorenie charakterizovan\u00e9 akumul\u00e1ciou zrel\u00fdch monoklon\u00e1lnych B-lymfocytov \u00a0v perif\u00e9rnej krvi, kostnej dreni a \u00a0lymfatick\u00fdch \u00a0tkaniv\u00e1ch. \u00a0Je naj\u010dastej\u0161ou \u00a0leuk\u00e9miou dospel\u00fdch z\u00e1padn\u00e9ho sveta a postihuje<\/p>\n","protected":false},"author":7,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_mi_skip_tracking":false,"footnotes":""},"categories":[290],"tags":[379,634,349,635],"class_list":["post-1033","post","type-post","status-publish","format-standard","hentry","category-genetics","tag-chromosome-aberrations-en","tag-chronic-lymphocytic-leukemia","tag-ighv-en","tag-prognostic-markers","typ_clanku-original-work"],"acf":{"abstrakt":"<p>Chronic lymphocytic leukemia (CLL) is a clinically and biologically substantially heterogenous disease. In general, patients are classified into two groups: patients with indolent disease form and patients with aggressive disease form and poor prognosis. The most reliable prognostic markers using in clinical practice are determining the mutation status of the IGHV gene coding the variable region of immunoglobulin heavy chain and detection of significant chromosome aberrations. In the sample comprising 200 patients, we researched representation and mutation status of IGHV genes and determined presence of trisomy 12 and deletions of 11q22-23, 13q14 and 17p13 in Slovak population. In the conclusion, we attempted to interpret mutual relations of the above prognostic markers.<\/p>\n<p>&nbsp;<\/p>\n<p><strong>Key words:<\/strong> chronic lymphocytic leukemia, prognostic markers, chromosome aberrations, IGHV<\/p>\n<p>&nbsp;<\/p>\n","casopis":[{"ID":735,"post_author":"7","post_date":"2017-04-06 13:21:01","post_date_gmt":"2017-04-06 11:21:01","post_content":"<ul>\r\n \t<li>Pseudoglandular nevus \u2013 a rare morphology of melanocytic nevus (case report)<\/li>\r\n \t<li>Differential molecular diagnosis of multiple myeloma and Waldenstr\u00f6m macroglobulinemia<\/li>\r\n \t<li>Molecular analysis of prognostically significant markers of chronic lymphocytic leukemia<\/li>\r\n \t<li>Prevalence of <em>Streptococcus pneumoniae<\/em> phyla in inflammatory diseases of upper airways in preschool age children and their resistance to antibiotics<\/li>\r\n \t<li>Malign melanoma - new aspects of research<\/li>\r\n \t<li style=\"list-style-type: none;\"><\/li>\r\n<\/ul>","post_title":"Newslab","post_excerpt":"","post_status":"publish","comment_status":"closed","ping_status":"closed","post_password":"","post_name":"newslab-2017-1","to_ping":"","pinged":"","post_modified":"2017-08-16 21:11:52","post_modified_gmt":"2017-08-16 19:11:52","post_content_filtered":"","post_parent":0,"guid":"http:\/\/www.newslab.sk\/?post_type=casopis&#038;p=735\/","menu_order":0,"post_type":"casopis","post_mime_type":"","comment_count":"0","filter":"raw"}],"strana":"38","upload_clanok":{"ID":1034,"id":1034,"title":"Molekulov\u00e1 anal\u00fdza prognosticky v\u00fdznamn\u00fdch markerov chronickej lymfocytovej leuk\u00e9mie","filename":"Molekulov\u00e1-anal\u00fdza-prognosticky-v\u00fdznamn\u00fdch-markerov-chronickej-lymfocytovej-leuk\u00e9mie.pdf","filesize":829990,"url":"https:\/\/www.newslab.sk\/wp-content\/uploads\/2017\/04\/Molekulov\u00e1-anal\u00fdza-prognosticky-v\u00fdznamn\u00fdch-markerov-chronickej-lymfocytovej-leuk\u00e9mie.pdf","link":"https:\/\/www.newslab.sk\/en\/molecular-analysis-of-prognostically-significant-markers-of-chronic-lymphocytic-leukemia\/molekulova-analyza-prognosticky-vyznamnych-markerov-chronickej-lymfocytovej-leukemie\/","alt":"","author":"7","description":"","caption":"","name":"molekulova-analyza-prognosticky-vyznamnych-markerov-chronickej-lymfocytovej-leukemie","status":"inherit","uploaded_to":1033,"date":"2017-04-07 12:07:55","modified":"2017-04-07 12:07:55","menu_order":0,"mime_type":"application\/pdf","type":"application","subtype":"pdf","icon":"https:\/\/www.newslab.sk\/wp-includes\/images\/media\/document.png"}},"_links":{"self":[{"href":"https:\/\/www.newslab.sk\/en\/wp-json\/wp\/v2\/posts\/1033","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.newslab.sk\/en\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.newslab.sk\/en\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.newslab.sk\/en\/wp-json\/wp\/v2\/users\/7"}],"replies":[{"embeddable":true,"href":"https:\/\/www.newslab.sk\/en\/wp-json\/wp\/v2\/comments?post=1033"}],"version-history":[{"count":0,"href":"https:\/\/www.newslab.sk\/en\/wp-json\/wp\/v2\/posts\/1033\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.newslab.sk\/en\/wp-json\/wp\/v2\/media?parent=1033"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.newslab.sk\/en\/wp-json\/wp\/v2\/categories?post=1033"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.newslab.sk\/en\/wp-json\/wp\/v2\/tags?post=1033"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}