Pseudo-Richter Transformation Following BTKi Interruption in CLL: A Systematic Review of Clinical, Biological, and Pathologic Features

Background Pseudo-Richter transformation (pseudo-RT) is a rare and recently recognized phenomenon characterized by a transient large B-cell proliferation occurring shortly after interruption of Bruton tyrosine kinase inhibitor (BTKi) therapy in chronic lymphocytic leukemia (CLL). Although it closely mimics true Richter transformation (RT) clinically and histologically, pseudo-RT follows a distinct and reversible course, and its recognition is essential to avoid misdiagnosis and inappropriate treatment. Methods We report a new case of pseudo-RT with circulating large atypical cells and present a systematic review of published cases. Results Fifteen cases were identified. The median age at pseudo-RT onset was 72 years, and 87% of patients were male. All analyzed CLL IGHV sequences were unmutated (5/5 tested). Trisomy 12 was the most frequent cytogenetic abnormality (7/9, 78%), and TP53 disruption was present in six patients, including del(17p) and TP53 mutations. Pseudo-RT typically developed 3–13 days after BTKi interruption and most cases presented with lymphadenopathy, B symptoms, lymphocytosis, and elevated lactate dehydrogenase levels. Histological examination consistently demonstrated diffuse large B-cell proliferations with high Ki-67 expression (50–90%) and retained expression of CD5 and CD23, with a non–germinal center B-cell phenotype in all evaluable cases (9/9). Reintroduction of BTKi therapy resulted in complete clinical, laboratory, and radiologic resolution in all patients. No cases of subsequent RT were reported during follow-up (3–36 months). Conclusion pseudo-RT is a reversible event, and awareness of its characteristic features is essential to prevent overtreatment. MicroAbstract Pseudo-Richter transformation is a transient Richter-like phenomenon that may occur shortly after temporary interruption of BTK inhibitor therapy in CLL. It may present with circulating blastoid cells and high-risk molecular features, yet shows rapid reversibility after BTKi reinitiation. Recognition of this entity may help avoid misdiagnosis and unnecessary treatment escalation.