Scientific Program

Day 1 :

Keynote Forum

Ojvind Lidegaard

University of Copenhagen, Denmark

Keynote: Hormonal contraception and the risk of breast cancer

Time : 10:00

Biography:

Øjvind Lidegaard is a Clinical Professor with expertise in Obstetrics & Gynaecology in University of Copenhagen, Denmark.

Abstract:

Background: We know little about the risk of breast cancer in users of newer types of hormonal contraception and in users of hormone intrauterine devices.

Methods: We assessed associations between hormonal contraception use and invasive breast cancer risk in a nationwide prospective cohort study following all women in Denmark aged 15–49 years without previous cancer, venous thromboembolism, or infertility treatment. Nationwide Registers provided individually updated information about use of hormonal contraception, breast cancer diagnoses, and information on potential confounders.

Results: Among 1.8 million women followed on average for 10.9 years with a total of 19.6 million person-years, 11,517 breast cancers occurred. Compared to never users, the relative risk of breast cancer among all current and recent users was 1.2 (95% CI 1.1-1.3), increasing from 1.1 (1.0-1.2) with less than one year of use to 1.4 (1.3-1.5) with more than ten years of use. There was little evidence that the risk varied by type of progestogen in the combined formulations. Current or recent users of the progestin-only intrauterine system also experienced an increased relative risk of breast cancer of 1.2 (1.1-1.3).
The overall absolute mean increase in breast cancers among current and recent users of any hormonal contraceptive for all ages was 13 (10-16) per 100,000 person-years; approximately one extra breast cancer for every 7690 women using hormonal contraception for one year; the absolute risk difference increased by age.

Conclusion: Breast cancer risk was increased among current and recent users of contemporary hormonal contraception and increased with longer durations of use; however, absolute increases in risk were small, and the same products protects against ovarian cancer.

Keynote Forum

Wancai Yang

Jining Medical University, China

Keynote: Chronic Colitis and Colitis-Associated Colorectal Carcinogenesis

Time : 10:40

Biography:

Wancai Yang is the Dean of the Institute of Precision Medicine and School of Basic Medical Sciences, Jining Medical University, China, and a Professor of Pathology, University of Illinois at Chicago, USA. He is also an Adjunct Professor of Biological Sciences, University of Texas, El Paso, USA. He obtained his MD degree and was trained a pathologist from China and received postdoctoral training on cancer biology from Rockefeller University and Albert Einstein Cancer Center, and was promoted as Assistant Professor. In 2006, he was moved to the Department of Pathology, University of Illinois at Chicago. He was serving grant reviewer for the National Institutes of Health (USA) and the National Nature Science Foundation of China. His research focuses on: (1) the determination of mechanisms of gastrointestinal carcinogenesis, (2) identification of biomarkers for cancer detection and patient selection for chemotherapy, (3) implication of precision medicine in cancers. He has published about 90 articles and has brought important impact in clinical significance.
 

Abstract:

The activation of Wnt/beta-catenin signaling pathway and chronic colitis malignant transformation are the two major causes to colorectal cancer. The former is well studies, but the mechanisms of colitis develops and how chronic colitis progress to malignance is largely unknown. Using a unique mouse model, we have demonstrated that the mice with targeted disruption of the intestinal mucin gene Muc2 spontaneously develop chronic inflammation at colon and rectum at early age, whose histopathology was similar to ulcerative colitis in human. In the aged mice, Muc2-/- mice develop colonic and rectal adenocarcinoma accompanying severe inflammation. To determine the mechanisms of the malignant transformation, we conducted miRNA array on the colonic epithelial cells from Muc2-/- and +/+ mice. MicroRNA profiling showed differential expression of miRNAs (i.e. lower or higher expression enrichments) in Muc2-/- mice. Based on relevance to cytokines and cancer, the miRNAs were validate and were found significantly downregulated or upregulated in human colitis and colorectal cancer tissues, respectively. The targets of the miRNAs were further characterized and their functions were investigated. More studies from the Muc2-/- mice showed disorder of gut microbiota. Moreover, a novel tumor suppressor PRSS8 also plays a critical role in colorectal carcinogenesis and progression, for instance, tissue-specific deletion of the PRSS8 gene resulted in intestinal inflammation and tumor formation in mice. Gene set enrichment analysis showed that the colitis and tumorigenesis were linked to the activation Wnt/beta-catenin, PI3K/AKT and EMT (epithelial-mesenchymal transition) signaling pathways. Taken above, the disorder of gut microbiota could result in genetic mutations, epigenetic alterations, and activation of oncogenic signaling, in colorectal epithelial cells, leading to colitis development, promoting malignant transformation and mediating colorectal cancer metastasis.

  • Blood Disorders

Session Introduction

Rajib De

Nilratan Sircar Medical College, India

Title: Comparative study of bone marrow and blood plasma level of IL-2 in aplastic anemia and their relation with disease severity
Speaker
Biography:

Rajib De(MD, DM-Clinical Hematology) is associate professor in the Department of Hematology, NRS Medical College & Hospital.  He is a Hemato-onlogist and bone marrow transplant physician. His areas of interest includes Thalassemia, Acute Lymphoblastic Leukemia and Aplastic Anemia. He has more than 10 publications in different national & international index journals. Some of his research areas are screening of Thalassemia carrier by nanotechnology based method, Label Free Characterization for Hematopoietic Stem Cells by Nanotechnology based methods, Development of Spion( super paramagnetic iron oxide nanoparticle) based ferritin sensor, Gene micromapping of Thalassaemia in West Bengal, Etiological role of environmental and genetic factors in Aplastic Anaemia, phenotypic variation of Hb E-Beta Thalassaemia. Present study looks into the etiological association of different cytokines in pathogenesis of aplastic anemia and in determining the disease severity.

Abstract:

Statement of the Problem: Interleukin-2 is a potent signalling molecule in the signalling cascade of the immune-mediated activation of T Lymphocytes leading to the destruction of haematopoietic stem cell. This forms the basis of acquired aplastic anaemia (AAA). The objective was to study the association of IL-2 in the bone marrow plasma (BMP) and peripheral blood plasma (PBP) in AAA patients. Methodology & Theoretical Orientation: Institutional ethical clearance was obtained and 52 BMP and PBP-paired samples were collected from the confirmed AAA patients and 10 non-aplastic anaemia controls. The level of IL-2 was measured by the quantitative enzyme-linked immunosorbent assay. The IL-2 level was compared between the AAA and control subjects as well as among the various severity grades of AAA. Mann– Whitney U test was used for statistical analysis. Findings: Significantly higher level of IL-2 was found in the BMP (75.33 ± 41.9 vs. 3.12 ± 1.82; p<0.00001) and PBP (48.54 ± 21.89 vs. 1.99 ± 1.25 p<0.00001) of AAA patients compared to the control subjects. The IL-2 levels were higher in patients with VSAA and SAA than those with NSAA in the PBP (65.6 ± 23.61 vs. 31.72 ± 7.64; p=0.00338) and (45.37 ± 16.25 vs. 31.72 ± 7.64; p=0.01468) respectively. The IL-2 levels were higher in patients with VSAA and SAA than those with NSAA in the BMP (115.01 ± 38.91 vs. 38.32 ± 19.49; p<0.00001) and (66.44 ± 23.34 vs. 38.32 ± 19.49; p=0.0006). The IL-2 level was higher in VSAA than SAA in PBP (65.6 ± 23.61vs. 45.37 ± 16.25; p=0.0114) and BMP (115.01 ± 38.91 vs. 66.44 ± 23.34; p=0.00044). Conclusion & Significance: Higher level of IL-2 in AAA patients compared to controls implies its role in the disease pathogenesis. Also, the higher the level of IL-2, more severe is the disease emphasizing its role in the disease severity.

Munira Borhany

National Institute of Blood Disease & BMT, Pakistan

Title: Application of the ISTH bleeding score in hemophilia
Speaker
Biography:

Munira Borhany is an Assistant Professor  and consultant hematologist in National Institute of Blood Disease & BMT, Pakistan.

Abstract:

Background:
Hemophilia is an inherited bleeding disorder. With proper treatment and self-care, persons with hemophilia can maintain an active, productive lifestyle. Hemophilia can be mild, moderate, or severe, depending on the degree of plasma clotting factor deficiency. The aim of the study was to assess the utility of ISTH-BAT in diagnosis, determining severity of the bleeding condition in newly diagnosed and known hemophilia patients, compare the bleeding score (BS) in adult and pediatric groups and investigate its association with plasma factor levels.
Methods: ISTH-BAT was used to assess BS in a total of 115 patients, 78 with hemophilia A, and 37 with hemophilia B and in 100 controls.
Results: BS was significantly higher in HA and HB patients as compared to controls, with no significant difference between HA and HB. The BS was very similar in newly diagnosed compared to known hemophilia patients, lower in pediatric compared to adult and higher in severe compared to mild HA patients.
Conclusion: The ISTH BAT can help identify hemophilia patients. Therefore it is a useful tool to distinguish between affected and unaffected individuals with bleeding. Moreover, an important finding of our study is that there is no major difference between the scores in known and newly diagnosed patients.

Nazish Mazari

University of Health Sciences, Pakistan

Title: Glucose-6-phosphate Dehydrogenase Defi ciency in Jaundiced Neonates and its Relationship with Severity of Hyperbilirubinemia
Speaker
Biography:

Nazish Mazari is the Assistant Professor of Haematology in the University of Health Sciences, Pakistan.

Abstract:

Statement of the Problem: G6PD is a house keeping enzyme, produced NADPH reduces free radicals and protects the body. Almost 7.5% of world population is carrier of G6PD deficiency. Neonatal jaundice is one of the manifestations of G6PD deficiency, observed in one third of newborns. Severe hyperbilirubinemia can cause kernicterus and even death. The purpose of this study is to determine the frequency of Glucose-6-Phosphate dehydrogenase deficiency in neonates with hyperbilirubinemia. Find the association between level of G6PD deficiency and severity of hyperbilirubinemia.
Methodology & Theoretical Orientation: We included 100 neonates with jaundice after excluding the other risk factors for hyperbilirubinemia. Initially screening for G6PD deficiency done with qualitative methods and deficient neonates were confirmed with quantitative method.History, examination and investigations like routine hematological investigations and total and direct bilirubin, Coomb’s test, G6PD qualitative and quantitative assay were done in all subjects. Findings: In this study following finding were found: 6% were G6PD deficient,In majority jaundice appeared on day third, Maternal age was found to higher in deficient neonates,There is increased rate of complication and death was found in deficient group, Bilirubin was higher and platelets were lower in deficient group that was statistically significant. Conclusion & Significance: G6PD deficiency is an important cause of neonatal jaundice and severe hyperbilirubinemia in newborns. Hemolysis may not be the sole factor for the development of jaundice in G6PD deficient neonates. There is association between lower enzyme activity and hyperbilirubinemia. Early identification and treatment may reduce the mortality and morbidity.

Hussam Ali Osman

Ahfad University for Women, Sudan

Title: Screening for 3.7 and 4.2 Deletion Mutations in Sudanese Patients Suspected with Alpha Thalassemia
Speaker
Biography:

Hussam Ali Osman is the Assistant Professor of Hemtology in Ahfad University for Women, Sudan.

Abstract:

Background: Alpha-thalassaemia is the genetic disorders that has high prevalence in human population around all over the world, characterised by microcytic and hypochromic anaemia. The carriers for the disease present with a mild anaemia and like these patients in the rural medical centres specially in Sudan can be miss diagnosed as iron deficiency anemia, because of low facilities to do further investigations for differentiation, so those patients could take iron therapy without response which exposes them to the risk of hemochromatosis. The disease was not known in Sudanese and there were no published data. The 3.7 and 4.2 alpha gene deletion mutations is the most common types of the alpha thalassaemia mutations in West Africa.
Aim: This study aimed to screen the participant samples for the 3.7 and 4.2 deletion mutations at the molecular level and to correlate the findings with the CBC parameters in order to find out an indicative criteria in routine haematological parameters that can help in diagnosis of alpha thalassaemia in Sudanese patients which should be confirmed later by genetic investigations.
Methods: This is a cross sectional study targeted 98 patients of highly suspected to have alpha thalassemia based on the microcytosis and hypochromasia of their RBCs, no past history of malaria (plasmodium falciparum infection), normal serum Ferritin level and free of any chronic diseases were selected to be screen for the 3.7 and 4.2 alpha gene deletion mutations by single tube multiplex GAP-PCR.
Results: The revealed of these 98 patients 7 were carriers for the 3.7 deletion mutation in the alpha globin genes and only one patient was 3.7 homozygous deletion mutation and all samples were negative for the 4.2 deletion mutation. The study revealed the 3.7 deletion mutation was found in Sudanese tribes originated from West Africa which are Four, Hawsa and Rezagat Tribes. The results showed the carrier patients of the 3.7 deletion mutation RBCs and HCT were significantly increased “P-value <0.05”, the RBCs were 7.230.78×1012/L in the adult male and 7.210.67×1012/L in adult female while in the children were 5.070.87×1012/L. The MCV and MCH were clearly decreased, but the MCHC slightly decreased. The Hb level revealed mild decrease without statistical significance “P-value ˃0.05” in the adult males were 11.70.57 g/dl and 11.250.64 g/dl while in the children were 11.62.95 g/dl. The Ferritin level was normal and the RDW_CV clearly increased. The quantitative Hb electrophoresis was normal in addition to the presence of many target cells in peripheral picture and no one of these carriers presence with clinical manifestations indicating for anaemia, but the homozygous 3.7 deletion mutation patient was anaemic and his basic haematological parameters were as follows RBCs 1.38×1012/L, Hb 4.99 g/dl, HCT 11%, MCV 79.7 fl, MCH 35.5 pg, MCHC 44.5 g/dl, RDW_CV 17.7% and the Ferritin level was1807 mg/dl and this elevation due to the blood transfusion.
Conclusion: The study confirmed the presence of the alpha thalassaemia in Sudanese population for the type 3.7 deletion mutation in the tribes that belong to the western reside of the Sudan and which is basically originated from the West Africa where the disease was already known and this transmission due to the migration.

Munira Borhany

National Institute of Blood Disease & BMT, Pakistan

Title: Congenital FXIII deficiency in Pakistan
Speaker
Biography:

Munira Borhany is an Assistant Professor  and consultant hematologist in National Institute of Blood Disease & BMT, Pakistan.

Abstract:

Introduction:
Factor XIII (FXIII) deficiency is a rare bleeding disorder (RBD) with an incidence of about one in 1–2.5 million and its incidence is higher in populations with consanguineous marriages.
Aim:
The aim of this study was to characterize patients and relatives from sixteen families with suspected FXIII deficiency from Pakistan and to identify the clinical characteristics and underlying mutations.
Material and Methods:
FXIII deficient patients, enrolled at National Institute of Blood diseases and Bone Marrow Transplantation were included in the study. The patients’ medical histories were recorded in a questionnaire. As a first indicator of FXIII deficiency, a 5M urea clot solubility test was used. Plasma FXIII A- and B-subunit antigen levels were determined by ELISA. FXIII activity was measured with an incorporation assay. Sequencing of all exons and intron/exon boundaries of F13A was performed.
Results:
We analyzed 16 families in which 32 (female 18 and 14 males) were severe FXIII deficient with FXIII level <1%. 19 first-degree relatives with mean FXIII level 71.19 ±21.1 are asymptomatic. Each family had a history of consanguineous marriages except one. 50% had significant family history of bleeding. Age at first presentation ranged from birth to 18 years. In these patients; we identified 23 mutations which includes 19 missense mutations, 2 Splicing mutations and 2-nonsense mutations with 7 novel mutations. Bleeding after injury (78%), umbilical cord bleeding (57%), intracranial bleed (43%), hematoma, bruises (39%), abortions and menorrhagia (38%), circumcision (35%) were the main clinical manifestations. Fresh frozen plasma / cryoprecipitate were used in the management of most patients and for prophylaxis in 8 patients with grade III bleeding
Conclusion:
We have analyzed a cohort of 51 individuals from 16 families in which 32 were severe FXIII deficient (homozygous or compound heterozygous) and remaining were FXIII deficient carriers (heterozygous). We identified 23 mutations in these families leading to congenital FXIII deficiency. Diagnosis of FXIII deficiency should be made on time
so that prophylaxis can be initiated immediately to prevent fatal bleeding and for genetic counseling.

  • Organ Specific Cancer

Session Introduction

Ojvind Lidegaard

University of Copenhagen, Denmark

Title: Newer oral contraceptives protect against ovarian cancer in young women
Speaker
Biography:

Øjvind Lidegaard is a Clinical Professor with expertise in Obstetrics & Gynaecology in University of Copenhagen, Denmark.

Abstract:

Material: Women 15-49 years during the period 1995-2014 were eligible. They were excluded if they immigrated after 1995, had previous cancer, venous thrombosis or were treated for infertility before entry. Final study population included 1,879,227 women.
Methods: Relative risk (RR) of ovarian cancer among users of any contemporary hormonal contraceptives was calculated using Poisson regression. Duration, time since last use and tumour histology were examined and the population prevented fraction calculated.
Results: During 21.4 million person-years, 1,249 incident ovarian cancers occurred. Compared to never users, reduced risks occurred with current or recent use; RR 0.58 (95% CI 0.49-0.68) and former use of any hormonal contraception RR 0.77 (0.66-0.91). RRs among current or recent users decreased with increasing duration; 0.82 (0.59-1.12) with Ë‚1-year use to 0.26 (0.16-0.43) with ≥10 years use. Similar results were achieved among women followed until first switch in contraceptive type. There was little evidence of major differences in risk estimates by tumour type or progestogen content of combined oral contraceptives. Progestogen-only products were not associated with ovarian cancer risk. Hormonal contraception prevented an estimated 21% of ovarian cancers in this population.
Conclusion: Contemporary combined hormonal contraceptives reduce ovarian cancer risk in young women, an effect related to duration of use, and which diminishes after stopping. Our data suggest no protective effect from progestogen-only products.

Olga P. Matylevich

NN Alexandrov National Cancer Center of Belarus, Belarus

Title: Pelvic Artery Embolization in Patients with Cervical Cancer Complicated by Hemorrhage: Single-Institution Experience in Belarus
Speaker
Biography:

Matylevich research and clinical interests evolve around treatment and prevention of cervical cancer. In 2008 Belarus implemented NCI clinical treatment guidelines for cervical cancer. Her research interests include epidemiology and statistical analysis of cervical cancer treatment outcomes following introduction of NCI treatment protocols. She is interested in standardization of National clinical protocols according to International treatments guidelines and she is interested in opportunities provided by International cancer research networks. She is interested in translational research and how it leads to meaningful health outcomes in the field of gynecologic oncology, particularly treatment of cervical cancer. She has been also included in the team of expert responsible for development and implementation of National Screening Program for gynecological cancers.

Abstract:

To investigate the efficacy of pelvic artery embolization (PAE) in patients with locally advanced and recurrent cervical cancer (CC) complicated by hemorrhage. Methods: A retrospective study was performed of consecutive 81 patients: 68 (84%) with primary locally advanced CC and 13 (16%) with recurrent disease. Results: The PAE controlled the hemorrhage in 76 (94%) patients. After successful embolization, 46 of 68 (68%) primary CC patients, started antineoplastic treatment and 29 of these women (43%) subsequently completed primary treatment. During the follow-up period, 67 (83%) patients died of disease, and 4 (5%) died of other causes. The adjusted one-year survival was 41.4% (SE 5.6%), five-year survival was 17.9% (SE 4.5%), and median adjusted survival was 8.4 months. Survival of the 22 (32%) patients who did not receive further treatment, and 46 (68%) patients who continued the treatment was significantly different, with a one-year adjusted survival of 15.2% (SE 8.1%) and 53.5% (SE 7.4%), respectively. None of the patients without further treatment survived 5 years whereas in the group undergoing further treatment, the 5-year-adjusted survival was 24.0% (SE 6.8%), and the median adjusted survival was 5.4 months and 12.8 months respectively (Ñ€ <0.001). Conclusions: PAE was effective in controlling hemorrhage in 94% of patients with locally advanced and recurrent CC. Sixty-eight percent of patients were able to undergo further antitumor treatment. PAE is a minimally invasive intervention that can be effective at any stage of treatment in patients with CC preventing with hemorrhage.

  • Hemato-Oncology & Blood Cancers

Session Introduction

Omer Naseem

University of Health Sciences, Pakistan

Title: Parovirus B19 in Patients of Acute Lymphoblastic Leukemia with prolonged Cytopenia
Speaker
Biography:

Omer Naseem graduated from FMH college of medicine and Dentistry in 2013 and after completing is housejob from Jinnah Hospital Lahore,developed a keen interest in Hematology and Oncology.He then worked with GIZ an ngo of international repute on the “ Safe blood transfusion project” where he was involved in inspections of blood bank practices and working to enhance the safety measures involved in blood banking in Pakistan.He then enrolled in Mphil Hematology programme in University of Health Sciences Lahore in 2015 and has since then participated in mulitple workshops and seminars and is keen to further enhance his vision and skills as a future hematologist.

Abstract:

INTRODUCTION: Parvovirus B19 is a small DNA virus and an important cause of cytopenia(s) and suppressed erythropoiesis. It is known to replicates exclusively in erythroid progenitor cells and also known to cause suppression of megakaryocytic colonies. Persistent B19 infection tends to occur in hematological malignancies. The aim of the study was to find the frequency of parvovirus b19 infection in patients with ALL with prolonged cytopenia.
MATERIALS AND METHOD: Forty nine patients suffering from ALL were enrolled for the study. All patients had persistent prolonged cytopenia for greater than 10 days beyond the scheduled date of next chemotherapy. B19 infection was investigated by detection of viral DNA in serum by Real time PCR.
RESULTS: Among the 49 patients enrolled with ALL only 6 (12.2%) were found to be Parvovirus B19 DNA positive. The infection wasn’t suspected on clinical grounds on any of the patients. Most of the patients were males (40 male and 9 females). All the patients were cytopenic with anemia, thrombocytopenia or neutropenia.
CONCLUSION:
We concluded that patients with ALL are at particular risk of persistent B19 infection. Moreover, it is important to consider B19 infection as a possible cause of unexplained cytopenia(s) in these patients. Thus screening for parvovirus B19 DNA by quantitative polymerase chain reaction in cytopenic patients with ALL is suggested.

Sanja Trajkova

University Clinic for Hematology, Macedonia

Title: Mutational Status of IGVH in correlation with Genetic Abnormalities of Patients with Chronic Lymphocytic Leukemia in Macedonia - Single Centre Experience
Speaker
Biography:

Sanja Trajkova is a specialist in Internal Medicine in the University Clinic for Hematology, Macedonia.

Abstract:

Background: B-cell chronic lymphocytic leukemia (CLL) is a clinically heterogeneous disease with many patients surviving for decades with watch and wait strategy or no treatment, whereas others have inferior survival despite therapy. In recent years, new molecular prognostic factors approached   that have significantly improved the stratification of the CLL patients. One of the most important molecular predictors, the immunoglobulin VH gene mutational status, divides CLL into two prognostic groups, where unmutated U-CLL are associated with remarkably worse prognosis than mutated M-CLL. In many studies multiple recurring chromosomal aberrations appear to be effective prognostic markers in CLL. The most common abnormalities include 11q deletions, trisomy 12, 17p deletions and 13q deletions.  The aim of the study was first time evaluation of rearrangement of IG genes and genetic abnormalities in Macedonian CLL patients.   Methods: In this study, mutational status and configuration of IGHV-IGHD-IGHJ rearrangements in 70 treatment naïve CLL patients were analyzed using reverse transcriptase– polymerase chain reaction (RT-PCR) and sequencing methodology at the center for bimolecular pharmaceutical analyses, faculty of pharmacy, Skopje, Macedonia. We used multiplex ligation-dependent probe amplification (MLPA) for detection of most common genetic abnormalities.   Results: Our evaluation have shown that 54.7% patients belonged to the U-CLL subset, whereas 45.3% belonged to the M-CLL subset. The most frequently expressed IGHV subgroup was IGHV3 (40%), followed by IGHV4 (29%), IGHV1(27%) and  IGHV5 (3%).  The most frequent subgroup with 8% were IGHV1-69*13 and IGHV4-34*0.  In the IGHD and IGHJ sets most frequently expressed was IGHD3 (59.7%), IGHJ6 gene (53.1%) respectively. We found that 80% of   IGHV1, 65.6% of IGHD3 and 83.3% of IGHJ6 gene were U-CLL (p=0.0005). Frequency of genetic aberrations by MLPA  were 13q14 deletion (20%)   follow by 11q deletion (14%) then  trisomy 12 (13%)and 17p deletion (6.6%),multipal mutations(6.7%) and NOTCH mutation(5.3%). Conclusions: Our evaluation of mutational status on IGVH, IGDH, and IGJH gene in Macedonian CLL patients resulted with data which are consubstantial to those from Mediterranean area. Novel mutations discovered in this study must be validated through large cohort studies and may offer clues to the mechanisms underlying the   difference in CLL  survival. In the future, therapeutic strategies targeting these genes should be evaluated and considered.   This is the first  mutation analysis of CLL patients in Macedonia using next generation sequencing.