Autoimmunity in Chronic Lymphocytic Leukemia Thomas M. Habermann, M.D. Professor of Medicine Mayo...

Autoimmunity in Chronic Lymphocytic Leukemia

Autoimmunity in Chronic Lymphocytic Leukemia

Thomas M. Habermann, M.D.

Professor of Medicine

Mayo Clinic College of Medicine

Rochester, MN

October 25, 2013

New York, New York

Thomas M. Habermann, M.D.

Professor of Medicine

Mayo Clinic College of Medicine

Rochester, MN

October 25, 2013

New York, New York

DisclosuresThomas M. Habermann, M.D.

DisclosuresThomas M. Habermann, M.D.

• NCI/NIH Grants:• ECOG U10 Grant PI: 1993-present• R01: Co-PI

• SNPs in lymphoma: 2002-present• Cancer Control: 2002-2012

• Lymphoma SPORE: co-investigator: 2002-present

• Foundation: Lymphoma Research Foundation: Mantle Cell Lymphoma

• NCI/NIH Grants:• ECOG U10 Grant PI: 1993-present• R01: Co-PI

• SNPs in lymphoma: 2002-present• Cancer Control: 2002-2012

• Lymphoma SPORE: co-investigator: 2002-present

• Foundation: Lymphoma Research Foundation: Mantle Cell Lymphoma

Four Questions Four Questions

• What are the clinical manifestations of autoimmunity in CLL?

• What are the associations of autoimmunity in CLL?

• What is the biology?

• What are the treatment approaches?

• What are the clinical manifestations of autoimmunity in CLL?

• What are the associations of autoimmunity in CLL?

• What is the biology?

• What are the treatment approaches?

RBCRBCHaptoglobinHaptoglobin

AlbuminAlbumin

HgbHgbHemosiderinHemosiderin

HgbHgbHgbHgb

HgbHgb

Hgb-HPcomplexHgb-HPcomplex

MethemalbuminMethemalbumin

Antihuman IgGAntihuman IgG

Antihuman Complement, Antihuman Complement, C3C3

Antihuman IgGAntihuman IgG

Antihuman Complement, Antihuman Complement, C3C3

Human IgG or C3Human IgG or C3red cell antibodyred cell antibodyHuman IgG or C3Human IgG or C3red cell antibodyred cell antibody

Red cellRed cell

Paraneoplastic PemphigusParaneoplastic Pemphigus

Paraneoplastic PemphigusParaneoplastic Pemphigus

Cold Agglutinin Cold Agglutinin

Rouleaux

Peripheral blood, Wright-Giemsa, 800x

Hodgson K, Ferrer G, Montserrat E, et al. Haematologica. 2011;96: 752-761.

Mechanisms of Autoimmune Disease in Chronic Lymphocytic LeukemiaMechanisms of Autoimmune Disease in Chronic Lymphocytic Leukemia

AA Antigenic presentationAntigenic presentation

DD Antigenic driveAntigenic drive CC Autoantibody secretionAutoantibody secretion

BB Cytokine secretionCytokine secretion and cell-cell contact and cell-cell contact

Loss of toleranceLoss of tolerance

AutoimmuneAutoimmunehemolytic anemiahemolytic anemia

Cold agglutininCold agglutinindiseasedisease

Paraneoplastic pemphigusParaneoplastic pemphigus

Dendritic cellDendritic cellMacrophageMacrophage

IL-6IL-6IL-10IL-10

TGF-TGF- TNFTNF

FAS-LFAS-L

T cellT cell

ErythrocyteErythrocyte

B cellsB cells

Polyclonal Polyclonal IgGIgG

Rh or B3Rh or B3

T cellT cell

CLL cell

Polyreactive BCRPolyreactive BCR

Auto-antigensAuto-antigens

Cross-reactiveCross-reactivemonoclonal monoclonal antibodiesantibodies

Anti-li IgMAnti-li IgM

NFBc-

Jun

c-Fos

NFB

++

++

CXCL12CXCL12

CXCR4 CXCR4

GCR

Germinal CenterGerminal Center

G

Post-inflammatoryGenes

BurgerJA, Motserrat E. Blood . 2013;121:1501-1509.

Burger JA, Montserrat E. Blood. 2013;121, 1501-1509.

PI3Ks

Btk

Syk

Syk

Btk

PI3KsG

Homing &retention

Survival &proliferation

CXCL12CXCL12

CXCR4,CXCR4,CXCR5CXCR5

T CellsT Cells

CCL3CCL3CCL4CCL4

BCRBCR

AntigenAntigenCD79CD79a,ba,b

CD49dCD49d(VLA-4)(VLA-4)

MSCMSC

CLL

VCAM-1, FNVCAM-1, FN

NLC

CXCL12,CXCL13

CD40LCD40LCD40CD40

++

Chronic Lymphocytic Leukemia:Biology

Chronic Lymphocytic Leukemia:Biology

• Acquired T-cell defects:• Numerical increase in T-cells• Inversion of the CD4:CD8 ratio

• Production of CLL cells of the inhibitory cytokines IL-6, Il-10, TNF, and TGF-beta

• Alterations in T-cell cytoskeleton formation and vesicle transportation

Görgün G, Holderried TAW, Zahrieh D, et al. J Clin Invest 2005;115:1797-1805.

Ramsay AG, Gribben J. Haematologica 2009;94:11198-1202.

• Acquired T-cell defects:• Numerical increase in T-cells• Inversion of the CD4:CD8 ratio

• Production of CLL cells of the inhibitory cytokines IL-6, Il-10, TNF, and TGF-beta

• Alterations in T-cell cytoskeleton formation and vesicle transportation

Görgün G, Holderried TAW, Zahrieh D, et al. J Clin Invest 2005;115:1797-1805.

Ramsay AG, Gribben J. Haematologica 2009;94:11198-1202.

Chronic Lymphocytic LeukemiaBiology ITP and AIHA Associations

Chronic Lymphocytic LeukemiaBiology ITP and AIHA Associations

• Unmutated IGHV gene

• High ZAP70 expression

• Increased serum beta-2 microglobulin

Zent CS, Ding W, Schwager SM, et al. Br J Haematol. 2008;141:615- 621.

Moreno C, Hodgson K, Ferrer G, et al. Blood. 2010116:4771-4776.

Visco C, Giaretta I, Ruggeri M, et al. Leukemia. 2007;21:1092-1093.

• Unmutated IGHV gene

• High ZAP70 expression

• Increased serum beta-2 microglobulin

Zent CS, Ding W, Schwager SM, et al. Br J Haematol. 2008;141:615- 621.

Moreno C, Hodgson K, Ferrer G, et al. Blood. 2010116:4771-4776.

Visco C, Giaretta I, Ruggeri M, et al. Leukemia. 2007;21:1092-1093.

Chronic Lymphocytic Leukemia:Biology

Chronic Lymphocytic Leukemia:Biology

• CLL is associated with impairment of the innate immune system

Schlesinger M, Broman I, Lugassy G. Leukemia 1996;10:1509-1513.

Maki G, Hayes GM, Naji A, et al. Leukemia 2008;22:998-1006.

• CLL is associated with impairment of the innate immune system

Schlesinger M, Broman I, Lugassy G. Leukemia 1996;10:1509-1513.

Maki G, Hayes GM, Naji A, et al. Leukemia 2008;22:998-1006.

Chronic Lymphocytic LeukemiaAutoimmunity: Why Else Important?

Chronic Lymphocytic LeukemiaAutoimmunity: Why Else Important?

• Is this is important in how a patient might be managed? A Rai stage III or IV or Binet stage C patient could be “down-staged” to a I or II or A.

• Patients with active AIHA and ITP are still excluded from randomized clinical trials

• “AID cytopenia occurred in all stages of CLL, patients responded well to treatment, AID did not alter OS, and AID contributed to death in only 6 (12%) of patients.”

Zent CS, Ding W, Reinalda MS, et al. Leuk & Lymph 2009;50:1261-1268.

• Is this is important in how a patient might be managed? A Rai stage III or IV or Binet stage C patient could be “down-staged” to a I or II or A.

• Patients with active AIHA and ITP are still excluded from randomized clinical trials

• “AID cytopenia occurred in all stages of CLL, patients responded well to treatment, AID did not alter OS, and AID contributed to death in only 6 (12%) of patients.”

Zent CS, Ding W, Reinalda MS, et al. Leuk & Lymph 2009;50:1261-1268.

Chronic Lymphocytic LeukemiaAutoimmunity: Why Important?Chronic Lymphocytic LeukemiaAutoimmunity: Why Important?

BM Failure AID p=

Total 228 (75%) 75 (25%)

Median OS 4.4 yrs 9.1 yrs <0.001

CLL dx 1 yr 9.3 yrs =0.881

♂/♀ 160/68 =0.05

Vs . OS

Without (yrs) 12.4/9.7 =.045

Zent CS, Ding W, Schwager SM, et al. Br J Haematol 2008;141:615-621.

BM Failure AID p=

Total 228 (75%) 75 (25%)

Median OS 4.4 yrs 9.1 yrs <0.001

CLL dx 1 yr 9.3 yrs =0.881

♂/♀ 160/68 =0.05

Vs . OS

Without (yrs) 12.4/9.7 =.045

Zent CS, Ding W, Schwager SM, et al. Br J Haematol 2008;141:615-621.

AID 75 47 29 15 8 4

228 123 66 33 11 4

Survival from Diagnosis of Cytopenia

Chronic Lymphocytic Leukemia:Positive DAT (Coombs’ test)

Chronic Lymphocytic Leukemia:Positive DAT (Coombs’ test)

• Incidence: 2.3%-7%

• AIHA associated with:• advanced stage• Active CLL• Older patients independent of stage or

durationMauro FR, Foa R, Cerretti R, et al. Blood 2000;95:2786-2792.

Moreno C, Hodgson K, Ferrer G, et al. Blood 2010;116:4771-4776.

Barcellini W, Capalbo S, Agostinelli RM, et al. Haematologica 2006;91:1689-1692.

Zent CS, Ding W, Reinalda MS, et al. Leuk & Lymph 2009;50:1261-1268.

• Incidence: 2.3%-7%

• AIHA associated with:• advanced stage• Active CLL• Older patients independent of stage or

durationMauro FR, Foa R, Cerretti R, et al. Blood 2000;95:2786-2792.

Moreno C, Hodgson K, Ferrer G, et al. Blood 2010;116:4771-4776.

Barcellini W, Capalbo S, Agostinelli RM, et al. Haematologica 2006;91:1689-1692.

Zent CS, Ding W, Reinalda MS, et al. Leuk & Lymph 2009;50:1261-1268.

Chronic Lymphocytic Leukemia:Positive DAT: prognosis

Chronic Lymphocytic Leukemia:Positive DAT: prognosis

Series # Prognosis

Mauro 1203 active disease, no OS influence

Zent 1750 Immune cytopenia superior OS

Moreno 961 Immune cytopenia superior OS

Dearden 783 + DAT poorer response to Rx

Mauro FR, Foa R, Cerretti R, et al. Blood 2000;95:2786-2792.

Zent C, Ding W, Schwager SM, et al. Br J Haematol 2008;141:615-621.

Moreno C, Hodgson K, Ferrer G, et al. Blood 2010;116:4771-4776.

Dearden C, Wase R, Else M, et al. Blood 2008;111:1820-1826.

Series # Prognosis

Mauro 1203 active disease, no OS influence

Zent 1750 Immune cytopenia superior OS

Moreno 961 Immune cytopenia superior OS

Dearden 783 + DAT poorer response to Rx

Mauro FR, Foa R, Cerretti R, et al. Blood 2000;95:2786-2792.

Zent C, Ding W, Schwager SM, et al. Br J Haematol 2008;141:615-621.

Moreno C, Hodgson K, Ferrer G, et al. Blood 2010;116:4771-4776.

Dearden C, Wase R, Else M, et al. Blood 2008;111:1820-1826.

Chronic Lymphocytic Leukemia:Positive DAT After Treatment

Chronic Lymphocytic Leukemia:Positive DAT After Treatment

• CCL4 trial:

Treatment +DAT AIHA p< • Chlorambucil 14% 12%• Fludarabine (F): 13% 11%• Fludarabine 10% 5% .01 + cyclophosphamide

• German CLL 8 trial FC +/-R AIHA risk: 1%

• Conclusion: Risk after purine analog no greaterDearden C, Wade R, Else M, et al. Blood 2008;111:1820-1826.

Hallek M, Fischer K, Fingerle-Rowson G, et al. Lancet 2010;376:1164-1174.

• CCL4 trial:

Treatment +DAT AIHA p< • Chlorambucil 14% 12%• Fludarabine (F): 13% 11%• Fludarabine 10% 5% .01 + cyclophosphamide

• German CLL 8 trial FC +/-R AIHA risk: 1%

• Conclusion: Risk after purine analog no greaterDearden C, Wade R, Else M, et al. Blood 2008;111:1820-1826.

Hallek M, Fischer K, Fingerle-Rowson G, et al. Lancet 2010;376:1164-1174.

Chronic Lymphocytic Leukemia:Positive DAT (Coombs’ test)

Chronic Lymphocytic Leukemia:Positive DAT (Coombs’ test)

• Treatment:• 34/37 treatment directed specifically at AIHA• 86% corticosteroids• 13 (35%) achieved a CR and 14 (38%) PR with

a median duration of response of 0.62 years

Zent CS, Ding W, Schwager SM, et al. 2008;141:615-621.

Other refrerences:

Moreno C, Hodgson K, Ferrer G, et al. Blood 2010;116:4771-4776.

Visco C, GiarettaI, Ruggeri M, et al. Leukemia 2008:222:998-1006.

• Treatment:• 34/37 treatment directed specifically at AIHA• 86% corticosteroids• 13 (35%) achieved a CR and 14 (38%) PR with

a median duration of response of 0.62 years

Zent CS, Ding W, Schwager SM, et al. 2008;141:615-621.

Other refrerences:

Moreno C, Hodgson K, Ferrer G, et al. Blood 2010;116:4771-4776.

Visco C, GiarettaI, Ruggeri M, et al. Leukemia 2008:222:998-1006.

Chronic Lymphocytic Leukemia:Immune Thrombocytopenia

Chronic Lymphocytic Leukemia:Immune Thrombocytopenia

• Incidence: <1%-5.0%

• The diagnosis is a clinical one • Sudden drop in platelet count (> 50% or <100

X 10(9)/L)• Absence of splenomegaly, infection, or

chemotherapy• Increased megakaryocytes

Zent CS, Ding W, Reinalda MS, et al. Leuk & Lymph 2009;50:1261-1268.

• Incidence: <1%-5.0%

• The diagnosis is a clinical one • Sudden drop in platelet count (> 50% or <100

X 10(9)/L)• Absence of splenomegaly, infection, or

chemotherapy• Increased megakaryocytes

Zent CS, Ding W, Reinalda MS, et al. Leuk & Lymph 2009;50:1261-1268.

Chronic Lymphocytic LeukemiaImmune Thrombocytopenia

Chronic Lymphocytic LeukemiaImmune Thrombocytopenia

• + DAT in 47% of patients with ITP

• 31 (89%) were treated• 27 (87%) received corticosteroids and only

treatment in 11 (35%)• 9 (29%) CR and 11 (35%) PR with a median

duration of response of 1.9 years

Zent CS, Ding W, Reinalda MS, et al. Leuk & Lymph 2009;50:1261-1268.

• + DAT in 47% of patients with ITP

• 31 (89%) were treated• 27 (87%) received corticosteroids and only

treatment in 11 (35%)• 9 (29%) CR and 11 (35%) PR with a median

duration of response of 1.9 years

Zent CS, Ding W, Reinalda MS, et al. Leuk & Lymph 2009;50:1261-1268.

Chronic Lymphocytic LeukemiaImmune Thrombocytopenia

Chronic Lymphocytic LeukemiaImmune Thrombocytopenia

• Treatment:• If CLL quiescent, then treat as ITP only:

• Corticosteroids, splenectomy• Alternative immunosuppression• Rituximab• IV immunoglobulin• Thrombopoietin receptor agonists

• If active disease, then treat the underlying disease

• Treatment:• If CLL quiescent, then treat as ITP only:

• Corticosteroids, splenectomy• Alternative immunosuppression• Rituximab• IV immunoglobulin• Thrombopoietin receptor agonists

• If active disease, then treat the underlying disease

Chronic Lymphocytic Leukemia and AIHA and ITP

Chronic Lymphocytic Leukemia and AIHA and ITP

• Purine analogs should be avoided in patients with a history of autoimmune cytopenias, particularly if related to purine-analog therapy

• R-CVP : 14/20 CR; 5/20 PR; median TTT 27.7 mos Bastion Y Coiffier B, Dumontet C, et al. Ann Oncol 1992;3:171-172.

Myint H, Copplestone JA, Orchard J, et al. Br J Haematol 1995;91:341-344.

Bowen DA, Call TG, Shanafelt TD, et al. Leuk & Ly 2010;51:620-627.

• Purine analogs should be avoided in patients with a history of autoimmune cytopenias, particularly if related to purine-analog therapy

• R-CVP : 14/20 CR; 5/20 PR; median TTT 27.7 mos Bastion Y Coiffier B, Dumontet C, et al. Ann Oncol 1992;3:171-172.

Myint H, Copplestone JA, Orchard J, et al. Br J Haematol 1995;91:341-344.

Bowen DA, Call TG, Shanafelt TD, et al. Leuk & Ly 2010;51:620-627.

Chronic Lymphocytic LeukemiaImmune Thrombocytopenia

Chronic Lymphocytic LeukemiaImmune Thrombocytopenia

• A study of 1,278 patients demonstrated that acute ITP at diagnosis or at any time in the disease was associated with an inferior outcome compared to those who never had ITP

• This was probably related to the association of ITP with an unmutated IGVH gene

Visco C, GiarettaI, Ruggeri M, et al. Leukemia 2007;21:1092-1093.

Visco C, Ruggeri M, Evangelista LM, et al. Blood 2008;111:1110-1116.

• A study of 1,278 patients demonstrated that acute ITP at diagnosis or at any time in the disease was associated with an inferior outcome compared to those who never had ITP

• This was probably related to the association of ITP with an unmutated IGVH gene

Visco C, GiarettaI, Ruggeri M, et al. Leukemia 2007;21:1092-1093.

Visco C, Ruggeri M, Evangelista LM, et al. Blood 2008;111:1110-1116.

Chronic Lymphocytic LeukemiaPure Red Cell Aplasia

Chronic Lymphocytic LeukemiaPure Red Cell Aplasia

• Incidence: 0.5%-2%

• Parvovirus IgM serology was positive in 3/6 patients

• 9/9 treatment; corticosteroids 7/9 and in 5 this was the only treatment

• Median duration of initial response was 0.24 years

Zent CS, Ding W, Reinalda MS, et al. Leuk & Lymph 2009;50:1261-1268.

• Incidence: 0.5%-2%

• Parvovirus IgM serology was positive in 3/6 patients

• 9/9 treatment; corticosteroids 7/9 and in 5 this was the only treatment

• Median duration of initial response was 0.24 years

Zent CS, Ding W, Reinalda MS, et al. Leuk & Lymph 2009;50:1261-1268.

Chronic Lymphocytic LeukemiaAutoimmune Neutropenia

Chronic Lymphocytic LeukemiaAutoimmune Neutropenia

• Incidence: <1%-2%

• Presentation: serious neutropenic infections

• No responders in Mayo Clinic experience

Zent CS, Ding W, Reinalda MS, et al. Leuk & Lymph 2009;50:1261-1268.

• Incidence: <1%-2%

• Presentation: serious neutropenic infections

• No responders in Mayo Clinic experience

Zent CS, Ding W, Reinalda MS, et al. Leuk & Lymph 2009;50:1261-1268.

Chronic Lymphocytic Leukemia:No Cases of

Chronic Lymphocytic Leukemia:No Cases of

• Acquired hemophilia

• Acquired von Willebrand disease

• Acquired hemophilia

• Acquired von Willebrand disease

Chronic Lymphocytic Leukemia:Is AID a risk for developing CLL?Chronic Lymphocytic Leukemia:Is AID a risk for developing CLL?

• Nordic case-control study: risk of CLL was much higher in patients with a positive personal or family history of CLL

• Individuals who developed CLL had a much higher incidence of AIHA: AIHA carried a 3.86-fold risk of developing CLL

• Positive OR (6.7) for AIHALandgren O, Engels EA, Caporaso NE, et al. Blood 2006;108:292-296

Landgren O, Gridley G, Check D, et al. Br J Haematol 2007;139:791-798.

Söderberg KC, Jonsson F, Winqvist O, et al. Eur J Cancer 2006;42:3028-3033

• Nordic case-control study: risk of CLL was much higher in patients with a positive personal or family history of CLL

• Individuals who developed CLL had a much higher incidence of AIHA: AIHA carried a 3.86-fold risk of developing CLL

• Positive OR (6.7) for AIHALandgren O, Engels EA, Caporaso NE, et al. Blood 2006;108:292-296

Landgren O, Gridley G, Check D, et al. Br J Haematol 2007;139:791-798.

Söderberg KC, Jonsson F, Winqvist O, et al. Eur J Cancer 2006;42:3028-3033

Chronic Lymphocytic Leukemia:Controversies

Chronic Lymphocytic Leukemia:Controversies

• Clinically apparent autoimmune disorders have been retrospectively reported in 2% to 12%

• Positive serum markers, “serologic autoimmunity” have been reported in 8%-41% of patients

• However, case control studies do not suggest an increase in AID in patients with CLL

Barcillini W, Capalbo S, Agostinelli RM, et al. Haematologica 2006;91:1689-1682.

Vanura K, Le T, Estabauer H, et al. Haematologica. 2008;93: 1912-1916.

Hamblin TJ, Osceier DG, Young BJ. J Clin Path 1986;39:713-716.

• Clinically apparent autoimmune disorders have been retrospectively reported in 2% to 12%

• Positive serum markers, “serologic autoimmunity” have been reported in 8%-41% of patients

• However, case control studies do not suggest an increase in AID in patients with CLL

Barcillini W, Capalbo S, Agostinelli RM, et al. Haematologica 2006;91:1689-1682.

Vanura K, Le T, Estabauer H, et al. Haematologica. 2008;93: 1912-1916.

Hamblin TJ, Osceier DG, Young BJ. J Clin Path 1986;39:713-716.

Chronic Lymphocytic Leukemia:Other Associations

Chronic Lymphocytic Leukemia:Other Associations

• Cold agglutinin disease

• Paraneoplastic pemphigus

• Peripheral neuropathy: anti-myelin-assoicated glycoprotein (anti-MAG)

• Focal cresentric pauci-immune glomerular injury (Antineutrophil cytoplasmic antibodies (ANCAs))

Ruzickova S, Pruss A, Odendahl M, et al. Blood 2002;100:3419-3422.

Taintor AR, Leiferman KM, Hashimoto T, et al. J AM Acad Dermatol 2007;56:S73-6.

Henricksen KJ, Hong RB, Sobrero MI, et al. Am J Kidney Diseases 25 October 2010. http://dx.doi.org/10.1053/j.ajkd.2010.08.011.

• Cold agglutinin disease

• Paraneoplastic pemphigus

• Peripheral neuropathy: anti-myelin-assoicated glycoprotein (anti-MAG)

• Focal cresentric pauci-immune glomerular injury (Antineutrophil cytoplasmic antibodies (ANCAs))

Ruzickova S, Pruss A, Odendahl M, et al. Blood 2002;100:3419-3422.

Taintor AR, Leiferman KM, Hashimoto T, et al. J AM Acad Dermatol 2007;56:S73-6.

Henricksen KJ, Hong RB, Sobrero MI, et al. Am J Kidney Diseases 25 October 2010. http://dx.doi.org/10.1053/j.ajkd.2010.08.011.

Chronic Lymphocytic Leukemia:Not Autoimmune Associations

Chronic Lymphocytic Leukemia:Not Autoimmune Associations

• Acquired angio-edema

• Renal disease (direct damage):• Membranoproliferative GN, cryoglobulinemic

GN, mebranous GN

• Acquired angio-edema

• Renal disease (direct damage):• Membranoproliferative GN, cryoglobulinemic

GN, mebranous GN

Chronic Lymphocytic Leukemia:Conclusions

Chronic Lymphocytic Leukemia:Conclusions

• AIHA and ITP are strongly associated with CLL

• Management of these require careful clinical considerations

• AIHA and ITP are strongly associated with CLL

• Management of these require careful clinical considerations

Thank YouThank You

Organizing Committee: Morton Coleman, MD; Ruben Niesvizky, MD;

Richard R. Furman, MD; John P. Leonard, MD

Imedex

Sandy Campbell, Faculty Liason

Sponsors

Patients

Attendees

Organizing Committee: Morton Coleman, MD; Ruben Niesvizky, MD;

Richard R. Furman, MD; John P. Leonard, MD

Imedex

Sandy Campbell, Faculty Liason

Sponsors

Patients

Attendees