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Background  Eradication of minimal residual disease (MRD), at the end of Fludarabine-Cyclophosphamide-Rituximab (FCR) treatment, is a validated surrogate marker for progression-free and overall survival in chronic lymphocytic leukaemia. But such deep responses are also associated with severe immuno-depletion, leading to infections and the development of secondary cancers.    Methods  We assessed, blood MRD and normal immune cell levels at the end of treatment, in 162 first-line FCR patients, and analysed survival and adverse event.    Results  Multivariate Landmark analysis 3 months after FCR completion identified unmutated  IGHV  status (HR, 2.03,  p  = 0.043), the level of MRD reached (intermediate versus low, HR, 2.43,  p  = 0.002; high versus low, HR, 4.56,  p  = 0.002) and CD4 > 200/mm 3  (HR, 3.30,  p  <  0.001) as factors independently associated with progression-free survival (PFS); neither CD8 nor NK counts were associated with PFS. The CD4 count was associated with PFS irrespective of  IGHV  mutational status, but only in patients with detectable MRD (HR, 3.51,  p  = 0.0004, whereas it had no prognostic impact in MRD < 10 − 4  patients:  p  = 0.6998). We next used a competitive risk model to investigate whether immune cell subsets could be associated with the risk of infection and found no association between CD4, CD8 and NK cells and infection.    Conclusions  Consolidation/maintenance trials based on detectable MRD after FCR should investigate CD4 T-cell numbers both as a selection and a response criterion, and consolidation treatments should target B-cell/T-cell interactions.

Prognostic role of CD4 T-cell depletion after frontline fludarabine, cyclophosphamide and rituximab in chronic lymphocytic leukaemia