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3q−, 3q+ anomaly in malignant proliferations in humans
3 q - , 3q + Anomaly in Malignant Proliferations in Humans Cristina Mecucci, Kristina Vermaelen, Guido Tricot, Andries Louwagie, Jean-Louis Michaux, Andr6 Bosly, Jos6 Thomas, Dario Barbieri, Herman Van Den Berghe
ABSTRACT: Anomalies of both No. 3 chromosomes, of the t(3q-; 3q+) type can be observed in human malignancy as reported previously. It is our experience that this anomaly is found predominantly in myeloproliferative disorders, as a rather rare event, though occurring more frequently than similar exchanges between other homologous chromosomes. Previous claims about a relationship between this anomaly and thrombocytosis could not be confirmed, but the features found in a few patients indicate that further research should be undertaken to clarify this point. INTRODUCTION Cytogenetic studies with b a n d i n g techniques have revealed the association of some specific structural chromosomal abnormalities and certain malignant hemopathies: e.g., t(9;22) and chronic myeloid leukemia; t(8;21) and acute n o n l y m phocytic leukemia; t(15;17) and acute promyelocytic leukemia; and t(8;14) and Bnrkitt's l y m p h o m a or Burkitt-type acute lymphoblastic leukemia. For various other structural anomalies, however, such a close relationship has not yet been established. A few years ago Golomb et al. [1] reported on the association of a t ( 3 q - ; 3 q + ) translocation and thrombocytosis (platelets more than 600 × 109/1) i n two patients with acute n o n l y m p h o c y t i c leukemia and hypothesized that the long arm of chromosome No. 3 may be involved in megakaryocyte maturation and platelet production. In the present paper hematological and cytogenetic findings in 10 patients with a t ( 3 q - ; 3q + ) translocation will be presented and the pertinent literature reviewed.
From the CIinicaMedica, PoliclinicoMonteluce,Universityof Perugia, Italy (C. M.);Divisionof Human Genetics, Departmentof Human Biology(C. M., K. V., H. V. D. B.), Divisionof Hematology,Department of Medical Research (G. T.), and Divisionof Oncology U. T.), Universityof Leuven, Belgium; Service d'H6matologie, University of Louvain in Brussels (J. -L. M.), Service d'H6matologie, Cliniques Universitaires Mont-Godinne(A. B.), and Dienst Hematologie, St. Jan-Ziekenhuis,Brugge (A. L.), Belgium;and Instituto di Ematologia,Univ. degli Studi, Ferrara, Italy (D. B.). Address requests for reprints to Dr. Herman Van Den Berghe, Center for Human Genetics, University of Leuven, B-3000 Leuven, Belgium. Beceived September 1, 1982; accepted December 16, 1982.
367 © Elsevier SciencePublishingCo., Inc., 1983 52 VanderbiltAve., New York, NY 10017
Cancer Geneticsand Cytogenetics 0165-4608/83/$03.00
F
F
F
F
F
2. H.M.
3. B.D.
4. C.K.
5. V.J.
Sex
1. L.Y.
Case No.
50
24
54
60
28
Age
CML
AML, M1
CML
CML
AML
Hematological diagnosis
1970
1981
1978
1979
1977
Year of diagrmsis
CP CP CP CP CP BC
Jun 71 Mar 80 Apr 80 Jun 80 Oct 80 Dee 89
therapy
After
Nov 81
BC
Aug 81
Diagnosis
CP CP BC
Oct 79 Mar 80 Mar 81
Sep 81
CP
BC
Oct 79
Mar 79
CP
Diagnosis After therapy
Mar 79
Nov 77 Jan 78
Date
Disease stage
M M B
M,B M,B
M
M
M,B
B
M
B M M
M,B
B
M
M,B
M,B B
Sample
1
3
2
1
1
3
5
-1
-44
--
--
1
2
1
47
11
no mitoses
1
1
14 14 3
18
4
4
17
23 8
46
4
6
6
--
--
48+
no mitoses no mitoses no mitoses no mitoses 2 3 3 1
18
--
--
4
1
5
2
1 1
45
Chromosome investigations
0%
0%
7%
0%
0%
2% 0% 0%
1%
0%
0%
0%
8% 0%
4N
Table 1 Cytogenetic investigations in seven patients with morpologically similar t(3q- ; 3q +)
----
--
--
---
% Normal cells
220
2530
22
152
--
239
900 550 396
201
491
257
303 614
Platelet count × I0°/1
48, XX, Ph ~ 47, XX, Ph~,del(2)(q32), t ( 3 q - ; 3 q +), +21
(Ph at
46, XX, t(9;22)(q34;q11)
- 7, t(o;?J(p24;?]
45, XX, t ( 3 q - ; 3 q + ) ,
48, XX, Ph 1, Ph ~, t ( 3 q - ; 3 q + ) , +19 48, XX, P h a , t ( 3 q - ; 3 q ÷) 48, XX, Ph ~, Ph ~ t ( 3 q - ; 3 q + ~ , + 19 48, XX, Ph ~, Ph ~, t ( 3 q - ; 3 q +), + 1 9
46, XX, t(9;22I (q34;q11) (Ph ~) 4fi, XX, Ph ~ 46, XX, Ph a 46, XX, Ph i
t ( 3 q - ;3q + ) 48, XX, Ph 1, t ( 3 q - ;3q + )
46, XX, Ph 1, t(3q-;3q+) 47, XX, Ph 7, Ph Z,
46, XX, t(9;22) (q34;q11) {Ph l)
46, XX t ( 3 q - ; 3 q + ) 48, XX, t ( 3 q - ; 3 q + }
Karyotypes
30 70
100
100
80
33 67
70
100 100 20
I00
190
86 14
100
100 109
%
F
7. L.F.
46
38
1966 1975 1977
Myelofibrosis Erythroleukemia
1976
PV
AMMoL, M4
--
9
2
2
34
M
20
13
B
1
Feb 77
7
7
no mitoses no mitoses
24
13
3
1
1
8 1
no mitoses 4
3
2
7 7
B
B
M
M M M M
M
s
After therapy
Diagnosis
Oct 75 Dec 76
Sep 75
Dec 76 Jan 77 Feb 77 Mar77
--
--
0%
5%
0%
8%
10%
6% 4% 26
290000
820 O0O
234
200
+M1, +M3 46 XX, t(6;22), 21, +M1 46, XX, t ( 3 q - ; 3 q + ) , t(6;22), - 7 , - 2 1 , +M1, +M3
+M1, + M 3 47, XX, t ( 3 q - ; 3 q + ) , t(6;22), - 2 1 , +M1, +M3 47, XX, t(6;22), - 2 1 ,
+M1 46, XX, t ( 3 q - ; 3 q + ) , t(6;22), - 7, - 21,
46, XX, t(6;22) (q27?;q11), - 2 1 , + M 45, XX, t ( 3 q - ; 3 q + ) , t(6;22), - 7, - 21, +M 46, XX, t(6;22), - 2 1 ,
(q27?;q11), - 2 1 , + M
4 6 , XX, t(6;22)
(q27?;q11), - 21, + M
4 6 , XX, t(6;22)
46, XX, t ( 3 q - ; 3 q + ) 46, XX, t ( 3 q - ; 3 q + )
25
41
4
7
40
18
13
100
75
100
74
CM, bone marrow, B, peripheral blood.
bCP, chronic phase; BC, blastic crisis.
aAML, acute myeloblastic leukemia; AMMoL, acute myelomonocytic leukemia; M1, M4, F r e n c h - A m e r i c a n - B r i t i s h classification; CML, chronic myeloid leukemia; PV, polycythemia vera.
F
6. VDB.C.
370
C. Mecucci et al.
MATERIAL AND METHODS Cytogenetic investigations were done on a routine basis on marrow or blood samples usually obtained at the time of diagnosis and before any treatment. As a rule, chromosomes were obtained from short-term incubations of at least 24 hr and no direct investigations have been performed. Banding technique of choice for hematological disorders in this laboratory is R-banding using Acridine orange. A total number of 10 patients has been found so far in our material since 1971 consisting of more than 400 CML, over 1000 AML, 300 ALL, and a total number of hematological patients of about I0,000. Clinical records and pertinent hematological data regarding these 10 patients are found in Appendixes 1 and 2. Cytogenetic results are summarized in Tables 1 and 2. RESULTS AND DISCUSSION To our knowledge seven cases of t ( 3 q - ; 3q+) have been published (Table 3). The conditions in which this anomaly was found varied from preleukemia to CML, and with one exception (case 5) they were all myeloid in nature. In our own material, the seven cases in which the cytogenetic anomaly was very similar were all myeloid. The two lymphoid cases reported in the present series had a 3q anomaly which was different from the other patients. The karyotype of the t ( 3 q - ; 3q+) lymphoma of the literature was not available for comparison. Golomb et al. [1, 2] suggested that because of the elevated platelet count in their two patients a relationship may possibly exist between this feature and the t ( 3 q - ; 3q +) anomaly. More recently Norrby et al. [3] as well as Carbonell et al. [4] also reported elevated platelet counts in their patients with t ( 3 q - ; 3q +). In our opinion this association should be handled with caution. In favor of a meaningful association it can be argued that 1. the overwhelming majority of cases with t ( 3 q - ; 3q+) are myeloid and 2. that AML cases with elevated platelet counts occur rarely, and that the case of acute myelofibrosis with t ( 3 q - ; 3q + ) might be a megakaryoblastic disorder [5]. On the other hand, the vast majority of CML and other myeloproliferative disorders with elevated platelet counts do not exhibit the t ( 3 q - ; 3q +). Moreover, the case of acute myelofibrosis published by Nowell and Finan [6] had thrombopenia, in two of the six other cases in the literature the platelet count was not mentioned, and in our own series four out of the seven cases of Table 1, had no thrombocytosis. In addition, in the case of CML published by Carbonell et al. [4] and in the two CML cases of the present series, the t ( 3 q - ; 3q +) appeared during the blastic phase at a time when the platelet count had decreased dramatically. In view of all these data, we do not believe that an association between t ( 3 q - ; 3q+) and thrombocytosis is particularly strong. Little has been reported on the light-microscopic or ultrastructural morphological characteristics of the megakaryocytes in these cases. Whatever anomaly was mentioned can be found in other cases of CML, preleukemia, and so on. With regard to megakaryocytic and platelet function no particular studies have been described, with the exception of a study by Carbonell et al. [4] who reported that in diffusion chambers, the t ( 3 q - ; 3q+) was among the +-30% cases of CML in which no megakaryocytes could be obtained. Morphological studies carried out in our own patients also failed to reveal unusual or specific characteristics of the megakaryocytes. The proportion of tetraploid or polyploid metaphases in our patients was within a normal range. With regard to the question of whether clinically the disorders with t ( 3 q - ; 3q+) have any specific characteristics, the present series of cases is too small for conclusions. What then is the nature of
NHL-CC
1982
Feb 82
Diagnosis
M a y 80 Diagnosis Feb 81 Diagnosis M
M M
Sample 3 6
-44 -1 1
15 - -
5 7 --
--
45 46 47 4 8 +
0%
0% 0%
80
-13
% Normal 4N cells
700
Platelet count × 109/1
of 3q
bSee text for explanation.
Karyotypes b 46, XX, der(3) 46, XY, t(1;4;1;4), t(2;4), t(2;3), t ( 3 q - ; 3 q + ) 46, XY, der(3)
°AML, acute myeloblastic leukemia; NHL-IB, non-Hodgkin |ymphoma immunoblastic; NHL-CC, non-Hodgkin's lymphoma centroblastic-centrocytic.
64
1980 1981
M
AML NHL-IB
3. V.J.
33 60
F M
1. K.S. 2. V.J.
Date
Disease stage
dissimilar rearrangement
Chromosome investigations
in three patients with morphologically
H e m a t o l o g i c a l Year of Sex Age d i a g n o s i s a diagnosis
Cytogenetic investigations
Case No.
Table 2
20
100 87
%
372
c. Mecucci et el.
Table 3
Cases with t ( 3 q - ; 3 q +) reported i n the literature
Case No. Sex Age
Diagnosis ~
1 2 3
F F M
47 40 69
4 5
? M
? 70
AML AMMoL Acute myelofibrosis CML MLIB
6
F
7
F
47 51
Preleukemia CML-BP
Karyotype 45, XX, ins(3;3)(q26;q21q26), - 7 46, XX, ins(3;3)(q21;q21q26) 45, XY, -2C(?7-10) +E(abn), t(3q- ;3q + ) 46, XY, t(9;22), t(3;3) 51, XY, +X, t(3;3)(q11 or 12; q27 or 29), +7, +12, +21, +21 46, XX, ins(3;3)(q27;q21q27) 46, XX, t(9;22)(q34;q11) ins(3;3)(q26;q21q26)
Platelet count × 109/1
References
1730 600 thrombocytopenia
[1, 2] [1, 7] [6]
? ?
[9] [8]
320-800 170-1200
[3]
[4]
°AML, acute myeloblastic leukemia; AMMoL, acute myelomonocyticleukemia; CML, chronic myeloid leukemia; BP, blastic phase; MLIB,malignantlymphomaimmunoblastic.
this t ( 3 q - ; 3 q + ) ? One possibility, as suggested by Golomb and Rowley [1, 2, 4, 7], could be that breaks occurred in or near bands q21 and q26 in the long arm of one chromosome No. 3, and that this segment was inserted into the long arm of the other chromosome No. 3 near band q21 or q26. Norrby et el. [3] equally believe that the anomaly is an insertion, but they put the breakpoints in bands q21 and q27. Both Golomb et el. [1, 2, 7] and Norrby et el. [3] used Q-banding, whereas Carbonell et el. [4] used G-banding. Reeves and Pickup [8], using G-banding, believed the anomaly was a translocation between both chromosomes No. 3 with breakpoints in q l l or q12 and q27 or q29; they do not state whether they believed this translocation to be reciprocal or not. Nowell and F i n a n [6] and Barlogie et el. [9] did not indicate what they believed the nature of the anomaly in their patients might have been. In our material comprising 10 cases, we found the a n o m a l y to be morphologically very similar in seven cases (Table 1), whereas in three other cases it was apparently of a different nature. In the seven cases of Table 1, we were u n a b l e to identify the nature of the anomaly with certainty (Fig. 1). Obviously, material is missing from the long arm of one No. 3, whereas in the other 3q, extra material is found. In both No. 3 chromosomes the short arm looks normal and the bright q21 (R-banding) b a n d seems to be in a normal position. In the 3 q - chromosome, this b a n d may be followed by a dark b a n d as in case 1, but in the other cases it cannot be clearly distinguished. In all 3 q - chromosomes, the terminal bands, if any, are rather bright and seems to fuse with b a n d q21, because the resulting fluorescence of the 3 q - corresponds to a b a n d or segment w h i c h is usually clearly larger than b a n d q21 in the 3q + chromosome. Breakpoints in the 3 q - may thus be q22, b a n d q24(?) in case the dark b a n d w o u l d not have come from the other No. 3 chromosome (3q+) and q26 or q28 to account for the presence of a bright terminal band in the 3 q - . In the 3q+ chromosome, the terminal segment q27-q29 looks normal in all seven cases, but between this segment and b a n d q21 there seems to be a variable a m o u n t of extra material, some of which appears as a bright band approximately in the middle of the long arm. It seems to us that although a m e c h a n i s m of insertion may be a likely explanation, the morphology of the 3q + is not compatible with a simple insertion of the 3 q derived material in all seven cases, and we are unable to positively identify the true nature of the 3 q - ; 3q + anomaly in these patients. The chromosome anomalies of the patients described in Table 2 obviously were
Figure 1 3q+).
Chromosomes No. 3 from seven patients with morphologically similar t(3q-;
Figure 2
Karyotype of case 2 of Table 2. Both No. 3 chromosomes are abnormal (see text).
Table 4 Type of disorder and karyotypes with anomaly of 3q other than (3q-;3q +) (patients of Leuven only) Record No./[ref]
Sex
Diagnosis °
Karyotype
6186
F
CML-BP
11341
M
11350 [12]
F
Multiple myeloma, AML AML
11449
F
Mycosis fungoides
13797 [13]
M
Benzene intoxication
14695 b 17847 b 17936
M M M
MPS CML AMoL
23913 b
F
CML-BP
26014 29905
F M
RAEB CML-BP
30761
M
CML-BP
37916
F
Hodgkin's disease, AUL
40232
F
AML
Sample
%
46, XX, 3 q - , t(7;16),t(9;22) (q34;q11) 46, XX, t(3;5)(q22;q12), t(7;16), t(9;22)(q34;q11) 45, XY, t(1;3)(p31;q13), - 5 , 7 q -
B M B M B, M
33 46 13 13 100
47, XX, l q + , t(3;22)(q26?26?;q11), +7, - 8 , der 8, 1 4 q + , - 1 8 , + m a r 51, X, - X , +1, +1, l q - , l q - , l q - , 2 q + , 3 q - , - 4 , +5, - 6 , - 6 , t(8;12), - 1 0 , - 1 5 , + 8 mars 46, XY, t(3q;16q), t(3p;16p}, t(4p;15q), t(4q;15q), t(9p;10p) 45, XY, t(3;17)(q26;q22), - 7, 1 6 q 46, XY, t(3;17}(q26;q22) 56, XY, 3 q + , 4 p + , +6, +7, +8, - 1 0 , - 1 1 , +13, - 1 4 , - 1 5 , - 1 6 , - 1 9 , + 12 mars 46, XX, t(3;17)(q26;q22), 5 q - , t(9;22) (q34;q11) 45, XX, t(2;3)(p14;q26), 5 q - , - 18 46, XY, t(1;3)(q31;q26), t(9q;10q); t(gq;12q), t(?;22)(?;q11) 46, XY, t(3;7)(q13;q21), t(9;22) (q34;q11) 47, XY, t(3;7)(q13;q21), t(9;22) + fragm 48, XY, t(3;7)(q13;q21), t(9;22), +8, +12 46, XX, l q + , t(3;8)(q26;q23), t(9p;15q) + fragm 46, XX, t(3q;8q), t(gp;15q) + fragm 45, XX, t(2;3)(p16;q26), - 7
B M M
73 56 8
M
100
B M M
93 100 20
B
100
M B
80 100
B M M
80 50 21
M
21
B
40
M B,M
40 100
SCML, chronic myelocytic leukemia; BP, blastic phase; AML, acute myeloblastic leukemia; MPS, myeloprolfferative syndrome; AMoL, acute monoblastic leukemia; AUL, acute undifferentiated leukemia. bThese cases will be published in detail elsewhere.
Table 5 Exchanges between the long arms of homologous chromosomes other than No. 3 (patients of Leuven only) Record No.
Sex
Age
Diagnosis ~
Sample b
Chromosome exchanges
No. cells/ total
10636 11171 13713
M M F
54 53 35
M B + PHA LN
t ( 4 q - ;4q + ) t(14q-;14q+) t ( 1 7 q - ;17q+)
7/9 7/25 4/4
20619 33841
M M
20 43
AL? CLL NHL, centrocytic centroblastic ALL AML, relapse
M B
t ( 9 q - ;9q + ) t(5q - ;5q + )
3/12 8/9
°AL, acute leukemia; CLL, chronic lymphocytic leukemia; NHL, non-Hodgkin lymphoma; ALL, acute lymphoblastic leukemia; AML, acute myeloblastic leukemia. bB, peripheral blood; M, bone marrow; LN, lymph node; PHA, phytohemagglutinin.
376
c. M e c u c c i et al.
different f r o m t h o s e of the cases d e s c r i b e d above. In case 1, A M L w i t h a h i g h platelet count, o n e of the No. 3 c h r o m o s o m e s was n o r m a l ; in the o t h e r c h r o m o s o m e an a n o m a l y was o b s e r v e d w h i c h is best e x p l a i n e d by a p a r a c e n t r i c i n v e r s i o n w i t h b r e a k p o i n t s in q21 and q26. W e h a v e b e e n u n a b l e to s t u d y the c o n s t i t u t i o n a l karyot y p e of this patient. C o n s t i t u t i o n a l p a r a c e n t r i c i n v e r s i o n s in the l o n g arm of chrom o s o m e No. 3 o c c u r not i n f r e q u e n t l y (Fryns and v a n d e n Berghe [10]). 1 Case 2, n o n - H o d g k i n l y m p h o m a of the i m m u n o b l a s t i c type, stage IV, h a d no n o r m a l No. 3
F i g u r e 3 Exchanges between homologous chromosomes: t ( 4 q - ; 4q+) and t ( 5 q - ; 5q+) in cases 1 and 5 of Table 5.
1After this paper was submitted a paper was published by Bernstein et al. [11] showing that in some cases of ANLL with paracentric inversion inv(3) (q21q26) apparently identical with our case 1 of Table 2, an unusually high thrombocyte count was present.
3 q - , 3 q + A n o m a l y in H u m a n s
377
c h r o m o s o m e s (Fig. 2), but also had several other structural rearrangements. This karyotypic a n o m a l y is probably very complex, and we are unable to identify positively the nature of all rearrangements. Case 3, non-Hodgkin l y m p h o m a of c e n t r o b l a s t i c - c e n t r o c y t i c type had a karyotype w h i c h could be 3 q - , 3 q + , but otherwise was very different from the cases in Table 1. The material deleted from the 3 q - , and the extra material in the 3q + was smaller than in those cases but could not be accurately identified. The cases of Table 2 m a y be more related to 16 of our cases in w h i c h the long arm of one c h r o m o s o m e No. 3 (rarely both) was involved; these are listed in Table 4. As can be seen from the table, anomalies of the 3q are not infrequent and m a y occur in a variety of hematologic malignancies. Exchanges between homologous chromosomes of the ( 3 q - ; 3q + ) type are not limited to No. 3 chromosomes. In our own material, s u m m a r i z e d in Table 5, such exchanges have been seen to occur among chromosomes No. 4, 5, 9, 14, and 17; all of these c h r o m o s o m e s are very frequently involved in characteristic c h r o m o s o m e anomalies in l e u k e m i a and lymphoma. Examples of ( 4 q - ; 4 q ÷ ) and ( 5 q - ; 5 q + ) are given in Figure 3. None of these, however, has been found with a frequency comparable to ( 3 q - ; 3q ÷ ). CONCLUSIONS Acquired exchanges between homologous No. 3 chromosomes w i t h breakpoints near bands q22 and q26 can be observed in h u m a n malignancy, particularly in myeloproliferative disorders. They a p p e a r to be rather rare events, but occur more frequently than similar exchanges between other homologous chromosomes. T h e y show no p r e d i l e c t i o n for a particular myeloproliferative disorder. Thrombocytosis does not systematically occur in these cases and prior claims about a locus on the 3q controlling megakaryocytic proliferation and platelet p r o d u c t i o n must await further confirmation.
REFERENCES
1. Golomb HM, Vardiman JW, Rowley JD, Testa JR, Mintz U (19781: Correlation of clinical findings with quinacrine-banded chromosomes in 90 adults with acute nonlymphocytic leukemia. N Engl J Med 299, 613-619. 2. Sweet DL, Golomb HM, Rowley JD Vardiman JM (1979): Acute myelogenous leukemia and thrombocythemia associated with an abnormality of chromosome No. 3. Cancer Genet Cytogenet 1, 33-37. 3. Norrby A, Ridell B, Swollin B, Westin J (1982): Rearrangement of chromosome No. 3 in a case of Preleukemia with thrombocytosis. Cancer Genet Cytogenet 5, 257-263. 4. Carbonell F, Hoelzer D, Thiel E, Bartl R (1982): Phi-positive CML associated with megakaryocytic hyperplasia and thrombocythemia and an abnormality of chromosome No. 3. Cancer Genet Cytogenet 6, 153-161. 5. Breton-Gorius J, Daniel MT, Flandrin G, Kinet Denoel G (1973): Fine structure and peroxidase activity of circulating micromegakaryoblasts and platelets in a case of acute myelofibrosis. Br J Haematol 25, 331-339. 6. Nowell PC, Finan JB (1978): Cytogenetics of acute and chronic myelofibrosis. Virchows Arch B Cell Pathol 29, 45-50. 7. Rowley JD, Potter D (1976): Chromosomal banding patterns in acute nonlymphocytic leukemia. Blood 47, 705-721. 8. Reeves BR, Pickup VL (1980): The chromosome changes in non-Burkitt lymphomas. Hum Genet 53, 349-355. 9. Barlogie B, Hittelman W, Spitzer G, Truyillo JM, Hart JS, Smallwood L, Drewinko B (1977): Correlation of DNA distribution abnormalities with cytogenetic findings in human adult leukemia and lymphoma. Cancer Res 37, 4400-4407.
378
c . M e c u c c i et al.
10. Fryns JP, van den Berghe H (1980): Paracentric inversion in man: personal experience and review of the literature. Hum Genet 54, 413-416. 11. Bernstein R, Pinto MR, Behr A, Mendelox B (1982): Chromosome 3 abnormalities in acute nonlymphocytic leukemia (ANLL) with abnormal thrombopoiesis: Report of three patients with a " n e w " inversion anomaly and a further case of homologous translocation. Blood 60, 613-617. 12. van den Berghe H, David G, Broeckaert-van Orshoven A, Louwagie A, Verwilghen R (1978): Unusual Ph ~ translocation in acute myeloblastic leukemia. N Engl J Med 299,360. 13. van den Berghe H, Louwagie A, Broeckaert-van Orshoven A, David G, Verwilghen R (1979): Chromosome analysis in two unusual malignant blood disorders presumably induced by benzene. Blood 53, 558-566.
APPENDIX 1
Clinical findings in seven patients with morphologically similar t(3q - ;3q + )
Case 1
L. Y. (20.361), a 28-year-old housewife, was hospitalized in October 1977 after two months of pyrexia (38°C), tiredness, gingival hemorrhages, and a left abdominal mass. On physical examination the spleen was palpable 6 cm below the costal margin. Hemoglobin was 9.4 g/dl; RBC 2960 x 109/]; WBC 25.3 × lOg/l with the following differential count: neutrophils 21%; eosinophils 1%; monocytes 21%; lymphocytes 22%; blasts 31%; myelocytes 2%; promyelocytes I 1%; promyelocytes II 1%. Platelets were 303 x 109/I. In addition, four erythroblasts to every 100 nucleated cells were present. Neutrophil alkaline phosphatase score was zero. Bone marrow showed a left shift of the granulocytic series. Erythroblasts were increased. Numerous monocytes, giant platelets, and megakaryocyte nuclei were noted. Cytogenetic analysis on bone marrow and peripheral blood showed a 46, XX, t(3q - ; 3q +) karyotype in every cell examined. A tentative diagnosis of chronic myeloid leukemia presenting in acute phase was made and treatment consisted of hydroxyurea and 6-mercaptopurine. During the following months no remission was obtained. A second chromosome investigation was performed in January 1978 on peripheral blood and the karyotype was unchanged. In February 1978 WBC count was 97 x 109/1 with 63% blasts; hemoglobin 11 g/d/; platelets 614 x 109/1. In April 1978 the patient received cyclophosphamide, vincristine, and cytosine arabinoside. She did not respond and died a few weeks later from her disease. Final hematological diagnosis in this patient is not clear. Although the LAP score was extremely low, there were no other convincing arguments in favor of a Ph I negative CML presenting in blastic phase, and the picture was rather that of a subacute AML.
Case 2
H. M. (26.004), a 60-year-old woman was submitted in March 1979 to gynecological surgery, but preoperative clinical examination revealed prominent hepatosplenomegaly. Hematological findings were: hemoglobin 11.4 g/dl; WBC 3.88 x 109/1; WBC 263 x 109/I (neutrophils 65%; eosinophils 2%; basophils 1%; lymphocytes 2%; metamyelocytes 6%; myelocytes 12%; promyelocytes 12%); platelets 257 × 109/1. Neutrophil alkaline phosphatase score was reduced to zero. Bone marrow was characterized by granulocytic hyperplasia, and an appreciable quantity of megakaryocytes and fibrosis (precollagen type 3). Cytogenetic analysis showed a Philadelphia chromosome in all the metaphases of bone marrow and peripheral blood. Busulfan treatment reduced the leukocyte count to 20 × 109/1 and the patient improved markedly. In May 1979 the operation, originally planned because of uterine prolapsus, was performed; the patient had a severe hemorrhage despite a normal platelet count, 277 × 109/1. The course of the disease changed to blastic phase in October 1979. At that time the WBC count was 20.1 × 109/1 with 36% blast cells. Platelets were 491 x lOg~1. The karyotype in peripheral blood showed that in addition to the Ph 1 chromosome, a
3q-,
3 q + A n o m a l y in H u m a n s
379
t ( 3 q - ; 3q +) had appeared in all metaphases examined. Despite treatment with hydroxyurea, 6-mercaptopurine, and vindesine, no remission was obtained. The highest value of platelets in this patient was 800 x 109/1 in December 1979. She died from her disease within a f e w weeks.
Case 3 B. D. (26.122) was born in June 1925. Chronic myeloid leukemia was diagnosed in March 1978 and busulfan therapy was started. A t diagnosis the hemoglobin was 11.8 g/dl, leukocytes 112 x lOg~l; platelets 291 x 109/1. The patient was referred to the hospital for hematological evaluation in March 1979 because an accelerated stage was suspected. Bone marrow aspirate revealed a very increased number of megakaryocytes and more than 10% blast cells. Cytogenetic analysis showed a Ph 1 chromosome in 100% of bone marrow and peripheral blood metaphases and no other anomalies. Busulfan therapy was continued. In July 1979 an increased number of platelets up to 900 x 109/1 was found. Karyotype analysis in October 1979 and March 1980 still showed a Ph 1 chromosome as the only anomaly in 100% of the cells. The busulfan treatment maintained the WBC count below 30 x 109/1 until April 1981 when the patient was readmitted in very poor general condition. A t this time the WBC count was increased up to 102 x 109/]. Bone marrow aspiration was characterized by marked granulocytic hyperplasia with a left shift. There were only a f e w erythroblasts and megakaryocytes. Platelet count at that time was 396 x 109/1. The karyotype of the bone marrow cells had changed with t(3q - ; 3q +) and + 19 as additional anomalies. Therapy with hydroxyurea and 6-mercaptopurine was attempted, but the patient's general condition deteriorated and she died on August 18, 1981.
Case 4 C. K. (38.386), a 24-year-old woman, was diagnosed as having acute leukemia in September 1981. The leukocyte count was 32.6 × 109/1 with 95% blasts; hemoglobin level 7.5 g/dl; platelets 152 x 10°/]. No immunological marker studies were performed but she was believed to have acute lymphoblastic leukemia and treated accordingly with methylprednisolone and vincristine for 5 weeks but no remission was obtained; adriamycin was added, but again without success. She was then referred to the Academic Hospital in November 1981 with spiking fever and bilateral sinusitis. Hemoglobin level was 13 g/dl; WBC 8.6 x 109/1 with 30% blasts and platelets 12 x 109/1. Bone marrow smears were normocellular and showed 30% blasts, the megakaryocytic series was apparently abnormal. The initial bone marrow of September 1981 was reexamined and revealed 80% myeloblasts and morphologically abnormal megakaryocytes. A diagnosis of ANLL, FAB M1, was made. She was treated with high doses of arabinoside cytosine and adriamycin but died 6 days after starting chemotherapy due to f u l m i n a n t sepsis with bilateral pneumonia. Cytogenetic investigation was done prior to any treatment and in all the cells the following karyotype was found: 45, XX, t ( 3 q - ; 3q+ ), - 7 , 9p+.
Case 5 V. ]. (5.681) was born in December 1920. A diagnosis of chronic myeloid leukemia was made in December 1970. The spleen was enlarged, WBC count was 200 × 109/1; platelets 180 x 109/1. She was treated with busulfan. She was referred to our hospital in June 1971 with a profound aplasia after an overdose of busulfan. Hemoglobin level 8.7 g/dl, WBC 3.2 x 109/I with 31% of PMN and 69% lymphocytes; platelets 22 x 109/1; the spleen was enlarged 3 cm below the left costal margin. Bone marrow smears were hypocellular with hypoplasia of the red cell precursors, myeloid series, and megakaryocytes. Cytogenetic investigation showed a Ph 1 chromosome without additional anomalies. Cytostatic treatment was stopped from 1971 to 1979. In 1980 a control bone marrow revealed 14% blast cells, probably megakaryablasts (bone marrow biopsy, electron microscopy). Hb level was 11.1 g/dl; WBC 7.9 x 109/1 and platelets 2530 x 109/I; she was treated with thrombopheresis and busulfan. In May 1980 she developed leukopenia and granulocytopenia and a busulfan lung. Busulfan therapy was
380
C. M e c u c c i et al.
stopped. In December 1980 she was admitted to our hospital with Hb level of 7.5 g/d/, WBC 31.6 x 109/1 with 67% blast cells and platelets 220 x 109/l. Bone marrow puncture gave a dry tap. She was treated with cyclophosphamide, vincristine, arabinoside cytosine, and prednisone with no results. She died in January 1981 from septic shock. Eight attempts to karyotype the leukemic cells between June 1971 and October 1980 were unsuccessful. Only in December 1980 when some growth was obtained in a peripheral blood culture, the karyotype showed a Philadelphia chromosome in all the cells but also a subclone with a t ( 3 q - ; 3q + ) and additional anomalies.
Case 6 VDBC (17.165), a 38-year-old housewife was admitted in December 1976. Past history was negative, except for pallor for several months, gingivitis in September, and s y m p t o m s of severe anemia plus fever immediately prior to admission. Clinical examination was unremarkable. There was neither hepatosplenamegaly nor adenopathy. Hb was 7.3 g/dl, WBC 5.8 × 109/1 with 4% blasts and immature forms, 44% lymphocytes, 20% monocytes, and 32% neutrophils. The marrow was normoeellular; the erythroid series was megaloblastic, there were 15% blasts and 34% monocytes. Peroxidase staining and NaF-esterase were negative. Megakaryocyte series was normal but some giant forms were seen. A diagnosis of AMMoL (FAB M4) was made on the basis of these data. Thrombocytes on admission were 200 × 109/1 and the highest value seen in this patient was 300 x 109/1. Three eytogenetic investigations were done, all within 4 weeks; the first investigation was performed before treatment was started. The karyotype was 46, XX, t(3q - ; 3q + ) and remained virtually unchanged despite treatment. This patient was lost to follow-up.
Case 7 L. F. (13.788) was born in June 1920. In March 1966 a diagnosis of polyeythemia vera was made. Hemoglobin level was 20.3 g/d/; leukocyte count 11 x 109/I, platelets 234 x lOQ/1; clinical investigation revealed splenomegaly (3 cm under the costal margin). Red cell mass was 43.9 ml/kg (normal values 28-32 ml/kg). She was treated with 32p, chlorambucil, and busulfan. In December 1975 she developed anemia: 11.7 g/dl with increasing hepatosplenomegaly; bone marrow biopsy was compatible with myelofibrosis. From February 1977 on, myeloblasts were present in the peripheral blood (27%) together with erythroblasts (58%); leukocyte count was 107.7 × 109/1. Bone marrow puncture was hypocellular with numerous myeloblasts and strongly proliferating dysplastic erythrocytic series. A diagnosis of erythroleukemia was made. She died 14 days later because of a cerebral hemorrhage. Cytogenetic investigation was performed three times during the course of the disease. In September 1975 bone marrow and peripheral blood karyotype showed a Ph 1 chromosome with a variant translocation (Table 1), a missing 21 chromosome and several unidentified markers. In December 1976 the peripheral blood t(6q +; 2 2 q - ) karyotype had not changed. In February 1977, however, additional changes occurred. Two different clones dominated the picture in bone marrow and peripheral blood. One clone, in addition to the anomalies previously present, showed a t ( 3 q - ; 3q +) anomaly plus monosomy 7 (Table 1).
APPENDIX 2 Clinical findings in three patients with morphologically dissimilar rearrangements of 3q.
Case 1 K. S. (31.682), a 33:year-old Greek woman in w h o m the diagnosis of acute leukemia was made in Greece, was admitted in April 1980 for further evaluation and treatment. Clinical examination revealed liver enlargement (6 cm below costal margin) and splenomegaly (9 cm below costal margin). Hematological investigations were as follows: hemoglobin 10 g/dl; WBC 45 x 109/I; platelets 700 x 109/1.
3q-,
3q+ Anomaly in Humans
381
The white blood cell differential count was as follows: neutrophils 23%; lymphocytes 23%; blast cells 54%. Bane marrow aspirate showed more than 60% of blasts and a prominent n u m b e r of micromegakaryocytes. The morphology of the blasts in the bone marrow and blood was characteristic of myeloblasts with following cytochemical findings: PAS negative; peroxidase positive; nonspecific esterases negative. Cytogenetic analysis was performed on bone marrow cells and in all cells a 46, XX, t(3q- ; 3q +) karyotype was found. After two courses of chemotherapy (rubidomycin and cytarabine), bone marrow punction showed persistance of massive infiltration by leukemic cells (blasts 82%). The patient was considered to be a nonresponder and was allowed to go back to her country with palliative therapy. Further follow-up is not available.
Case 2
V. J. (35.357) was a 60-year-old male with no medical history except for surgery and local radiotherapy for a squamous cell carcinoma of the nose in 1980. His present disease began in January 1981 with a painless enlarged lymph node in the right cervical region. Biopsy showed a non-Hodgkin lymphoma: high grade malignant, diffuse, immunoblastic sarcoma. Other enlarged nodes were found in the right cervical, supraclavicular area, the right axilla, mediastinum, and hill of the lungs; there was a pleural effusion on the right, and bone marrow invasion was documented by cytology and bone marrow biopsy. Hematological findings were: hemoglobin 13.5 g/dl; WBC 13.5 x 109/1, and a normal platelet count. Treatment consisted of combination chemotherapy (EORTC trial 20 802) Doxorubicin, Etoposide, cyclophosphamide, and prednisone. The disease stabilized until July 1981, when meningeal localization occurred. The patient went into a deep coma and despite irradiation of the brain and spine and administration of methotrexate intrathecally, died August 15, 1981. A cytogenetical study was done in February 1981 on bone marrow before treatment and a 46, XY, t(1;4;I;4), t(2;4); t(2;3); t(3q- ; 3q +) karyotype was present in all the cells examined.
Case 3
V. 1. (41.112), a 64-year-old man, was referred to the hospital in January 1981 because of difficulties in swallowing and alteration of his voice. On admission laboratory data were all normal. Clinical examination revealed enlarged lymph nodes in the left cervical region and splenomegaly. A tumoral mass was found at the base of the tongue and biopsy showed massive infiltration by a centrocytic-centroblastic non-Hodgkin lymphoma. On staging, pathological lymph nodes above a n d below the diaphragm were found and a bone core biopsy showed multifocal invasion by atypical lymphocytes. On these grounds clinical stage /V A was diagnosed. Chemotherapy (CHOP, cyclofosfamide, adriamicyne, vincristin, prednisone) was started. A good clinical response was seen with complete disappearance of lymphadenopathies and splenomegaly, after four courses of chemotherapy. At present, the patient appears to be in full remission. Cytogenetic examination of bone marrow at diagnosis confirmed medullary invasion by malignant cells. The karyotypic abnormality was a 46, XY, der(3) appearing as the sole anomaly in 20% of the cells examined.
ABSTRACT: Anomalies of both No. 3 chromosomes, of the t(3q-; 3q+) type can be observed in human malignancy as reported previously. It is our experience that this anomaly is found predominantly in myeloproliferative disorders, as a rather rare event, though occurring more frequently than similar exchanges between other homologous chromosomes. Previous claims about a relationship between this anomaly and thrombocytosis could not be confirmed, but the features found in a few patients indicate that further research should be undertaken to clarify this point. INTRODUCTION Cytogenetic studies with b a n d i n g techniques have revealed the association of some specific structural chromosomal abnormalities and certain malignant hemopathies: e.g., t(9;22) and chronic myeloid leukemia; t(8;21) and acute n o n l y m phocytic leukemia; t(15;17) and acute promyelocytic leukemia; and t(8;14) and Bnrkitt's l y m p h o m a or Burkitt-type acute lymphoblastic leukemia. For various other structural anomalies, however, such a close relationship has not yet been established. A few years ago Golomb et al. [1] reported on the association of a t ( 3 q - ; 3 q + ) translocation and thrombocytosis (platelets more than 600 × 109/1) i n two patients with acute n o n l y m p h o c y t i c leukemia and hypothesized that the long arm of chromosome No. 3 may be involved in megakaryocyte maturation and platelet production. In the present paper hematological and cytogenetic findings in 10 patients with a t ( 3 q - ; 3q + ) translocation will be presented and the pertinent literature reviewed.
From the CIinicaMedica, PoliclinicoMonteluce,Universityof Perugia, Italy (C. M.);Divisionof Human Genetics, Departmentof Human Biology(C. M., K. V., H. V. D. B.), Divisionof Hematology,Department of Medical Research (G. T.), and Divisionof Oncology U. T.), Universityof Leuven, Belgium; Service d'H6matologie, University of Louvain in Brussels (J. -L. M.), Service d'H6matologie, Cliniques Universitaires Mont-Godinne(A. B.), and Dienst Hematologie, St. Jan-Ziekenhuis,Brugge (A. L.), Belgium;and Instituto di Ematologia,Univ. degli Studi, Ferrara, Italy (D. B.). Address requests for reprints to Dr. Herman Van Den Berghe, Center for Human Genetics, University of Leuven, B-3000 Leuven, Belgium. Beceived September 1, 1982; accepted December 16, 1982.
367 © Elsevier SciencePublishingCo., Inc., 1983 52 VanderbiltAve., New York, NY 10017
Cancer Geneticsand Cytogenetics 0165-4608/83/$03.00
F
F
F
F
F
2. H.M.
3. B.D.
4. C.K.
5. V.J.
Sex
1. L.Y.
Case No.
50
24
54
60
28
Age
CML
AML, M1
CML
CML
AML
Hematological diagnosis
1970
1981
1978
1979
1977
Year of diagrmsis
CP CP CP CP CP BC
Jun 71 Mar 80 Apr 80 Jun 80 Oct 80 Dee 89
therapy
After
Nov 81
BC
Aug 81
Diagnosis
CP CP BC
Oct 79 Mar 80 Mar 81
Sep 81
CP
BC
Oct 79
Mar 79
CP
Diagnosis After therapy
Mar 79
Nov 77 Jan 78
Date
Disease stage
M M B
M,B M,B
M
M
M,B
B
M
B M M
M,B
B
M
M,B
M,B B
Sample
1
3
2
1
1
3
5
-1
-44
--
--
1
2
1
47
11
no mitoses
1
1
14 14 3
18
4
4
17
23 8
46
4
6
6
--
--
48+
no mitoses no mitoses no mitoses no mitoses 2 3 3 1
18
--
--
4
1
5
2
1 1
45
Chromosome investigations
0%
0%
7%
0%
0%
2% 0% 0%
1%
0%
0%
0%
8% 0%
4N
Table 1 Cytogenetic investigations in seven patients with morpologically similar t(3q- ; 3q +)
----
--
--
---
% Normal cells
220
2530
22
152
--
239
900 550 396
201
491
257
303 614
Platelet count × I0°/1
48, XX, Ph ~ 47, XX, Ph~,del(2)(q32), t ( 3 q - ; 3 q +), +21
(Ph at
46, XX, t(9;22)(q34;q11)
- 7, t(o;?J(p24;?]
45, XX, t ( 3 q - ; 3 q + ) ,
48, XX, Ph 1, Ph ~, t ( 3 q - ; 3 q + ) , +19 48, XX, P h a , t ( 3 q - ; 3 q ÷) 48, XX, Ph ~, Ph ~ t ( 3 q - ; 3 q + ~ , + 19 48, XX, Ph ~, Ph ~, t ( 3 q - ; 3 q +), + 1 9
46, XX, t(9;22I (q34;q11) (Ph ~) 4fi, XX, Ph ~ 46, XX, Ph a 46, XX, Ph i
t ( 3 q - ;3q + ) 48, XX, Ph 1, t ( 3 q - ;3q + )
46, XX, Ph 1, t(3q-;3q+) 47, XX, Ph 7, Ph Z,
46, XX, t(9;22) (q34;q11) {Ph l)
46, XX t ( 3 q - ; 3 q + ) 48, XX, t ( 3 q - ; 3 q + }
Karyotypes
30 70
100
100
80
33 67
70
100 100 20
I00
190
86 14
100
100 109
%
F
7. L.F.
46
38
1966 1975 1977
Myelofibrosis Erythroleukemia
1976
PV
AMMoL, M4
--
9
2
2
34
M
20
13
B
1
Feb 77
7
7
no mitoses no mitoses
24
13
3
1
1
8 1
no mitoses 4
3
2
7 7
B
B
M
M M M M
M
s
After therapy
Diagnosis
Oct 75 Dec 76
Sep 75
Dec 76 Jan 77 Feb 77 Mar77
--
--
0%
5%
0%
8%
10%
6% 4% 26
290000
820 O0O
234
200
+M1, +M3 46 XX, t(6;22), 21, +M1 46, XX, t ( 3 q - ; 3 q + ) , t(6;22), - 7 , - 2 1 , +M1, +M3
+M1, + M 3 47, XX, t ( 3 q - ; 3 q + ) , t(6;22), - 2 1 , +M1, +M3 47, XX, t(6;22), - 2 1 ,
+M1 46, XX, t ( 3 q - ; 3 q + ) , t(6;22), - 7, - 21,
46, XX, t(6;22) (q27?;q11), - 2 1 , + M 45, XX, t ( 3 q - ; 3 q + ) , t(6;22), - 7, - 21, +M 46, XX, t(6;22), - 2 1 ,
(q27?;q11), - 2 1 , + M
4 6 , XX, t(6;22)
(q27?;q11), - 21, + M
4 6 , XX, t(6;22)
46, XX, t ( 3 q - ; 3 q + ) 46, XX, t ( 3 q - ; 3 q + )
25
41
4
7
40
18
13
100
75
100
74
CM, bone marrow, B, peripheral blood.
bCP, chronic phase; BC, blastic crisis.
aAML, acute myeloblastic leukemia; AMMoL, acute myelomonocytic leukemia; M1, M4, F r e n c h - A m e r i c a n - B r i t i s h classification; CML, chronic myeloid leukemia; PV, polycythemia vera.
F
6. VDB.C.
370
C. Mecucci et al.
MATERIAL AND METHODS Cytogenetic investigations were done on a routine basis on marrow or blood samples usually obtained at the time of diagnosis and before any treatment. As a rule, chromosomes were obtained from short-term incubations of at least 24 hr and no direct investigations have been performed. Banding technique of choice for hematological disorders in this laboratory is R-banding using Acridine orange. A total number of 10 patients has been found so far in our material since 1971 consisting of more than 400 CML, over 1000 AML, 300 ALL, and a total number of hematological patients of about I0,000. Clinical records and pertinent hematological data regarding these 10 patients are found in Appendixes 1 and 2. Cytogenetic results are summarized in Tables 1 and 2. RESULTS AND DISCUSSION To our knowledge seven cases of t ( 3 q - ; 3q+) have been published (Table 3). The conditions in which this anomaly was found varied from preleukemia to CML, and with one exception (case 5) they were all myeloid in nature. In our own material, the seven cases in which the cytogenetic anomaly was very similar were all myeloid. The two lymphoid cases reported in the present series had a 3q anomaly which was different from the other patients. The karyotype of the t ( 3 q - ; 3q+) lymphoma of the literature was not available for comparison. Golomb et al. [1, 2] suggested that because of the elevated platelet count in their two patients a relationship may possibly exist between this feature and the t ( 3 q - ; 3q +) anomaly. More recently Norrby et al. [3] as well as Carbonell et al. [4] also reported elevated platelet counts in their patients with t ( 3 q - ; 3q +). In our opinion this association should be handled with caution. In favor of a meaningful association it can be argued that 1. the overwhelming majority of cases with t ( 3 q - ; 3q+) are myeloid and 2. that AML cases with elevated platelet counts occur rarely, and that the case of acute myelofibrosis with t ( 3 q - ; 3q + ) might be a megakaryoblastic disorder [5]. On the other hand, the vast majority of CML and other myeloproliferative disorders with elevated platelet counts do not exhibit the t ( 3 q - ; 3q +). Moreover, the case of acute myelofibrosis published by Nowell and Finan [6] had thrombopenia, in two of the six other cases in the literature the platelet count was not mentioned, and in our own series four out of the seven cases of Table 1, had no thrombocytosis. In addition, in the case of CML published by Carbonell et al. [4] and in the two CML cases of the present series, the t ( 3 q - ; 3q +) appeared during the blastic phase at a time when the platelet count had decreased dramatically. In view of all these data, we do not believe that an association between t ( 3 q - ; 3q+) and thrombocytosis is particularly strong. Little has been reported on the light-microscopic or ultrastructural morphological characteristics of the megakaryocytes in these cases. Whatever anomaly was mentioned can be found in other cases of CML, preleukemia, and so on. With regard to megakaryocytic and platelet function no particular studies have been described, with the exception of a study by Carbonell et al. [4] who reported that in diffusion chambers, the t ( 3 q - ; 3q+) was among the +-30% cases of CML in which no megakaryocytes could be obtained. Morphological studies carried out in our own patients also failed to reveal unusual or specific characteristics of the megakaryocytes. The proportion of tetraploid or polyploid metaphases in our patients was within a normal range. With regard to the question of whether clinically the disorders with t ( 3 q - ; 3q+) have any specific characteristics, the present series of cases is too small for conclusions. What then is the nature of
NHL-CC
1982
Feb 82
Diagnosis
M a y 80 Diagnosis Feb 81 Diagnosis M
M M
Sample 3 6
-44 -1 1
15 - -
5 7 --
--
45 46 47 4 8 +
0%
0% 0%
80
-13
% Normal 4N cells
700
Platelet count × 109/1
of 3q
bSee text for explanation.
Karyotypes b 46, XX, der(3) 46, XY, t(1;4;1;4), t(2;4), t(2;3), t ( 3 q - ; 3 q + ) 46, XY, der(3)
°AML, acute myeloblastic leukemia; NHL-IB, non-Hodgkin |ymphoma immunoblastic; NHL-CC, non-Hodgkin's lymphoma centroblastic-centrocytic.
64
1980 1981
M
AML NHL-IB
3. V.J.
33 60
F M
1. K.S. 2. V.J.
Date
Disease stage
dissimilar rearrangement
Chromosome investigations
in three patients with morphologically
H e m a t o l o g i c a l Year of Sex Age d i a g n o s i s a diagnosis
Cytogenetic investigations
Case No.
Table 2
20
100 87
%
372
c. Mecucci et el.
Table 3
Cases with t ( 3 q - ; 3 q +) reported i n the literature
Case No. Sex Age
Diagnosis ~
1 2 3
F F M
47 40 69
4 5
? M
? 70
AML AMMoL Acute myelofibrosis CML MLIB
6
F
7
F
47 51
Preleukemia CML-BP
Karyotype 45, XX, ins(3;3)(q26;q21q26), - 7 46, XX, ins(3;3)(q21;q21q26) 45, XY, -2C(?7-10) +E(abn), t(3q- ;3q + ) 46, XY, t(9;22), t(3;3) 51, XY, +X, t(3;3)(q11 or 12; q27 or 29), +7, +12, +21, +21 46, XX, ins(3;3)(q27;q21q27) 46, XX, t(9;22)(q34;q11) ins(3;3)(q26;q21q26)
Platelet count × 109/1
References
1730 600 thrombocytopenia
[1, 2] [1, 7] [6]
? ?
[9] [8]
320-800 170-1200
[3]
[4]
°AML, acute myeloblastic leukemia; AMMoL, acute myelomonocyticleukemia; CML, chronic myeloid leukemia; BP, blastic phase; MLIB,malignantlymphomaimmunoblastic.
this t ( 3 q - ; 3 q + ) ? One possibility, as suggested by Golomb and Rowley [1, 2, 4, 7], could be that breaks occurred in or near bands q21 and q26 in the long arm of one chromosome No. 3, and that this segment was inserted into the long arm of the other chromosome No. 3 near band q21 or q26. Norrby et el. [3] equally believe that the anomaly is an insertion, but they put the breakpoints in bands q21 and q27. Both Golomb et el. [1, 2, 7] and Norrby et el. [3] used Q-banding, whereas Carbonell et el. [4] used G-banding. Reeves and Pickup [8], using G-banding, believed the anomaly was a translocation between both chromosomes No. 3 with breakpoints in q l l or q12 and q27 or q29; they do not state whether they believed this translocation to be reciprocal or not. Nowell and F i n a n [6] and Barlogie et el. [9] did not indicate what they believed the nature of the anomaly in their patients might have been. In our material comprising 10 cases, we found the a n o m a l y to be morphologically very similar in seven cases (Table 1), whereas in three other cases it was apparently of a different nature. In the seven cases of Table 1, we were u n a b l e to identify the nature of the anomaly with certainty (Fig. 1). Obviously, material is missing from the long arm of one No. 3, whereas in the other 3q, extra material is found. In both No. 3 chromosomes the short arm looks normal and the bright q21 (R-banding) b a n d seems to be in a normal position. In the 3 q - chromosome, this b a n d may be followed by a dark b a n d as in case 1, but in the other cases it cannot be clearly distinguished. In all 3 q - chromosomes, the terminal bands, if any, are rather bright and seems to fuse with b a n d q21, because the resulting fluorescence of the 3 q - corresponds to a b a n d or segment w h i c h is usually clearly larger than b a n d q21 in the 3q + chromosome. Breakpoints in the 3 q - may thus be q22, b a n d q24(?) in case the dark b a n d w o u l d not have come from the other No. 3 chromosome (3q+) and q26 or q28 to account for the presence of a bright terminal band in the 3 q - . In the 3q+ chromosome, the terminal segment q27-q29 looks normal in all seven cases, but between this segment and b a n d q21 there seems to be a variable a m o u n t of extra material, some of which appears as a bright band approximately in the middle of the long arm. It seems to us that although a m e c h a n i s m of insertion may be a likely explanation, the morphology of the 3q + is not compatible with a simple insertion of the 3 q derived material in all seven cases, and we are unable to positively identify the true nature of the 3 q - ; 3q + anomaly in these patients. The chromosome anomalies of the patients described in Table 2 obviously were
Figure 1 3q+).
Chromosomes No. 3 from seven patients with morphologically similar t(3q-;
Figure 2
Karyotype of case 2 of Table 2. Both No. 3 chromosomes are abnormal (see text).
Table 4 Type of disorder and karyotypes with anomaly of 3q other than (3q-;3q +) (patients of Leuven only) Record No./[ref]
Sex
Diagnosis °
Karyotype
6186
F
CML-BP
11341
M
11350 [12]
F
Multiple myeloma, AML AML
11449
F
Mycosis fungoides
13797 [13]
M
Benzene intoxication
14695 b 17847 b 17936
M M M
MPS CML AMoL
23913 b
F
CML-BP
26014 29905
F M
RAEB CML-BP
30761
M
CML-BP
37916
F
Hodgkin's disease, AUL
40232
F
AML
Sample
%
46, XX, 3 q - , t(7;16),t(9;22) (q34;q11) 46, XX, t(3;5)(q22;q12), t(7;16), t(9;22)(q34;q11) 45, XY, t(1;3)(p31;q13), - 5 , 7 q -
B M B M B, M
33 46 13 13 100
47, XX, l q + , t(3;22)(q26?26?;q11), +7, - 8 , der 8, 1 4 q + , - 1 8 , + m a r 51, X, - X , +1, +1, l q - , l q - , l q - , 2 q + , 3 q - , - 4 , +5, - 6 , - 6 , t(8;12), - 1 0 , - 1 5 , + 8 mars 46, XY, t(3q;16q), t(3p;16p}, t(4p;15q), t(4q;15q), t(9p;10p) 45, XY, t(3;17)(q26;q22), - 7, 1 6 q 46, XY, t(3;17}(q26;q22) 56, XY, 3 q + , 4 p + , +6, +7, +8, - 1 0 , - 1 1 , +13, - 1 4 , - 1 5 , - 1 6 , - 1 9 , + 12 mars 46, XX, t(3;17)(q26;q22), 5 q - , t(9;22) (q34;q11) 45, XX, t(2;3)(p14;q26), 5 q - , - 18 46, XY, t(1;3)(q31;q26), t(9q;10q); t(gq;12q), t(?;22)(?;q11) 46, XY, t(3;7)(q13;q21), t(9;22) (q34;q11) 47, XY, t(3;7)(q13;q21), t(9;22) + fragm 48, XY, t(3;7)(q13;q21), t(9;22), +8, +12 46, XX, l q + , t(3;8)(q26;q23), t(9p;15q) + fragm 46, XX, t(3q;8q), t(gp;15q) + fragm 45, XX, t(2;3)(p16;q26), - 7
B M M
73 56 8
M
100
B M M
93 100 20
B
100
M B
80 100
B M M
80 50 21
M
21
B
40
M B,M
40 100
SCML, chronic myelocytic leukemia; BP, blastic phase; AML, acute myeloblastic leukemia; MPS, myeloprolfferative syndrome; AMoL, acute monoblastic leukemia; AUL, acute undifferentiated leukemia. bThese cases will be published in detail elsewhere.
Table 5 Exchanges between the long arms of homologous chromosomes other than No. 3 (patients of Leuven only) Record No.
Sex
Age
Diagnosis ~
Sample b
Chromosome exchanges
No. cells/ total
10636 11171 13713
M M F
54 53 35
M B + PHA LN
t ( 4 q - ;4q + ) t(14q-;14q+) t ( 1 7 q - ;17q+)
7/9 7/25 4/4
20619 33841
M M
20 43
AL? CLL NHL, centrocytic centroblastic ALL AML, relapse
M B
t ( 9 q - ;9q + ) t(5q - ;5q + )
3/12 8/9
°AL, acute leukemia; CLL, chronic lymphocytic leukemia; NHL, non-Hodgkin lymphoma; ALL, acute lymphoblastic leukemia; AML, acute myeloblastic leukemia. bB, peripheral blood; M, bone marrow; LN, lymph node; PHA, phytohemagglutinin.
376
c. M e c u c c i et al.
different f r o m t h o s e of the cases d e s c r i b e d above. In case 1, A M L w i t h a h i g h platelet count, o n e of the No. 3 c h r o m o s o m e s was n o r m a l ; in the o t h e r c h r o m o s o m e an a n o m a l y was o b s e r v e d w h i c h is best e x p l a i n e d by a p a r a c e n t r i c i n v e r s i o n w i t h b r e a k p o i n t s in q21 and q26. W e h a v e b e e n u n a b l e to s t u d y the c o n s t i t u t i o n a l karyot y p e of this patient. C o n s t i t u t i o n a l p a r a c e n t r i c i n v e r s i o n s in the l o n g arm of chrom o s o m e No. 3 o c c u r not i n f r e q u e n t l y (Fryns and v a n d e n Berghe [10]). 1 Case 2, n o n - H o d g k i n l y m p h o m a of the i m m u n o b l a s t i c type, stage IV, h a d no n o r m a l No. 3
F i g u r e 3 Exchanges between homologous chromosomes: t ( 4 q - ; 4q+) and t ( 5 q - ; 5q+) in cases 1 and 5 of Table 5.
1After this paper was submitted a paper was published by Bernstein et al. [11] showing that in some cases of ANLL with paracentric inversion inv(3) (q21q26) apparently identical with our case 1 of Table 2, an unusually high thrombocyte count was present.
3 q - , 3 q + A n o m a l y in H u m a n s
377
c h r o m o s o m e s (Fig. 2), but also had several other structural rearrangements. This karyotypic a n o m a l y is probably very complex, and we are unable to identify positively the nature of all rearrangements. Case 3, non-Hodgkin l y m p h o m a of c e n t r o b l a s t i c - c e n t r o c y t i c type had a karyotype w h i c h could be 3 q - , 3 q + , but otherwise was very different from the cases in Table 1. The material deleted from the 3 q - , and the extra material in the 3q + was smaller than in those cases but could not be accurately identified. The cases of Table 2 m a y be more related to 16 of our cases in w h i c h the long arm of one c h r o m o s o m e No. 3 (rarely both) was involved; these are listed in Table 4. As can be seen from the table, anomalies of the 3q are not infrequent and m a y occur in a variety of hematologic malignancies. Exchanges between homologous chromosomes of the ( 3 q - ; 3q + ) type are not limited to No. 3 chromosomes. In our own material, s u m m a r i z e d in Table 5, such exchanges have been seen to occur among chromosomes No. 4, 5, 9, 14, and 17; all of these c h r o m o s o m e s are very frequently involved in characteristic c h r o m o s o m e anomalies in l e u k e m i a and lymphoma. Examples of ( 4 q - ; 4 q ÷ ) and ( 5 q - ; 5 q + ) are given in Figure 3. None of these, however, has been found with a frequency comparable to ( 3 q - ; 3q ÷ ). CONCLUSIONS Acquired exchanges between homologous No. 3 chromosomes w i t h breakpoints near bands q22 and q26 can be observed in h u m a n malignancy, particularly in myeloproliferative disorders. They a p p e a r to be rather rare events, but occur more frequently than similar exchanges between other homologous chromosomes. T h e y show no p r e d i l e c t i o n for a particular myeloproliferative disorder. Thrombocytosis does not systematically occur in these cases and prior claims about a locus on the 3q controlling megakaryocytic proliferation and platelet p r o d u c t i o n must await further confirmation.
REFERENCES
1. Golomb HM, Vardiman JW, Rowley JD, Testa JR, Mintz U (19781: Correlation of clinical findings with quinacrine-banded chromosomes in 90 adults with acute nonlymphocytic leukemia. N Engl J Med 299, 613-619. 2. Sweet DL, Golomb HM, Rowley JD Vardiman JM (1979): Acute myelogenous leukemia and thrombocythemia associated with an abnormality of chromosome No. 3. Cancer Genet Cytogenet 1, 33-37. 3. Norrby A, Ridell B, Swollin B, Westin J (1982): Rearrangement of chromosome No. 3 in a case of Preleukemia with thrombocytosis. Cancer Genet Cytogenet 5, 257-263. 4. Carbonell F, Hoelzer D, Thiel E, Bartl R (1982): Phi-positive CML associated with megakaryocytic hyperplasia and thrombocythemia and an abnormality of chromosome No. 3. Cancer Genet Cytogenet 6, 153-161. 5. Breton-Gorius J, Daniel MT, Flandrin G, Kinet Denoel G (1973): Fine structure and peroxidase activity of circulating micromegakaryoblasts and platelets in a case of acute myelofibrosis. Br J Haematol 25, 331-339. 6. Nowell PC, Finan JB (1978): Cytogenetics of acute and chronic myelofibrosis. Virchows Arch B Cell Pathol 29, 45-50. 7. Rowley JD, Potter D (1976): Chromosomal banding patterns in acute nonlymphocytic leukemia. Blood 47, 705-721. 8. Reeves BR, Pickup VL (1980): The chromosome changes in non-Burkitt lymphomas. Hum Genet 53, 349-355. 9. Barlogie B, Hittelman W, Spitzer G, Truyillo JM, Hart JS, Smallwood L, Drewinko B (1977): Correlation of DNA distribution abnormalities with cytogenetic findings in human adult leukemia and lymphoma. Cancer Res 37, 4400-4407.
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10. Fryns JP, van den Berghe H (1980): Paracentric inversion in man: personal experience and review of the literature. Hum Genet 54, 413-416. 11. Bernstein R, Pinto MR, Behr A, Mendelox B (1982): Chromosome 3 abnormalities in acute nonlymphocytic leukemia (ANLL) with abnormal thrombopoiesis: Report of three patients with a " n e w " inversion anomaly and a further case of homologous translocation. Blood 60, 613-617. 12. van den Berghe H, David G, Broeckaert-van Orshoven A, Louwagie A, Verwilghen R (1978): Unusual Ph ~ translocation in acute myeloblastic leukemia. N Engl J Med 299,360. 13. van den Berghe H, Louwagie A, Broeckaert-van Orshoven A, David G, Verwilghen R (1979): Chromosome analysis in two unusual malignant blood disorders presumably induced by benzene. Blood 53, 558-566.
APPENDIX 1
Clinical findings in seven patients with morphologically similar t(3q - ;3q + )
Case 1
L. Y. (20.361), a 28-year-old housewife, was hospitalized in October 1977 after two months of pyrexia (38°C), tiredness, gingival hemorrhages, and a left abdominal mass. On physical examination the spleen was palpable 6 cm below the costal margin. Hemoglobin was 9.4 g/dl; RBC 2960 x 109/]; WBC 25.3 × lOg/l with the following differential count: neutrophils 21%; eosinophils 1%; monocytes 21%; lymphocytes 22%; blasts 31%; myelocytes 2%; promyelocytes I 1%; promyelocytes II 1%. Platelets were 303 x 109/I. In addition, four erythroblasts to every 100 nucleated cells were present. Neutrophil alkaline phosphatase score was zero. Bone marrow showed a left shift of the granulocytic series. Erythroblasts were increased. Numerous monocytes, giant platelets, and megakaryocyte nuclei were noted. Cytogenetic analysis on bone marrow and peripheral blood showed a 46, XX, t(3q - ; 3q +) karyotype in every cell examined. A tentative diagnosis of chronic myeloid leukemia presenting in acute phase was made and treatment consisted of hydroxyurea and 6-mercaptopurine. During the following months no remission was obtained. A second chromosome investigation was performed in January 1978 on peripheral blood and the karyotype was unchanged. In February 1978 WBC count was 97 x 109/1 with 63% blasts; hemoglobin 11 g/d/; platelets 614 x 109/1. In April 1978 the patient received cyclophosphamide, vincristine, and cytosine arabinoside. She did not respond and died a few weeks later from her disease. Final hematological diagnosis in this patient is not clear. Although the LAP score was extremely low, there were no other convincing arguments in favor of a Ph I negative CML presenting in blastic phase, and the picture was rather that of a subacute AML.
Case 2
H. M. (26.004), a 60-year-old woman was submitted in March 1979 to gynecological surgery, but preoperative clinical examination revealed prominent hepatosplenomegaly. Hematological findings were: hemoglobin 11.4 g/dl; WBC 3.88 x 109/1; WBC 263 x 109/I (neutrophils 65%; eosinophils 2%; basophils 1%; lymphocytes 2%; metamyelocytes 6%; myelocytes 12%; promyelocytes 12%); platelets 257 × 109/1. Neutrophil alkaline phosphatase score was reduced to zero. Bone marrow was characterized by granulocytic hyperplasia, and an appreciable quantity of megakaryocytes and fibrosis (precollagen type 3). Cytogenetic analysis showed a Philadelphia chromosome in all the metaphases of bone marrow and peripheral blood. Busulfan treatment reduced the leukocyte count to 20 × 109/1 and the patient improved markedly. In May 1979 the operation, originally planned because of uterine prolapsus, was performed; the patient had a severe hemorrhage despite a normal platelet count, 277 × 109/1. The course of the disease changed to blastic phase in October 1979. At that time the WBC count was 20.1 × 109/1 with 36% blast cells. Platelets were 491 x lOg~1. The karyotype in peripheral blood showed that in addition to the Ph 1 chromosome, a
3q-,
3 q + A n o m a l y in H u m a n s
379
t ( 3 q - ; 3q +) had appeared in all metaphases examined. Despite treatment with hydroxyurea, 6-mercaptopurine, and vindesine, no remission was obtained. The highest value of platelets in this patient was 800 x 109/1 in December 1979. She died from her disease within a f e w weeks.
Case 3 B. D. (26.122) was born in June 1925. Chronic myeloid leukemia was diagnosed in March 1978 and busulfan therapy was started. A t diagnosis the hemoglobin was 11.8 g/dl, leukocytes 112 x lOg~l; platelets 291 x 109/1. The patient was referred to the hospital for hematological evaluation in March 1979 because an accelerated stage was suspected. Bone marrow aspirate revealed a very increased number of megakaryocytes and more than 10% blast cells. Cytogenetic analysis showed a Ph 1 chromosome in 100% of bone marrow and peripheral blood metaphases and no other anomalies. Busulfan therapy was continued. In July 1979 an increased number of platelets up to 900 x 109/1 was found. Karyotype analysis in October 1979 and March 1980 still showed a Ph 1 chromosome as the only anomaly in 100% of the cells. The busulfan treatment maintained the WBC count below 30 x 109/1 until April 1981 when the patient was readmitted in very poor general condition. A t this time the WBC count was increased up to 102 x 109/]. Bone marrow aspiration was characterized by marked granulocytic hyperplasia with a left shift. There were only a f e w erythroblasts and megakaryocytes. Platelet count at that time was 396 x 109/1. The karyotype of the bone marrow cells had changed with t(3q - ; 3q +) and + 19 as additional anomalies. Therapy with hydroxyurea and 6-mercaptopurine was attempted, but the patient's general condition deteriorated and she died on August 18, 1981.
Case 4 C. K. (38.386), a 24-year-old woman, was diagnosed as having acute leukemia in September 1981. The leukocyte count was 32.6 × 109/1 with 95% blasts; hemoglobin level 7.5 g/dl; platelets 152 x 10°/]. No immunological marker studies were performed but she was believed to have acute lymphoblastic leukemia and treated accordingly with methylprednisolone and vincristine for 5 weeks but no remission was obtained; adriamycin was added, but again without success. She was then referred to the Academic Hospital in November 1981 with spiking fever and bilateral sinusitis. Hemoglobin level was 13 g/dl; WBC 8.6 x 109/1 with 30% blasts and platelets 12 x 109/1. Bone marrow smears were normocellular and showed 30% blasts, the megakaryocytic series was apparently abnormal. The initial bone marrow of September 1981 was reexamined and revealed 80% myeloblasts and morphologically abnormal megakaryocytes. A diagnosis of ANLL, FAB M1, was made. She was treated with high doses of arabinoside cytosine and adriamycin but died 6 days after starting chemotherapy due to f u l m i n a n t sepsis with bilateral pneumonia. Cytogenetic investigation was done prior to any treatment and in all the cells the following karyotype was found: 45, XX, t ( 3 q - ; 3q+ ), - 7 , 9p+.
Case 5 V. ]. (5.681) was born in December 1920. A diagnosis of chronic myeloid leukemia was made in December 1970. The spleen was enlarged, WBC count was 200 × 109/1; platelets 180 x 109/1. She was treated with busulfan. She was referred to our hospital in June 1971 with a profound aplasia after an overdose of busulfan. Hemoglobin level 8.7 g/dl, WBC 3.2 x 109/I with 31% of PMN and 69% lymphocytes; platelets 22 x 109/1; the spleen was enlarged 3 cm below the left costal margin. Bone marrow smears were hypocellular with hypoplasia of the red cell precursors, myeloid series, and megakaryocytes. Cytogenetic investigation showed a Ph 1 chromosome without additional anomalies. Cytostatic treatment was stopped from 1971 to 1979. In 1980 a control bone marrow revealed 14% blast cells, probably megakaryablasts (bone marrow biopsy, electron microscopy). Hb level was 11.1 g/dl; WBC 7.9 x 109/1 and platelets 2530 x 109/I; she was treated with thrombopheresis and busulfan. In May 1980 she developed leukopenia and granulocytopenia and a busulfan lung. Busulfan therapy was
380
C. M e c u c c i et al.
stopped. In December 1980 she was admitted to our hospital with Hb level of 7.5 g/d/, WBC 31.6 x 109/1 with 67% blast cells and platelets 220 x 109/l. Bone marrow puncture gave a dry tap. She was treated with cyclophosphamide, vincristine, arabinoside cytosine, and prednisone with no results. She died in January 1981 from septic shock. Eight attempts to karyotype the leukemic cells between June 1971 and October 1980 were unsuccessful. Only in December 1980 when some growth was obtained in a peripheral blood culture, the karyotype showed a Philadelphia chromosome in all the cells but also a subclone with a t ( 3 q - ; 3q + ) and additional anomalies.
Case 6 VDBC (17.165), a 38-year-old housewife was admitted in December 1976. Past history was negative, except for pallor for several months, gingivitis in September, and s y m p t o m s of severe anemia plus fever immediately prior to admission. Clinical examination was unremarkable. There was neither hepatosplenamegaly nor adenopathy. Hb was 7.3 g/dl, WBC 5.8 × 109/1 with 4% blasts and immature forms, 44% lymphocytes, 20% monocytes, and 32% neutrophils. The marrow was normoeellular; the erythroid series was megaloblastic, there were 15% blasts and 34% monocytes. Peroxidase staining and NaF-esterase were negative. Megakaryocyte series was normal but some giant forms were seen. A diagnosis of AMMoL (FAB M4) was made on the basis of these data. Thrombocytes on admission were 200 × 109/1 and the highest value seen in this patient was 300 x 109/1. Three eytogenetic investigations were done, all within 4 weeks; the first investigation was performed before treatment was started. The karyotype was 46, XX, t(3q - ; 3q + ) and remained virtually unchanged despite treatment. This patient was lost to follow-up.
Case 7 L. F. (13.788) was born in June 1920. In March 1966 a diagnosis of polyeythemia vera was made. Hemoglobin level was 20.3 g/d/; leukocyte count 11 x 109/I, platelets 234 x lOQ/1; clinical investigation revealed splenomegaly (3 cm under the costal margin). Red cell mass was 43.9 ml/kg (normal values 28-32 ml/kg). She was treated with 32p, chlorambucil, and busulfan. In December 1975 she developed anemia: 11.7 g/dl with increasing hepatosplenomegaly; bone marrow biopsy was compatible with myelofibrosis. From February 1977 on, myeloblasts were present in the peripheral blood (27%) together with erythroblasts (58%); leukocyte count was 107.7 × 109/1. Bone marrow puncture was hypocellular with numerous myeloblasts and strongly proliferating dysplastic erythrocytic series. A diagnosis of erythroleukemia was made. She died 14 days later because of a cerebral hemorrhage. Cytogenetic investigation was performed three times during the course of the disease. In September 1975 bone marrow and peripheral blood karyotype showed a Ph 1 chromosome with a variant translocation (Table 1), a missing 21 chromosome and several unidentified markers. In December 1976 the peripheral blood t(6q +; 2 2 q - ) karyotype had not changed. In February 1977, however, additional changes occurred. Two different clones dominated the picture in bone marrow and peripheral blood. One clone, in addition to the anomalies previously present, showed a t ( 3 q - ; 3q +) anomaly plus monosomy 7 (Table 1).
APPENDIX 2 Clinical findings in three patients with morphologically dissimilar rearrangements of 3q.
Case 1 K. S. (31.682), a 33:year-old Greek woman in w h o m the diagnosis of acute leukemia was made in Greece, was admitted in April 1980 for further evaluation and treatment. Clinical examination revealed liver enlargement (6 cm below costal margin) and splenomegaly (9 cm below costal margin). Hematological investigations were as follows: hemoglobin 10 g/dl; WBC 45 x 109/I; platelets 700 x 109/1.
3q-,
3q+ Anomaly in Humans
381
The white blood cell differential count was as follows: neutrophils 23%; lymphocytes 23%; blast cells 54%. Bane marrow aspirate showed more than 60% of blasts and a prominent n u m b e r of micromegakaryocytes. The morphology of the blasts in the bone marrow and blood was characteristic of myeloblasts with following cytochemical findings: PAS negative; peroxidase positive; nonspecific esterases negative. Cytogenetic analysis was performed on bone marrow cells and in all cells a 46, XX, t(3q- ; 3q +) karyotype was found. After two courses of chemotherapy (rubidomycin and cytarabine), bone marrow punction showed persistance of massive infiltration by leukemic cells (blasts 82%). The patient was considered to be a nonresponder and was allowed to go back to her country with palliative therapy. Further follow-up is not available.
Case 2
V. J. (35.357) was a 60-year-old male with no medical history except for surgery and local radiotherapy for a squamous cell carcinoma of the nose in 1980. His present disease began in January 1981 with a painless enlarged lymph node in the right cervical region. Biopsy showed a non-Hodgkin lymphoma: high grade malignant, diffuse, immunoblastic sarcoma. Other enlarged nodes were found in the right cervical, supraclavicular area, the right axilla, mediastinum, and hill of the lungs; there was a pleural effusion on the right, and bone marrow invasion was documented by cytology and bone marrow biopsy. Hematological findings were: hemoglobin 13.5 g/dl; WBC 13.5 x 109/1, and a normal platelet count. Treatment consisted of combination chemotherapy (EORTC trial 20 802) Doxorubicin, Etoposide, cyclophosphamide, and prednisone. The disease stabilized until July 1981, when meningeal localization occurred. The patient went into a deep coma and despite irradiation of the brain and spine and administration of methotrexate intrathecally, died August 15, 1981. A cytogenetical study was done in February 1981 on bone marrow before treatment and a 46, XY, t(1;4;I;4), t(2;4); t(2;3); t(3q- ; 3q +) karyotype was present in all the cells examined.
Case 3
V. 1. (41.112), a 64-year-old man, was referred to the hospital in January 1981 because of difficulties in swallowing and alteration of his voice. On admission laboratory data were all normal. Clinical examination revealed enlarged lymph nodes in the left cervical region and splenomegaly. A tumoral mass was found at the base of the tongue and biopsy showed massive infiltration by a centrocytic-centroblastic non-Hodgkin lymphoma. On staging, pathological lymph nodes above a n d below the diaphragm were found and a bone core biopsy showed multifocal invasion by atypical lymphocytes. On these grounds clinical stage /V A was diagnosed. Chemotherapy (CHOP, cyclofosfamide, adriamicyne, vincristin, prednisone) was started. A good clinical response was seen with complete disappearance of lymphadenopathies and splenomegaly, after four courses of chemotherapy. At present, the patient appears to be in full remission. Cytogenetic examination of bone marrow at diagnosis confirmed medullary invasion by malignant cells. The karyotypic abnormality was a 46, XY, der(3) appearing as the sole anomaly in 20% of the cells examined.