A new nonrandom chromosomal abnormality, t(2;16)(p11.2;p11.2), possibly associated with poor outcome in childhood acute lymphoblastic leukemia

A New Nonrandom Chromosomal Abnormality, t(2;16)(p11.2;p11.2), Possibly Associated with Poor Outcome in Childhood Acute Lymphoblastic Leukemia Lisa R. Lowe, Nyla A. Heerema, Alexandra C. Cheerva, and Catherine G. Palmer

ABSTRACT: We report a new, nonrandom t( 2;16 )(p11.2 ;p11.2 ) in childhood acute lymphoblastic leuke-

mia (ALL). Three of 292 patients with childhood ALL studied at Indiana University Medical Center had this translocation. All three had additional chromosomal abnormalities at diagnosis and were classified as having low hyperdiploidy (47-49 chromosomes) with structural abnormalities. The patients, two boys and one girl, ranged in age from 3 to 13 years. Peripheral white blood cells (WBC) counts ranged from 1.8 to 107.4 × 109/L, all were classified as French-American-British (FAB) type L1, and all had B-lineage ALL. Because all three patients have relapsed after first remissions of 2 years 8 months to 6 years, the t(2;16) may indicate a poor prognosis and more aggressive treatment may be indicated for such patients. Because this translocation was the sole abnormality in one clone of patient 2 at relapse, it may be considered the primary abnormality. Therefore, it may also be the primary abnormality in the other two patients, and the genes involved in the breakpoints may be important in leukemogenesis.

INTRODUCTION

Patient 1

Many nonrandom chromosomal rearrangements have been described in childhood acute lymphoblastic leukemia (ALL) [1-3] including many translocations, such as t(9;22)(q34;q11), t(8;14)(q24;q32), t(1;19)(q23;p13), t(10;14) (q24;q11), and t(11;14)(p13;q11). The genes at or near the breakpoints of these recurring translocations have been implicated in the neoplastic process. In addition, correlations between clinical and cytogenetic data are useful for determining both diagnosis and prognosis [1]; e.g., the t(9;22)(q34;q11) is associated with poor prognosis [1, 2], whereas the dic(9;12)(p1?1;pl?2) appears to be associated with good prognosis [4]. We report a new nonrandom translocation, t(2;16)(p11.2;p11.2). Three patients with childhood ALL studied at Indiana University School of Medicine from 1985 until now were shown to have this translocation.

A 6-year-old boy had a 1½-week history of fever, streptococcal pharyngitis, and left calf pain. Physical examination showed a well-developed, well-nourished white male. He had an eczematous, weeping rash over the left forearm, petechiae around the eyes and right forearm, and contact dermatitis over the abdomen. Bone marrow (BM) aspiration showed an aparticulate marrow with absent megakaryocytes. Immunophenotyping showed B-lineage immunophenotype (Table 2). Cerebrospinal fluid (CSF) examination was negative. The patient was started on chemotherapy for intermediate-risk patients according to CCG 105, regimen B. He achieved complete remission by day 28. He subsequently did well on chemotherapy until 2 years 2 months after diagnosis, when a routine spinal fluid examination showed a few suspicious cells, although CSF white blood cell (WBC) count was only 1. He continued to have occasional suspicious cells in the CSF, with a low total WBC count until 6 months later, when he had an overt central nervous system (CNS) relapse. His CSF WBC count was 11, with 44% blasts. Seventy-seven percent of these were common ALL antigen (CALLA) ÷. BM examination at that time showed a cellular remission marrow. He was started on reinduction chemotherapy and continues to do well 13 months after overt CNS relapse.

MATERIALS A N D METHODS

Clinical information is summarized in Table 1.

From the Departments of Medical and Molecular Genetics (L. R. L., N. A. H., C. G. P.) and Pediatrics (A. C. C.), Indiana University School of Medicine, Indianapolis, Indiana. Address reprint requests to: Dr. Nyla A. Heerema, Department of Medical and Molecular Genetics, Indiana University School of Medicine, 975 W. Walnut St., IB130, Indianapolis, IN 46202-5251. Received April 27, 1992; accepted June 25, 1992.

Patient 2

A 3-year-old girl had bruising, petechiae, lethargy, decreased appetite, and sore throat. Physical examination

60 Cancer Genet Cytogenet 6 4 : 6 0 - 6 4 (1992) 0165-4608/92/$05.00

© 1992 Elsevier Science P u b l i s h i n g Co., Inc. 655 A v e n u e of the Americas, N e w York, NY 10010

t(2;16)(p11.2;p11.2) in Childhood ALL

61

Table 1 Clinical data of patients at diagnosis and relapse Patient Sex Age WBC (x 109/L) Diagnosis Relapse Hemoglobin (g/dl) Diagnosis Relapse Platelets ( × 109/L) Diagnosis Relapse Differential leukocyte count (%) Diagnosis Blasts Lymphocytes Monocytes Bands Polymorphonuclear lymphocytes Relapse Blasts Lymphocytes Blasts in marrow/FAB Diagnosis Relapse Lymph node involvement Diagnosis Relapse Spleen involvement Diagnosis Relapse Liver involvement Diagnosis Relapse

1 M 6 yr

2 F 3 yr 9 mo

21.0 NA

107.4 237.O

1.8 NA

5.6 NA

4.4 5.9

8.3 NA

18.0 NA

9.0 24.0

78.0 NA

45 51 4

91 9

16 67 1 2 14

97 3

66

89% L1 94% L1

89% L1 75% L2

NA

91% L1 NA

3 M 13 yr 11 mo

+ NA

+ +

NA

NA

+

NA

NA

+ +

NA

Abbreviations: NA, not available; FAB, French-American-British; WBC, white blood cells.

showed a pale, white female in no acute distress. She had scattered buccal and oromucosal petechiae. A chest roentgenogram showed cardiomegaly with no evidence of mediastinal mass. BM immunophenotyping results showed B - l i n e a g e l e u k e m i a ( T a b l e 2). C S F e x a m i n a t i o n s h o w e d 26

Table 2

Immunophenotyping

red blood cells (RBC) and no WBC. The patient was entered o n CCG p r o t o c o l 106, r e g i m e n B for h i g h - r i s k p a t i e n t s a n d w a s i n c o m p l e t e r e m i s s i o n b y d a y 28. S h e w a s t a k e n off t h e r a p y 2 y e a r s 3 m o n t h s after d i a g n o s i s . E l e v e n m o n t h s later, s h e h a d m u l t i p l e e c c h y m o s e s , p e t e c h i a e , p a l l o r , a n d

d a t a of p a t i e n t s at d i a g n o s i s a n d r e l a p s e

Patient 1

Patient 2

Patient 3

Antibody

D

R

D

R*

D

R

Tdt HLA-DR CALLA(CD10) CD19(Leu12) CD24(BA-1) CD9(BA-2) CD33 cIG sIG

90 1 94 ND ND ND ND <1 ND 0

ND ND ND ND ND ND ND ND ND ND

85 ND 93 ND 87 ND ND ND ND Negative

97 99 90 70 ND 83 ND <1 ND 2/1

+ ND 45 ND 47 6 ND ND ND ND

52 82 69 76 86 ND 24 11 5-10 12/7

r/)~

Abbreviations: ND, not determined; D, diagnosis; R, relapse; R*, first relapse, involving bone marrow only.

My9, E-rosette, CD2, CD5, CD7, CD20, CD3, and CD34 were all less than 20% and thus were classified as negative.

62 Table 3

L.R. Lowe et al. BM cytogenetic data of patients

Patient/disease stage (site)

Time to relapse, yr + mo (from diagnosis)

Cytogenetic result

2+ 8

49,XY,t(2;16)(p11.2;p11.2),add(4)(p12),+ del(10)(q24), add(12)(p12),+ 21,+ mar1112]/46,XY[3] 46,XY[20]

3+ 1 4 + 5

47,XX,t(2;16)(p11;p11),+mar[4]/46,XX[11] 46,XX,t(2;16) (pl 1 ;pl 1)[5]/47,idem, + mar[2 ]/46,XX[1] 46,XX[20]

1

Diagnosis Relapse (CNS) 2a Diagnosis Relapse 1 (BM) Relapse 2 (CNS) 3 Diagnosis Relapse (BM, T)

47,XY,t(2;16)(p11.2;p11.2),del(6)(q21q23),del(22) (q11),+ mar[11]/46,XY[23] 47,XY,t(2;16)(p11.2;p11.2),del(6)(q21q23),del(22) (ql 1) +mar[9]/46,XY[20]

6

BM, bone marrow; CNS, central nervous system; T, testis. a Reported previously [5, 21]. Abbreviations:

lethargy. Examination of CSF showed two RBC and no WBC. BM immunophenotyping again showed B-lineage leukemia (Table 2). The patient was started on induction chemotherapy according to CCG 123 regimen D. Remission was attained by day 28. Routine examination 16 months after BM relapse showed that CSF contained eight WBC with 12% blasts, signifying CNS relapse. BM examination at that time showed a cellular remission marrow. She was kept on a maintenance schedule according to CCG 123 regimen D protocol while plans for BM transplantation were made. Ten months after CNS relapse, she underwent T-lymphocyte-depleted BM transplant (BMT) from her mismatched male sibling donor at the University of Iowa. Engraftment of the donor BM was slow. In the fourth week after BMT, severe cutaneous graft-versus-host disease (GVHD) developed. This gradually resolved, and she was discharged 106 days after BMT. She initially did well, but 4 months after BMT, she experienced bilateral pulmonary interstitial infiltrates, small pericardial effusion, and mild congestive heart failure. She was treated with diuretics, antibiotics, and antivirals and improved. She was readmitted with respiratory distress 1 month later and was shown to have left lower lobe pneumonia. The patient's cardiorespiratory status worsened, and she died after 15 days. There was no evidence of leukemia at the time of death. Patient 3

A 13-year-old boy had severe lower back pain, pancytopenia, and a 2-week history of fever. Physical examination showed a well-developed, well-nourished white male in obvious generalized pain. He had no petechiae or bruising. Examination of CSF showed no RBC cells and one WBC with lymphocytes and 80% monocytes. BM aspirate showed increased cellularity and decreased megakaryocytes. The patient's i m m u n o p h e n o t y p e was consistent with B-lineage leukemia (Table 2). The patient was entered on CCG protocol 106 regimen A for high-risk patients. He was in complete remission on day 28. Chemotherapy was discontinued after 3 years. Six years after diagnosis, he had

testicular swelling, which on biopsy proved to be relapsed ALL. Low viability and cellularity precluded immunophenotyping of the testicular biopsy tissue. BM immunophenotyping results again showed B-lineage leukemia (Table 2). CSF was negtive for leukemic cells. He underwent induction chemotherapy, and his BM on day 21 was consistent with remission. Three months after relapse, he underwent T-cell-depleted allogeneic BMT from a matched unrelated donor. Three months after BMT, grade II GVHD of the skin developed, requiring an increase in his prednisone dose. He is doing well, with no evidence of leukemia, 5 months after allogeneic BMT. Cytogenetics

Cytogenetic analyses were completed according to standard procedures using both direct and short-term cultures [5, 6]. Giant cell tumor-conditioned media (GCT-CM) was added to some of the 24-hour cultures [7], and some cultures were synchronized [8]. All slides were GTG-banded [9]; 15-34 metaphases were completely analyzed at diagnosis, and 8 - 3 0 metaphases were analyzed completely at relapse. RESULTS Cytogenetic results are shown in Table 3. All three patients had a t(2;16)(pll.2;p11.2) in all abnormal cells. Figure 1 shows the complete karyotype of patient 1 and partial karyotypes with the t(2;16) and corresponding normal homologs of patients 2 and 3. All three patients had additional abnormalities at diagnosis. Patient 1 relapsed in the CNS, and cytogenetic analysis of a BM aspirate showed normal chromosomes. At first relapse, patient 2 had a clone of cells in which t(2;16) was the sole abnormality and a second clone identical to the clone observed at diagnosis. The second relapse of patient 2 was a CNS relapse, and only cytogenetically normal cells were observed in a BM aspirate. Patient 3 had identical karyotypes at diagnosis and relapse.

t(2;16)(p11.2;p11.2) in Childhood ALL

1

63

2

3

1| It ~7

8

I1 13

14

15

19

20

6

4

9

.t,I¢ 10

16

21

5

22

"

11

17

Sex

~1

i!1" 12

18

Chronosoms8

Figure 1 (a) Karyotype of patient 1:49,XY,t(2;16)(p11.2;p11.2),add(4}(p12),+del(10}(q24),add(12}(p12),+21, + marl. (b and c) Abnormal chromosomes and corresponding normal homologs from patients 2 and 3, respectively.

DISCUSSION We describe a new, nonrandom chromosomal translocation, t(2;16)(p11.2;p11.2), in childhood ALL. This translocation occurred m three of 292 patients with childhood ALL. All three patients relapsed. All had B-lineage ALL and were French-American-British (FAB) type L1 at diagnosis. No patient had CNS disease at diagnosis, but patients 1 and 2 both had a CNS relapse. This translocation has been reported in one additional patient [10-13], with the karyotype 45,XX,-20,-22, t(2;16)(p1?2;p?11),+ mar at diagnosis [10]. With this patient and ours, there are now four patients with this translocation, all of whom have relapsed. Three of the four have relapsed in the BM, whereas one had an isolated CNS relapse. Of those that relapsed in the BM, one had a concurrent testicular relapse and the two others have had additional CNS relapses with no evidence of BM relapse. The relapse BMs have shown karyotypes similar to those observed at diagnosis in the present series. The previously reported patient relapsed with an unrelated karyotype, 46,XX,t(4;11)(q21;q23), and a shift in immunophenotype (from CALLA* to CALLA-) [11]. The three patients we report all had low hyperdiploidy (47-49 chromosomes) with structural abnormalities at diagnosis. These chromosomal results are consistent with a cytogenetic category

associated with an intermediate prognosis [14]. Two of the three patients also had multiple chromosomal abnormalities that have been associated with poor prognosis in acute nonlymphoblastic leukemia (ANLL) [15]. The patient reported previously [10-13] was hypodiploid at diagnosis, which may also indicate poor prognosis [12]. Because this translocation was the sole abnormality in one clone of patient 2 at relapse, it may be considered the primary abnormality in that patient. It may also be the primary abnormality in patients I and 3. The genes located at the breakpoints thus might be important for leukemogenesis in these patients. We have interpreted the breakpoint in chromosome 2 in the t(2;16) to be 2p11.2. The proximity of this breakpoint to the immunoglobulin K locus may be significant. The breakpoint 2p12 is associated with Burkitt lymphoma and leukemia, in which the most common translocation is the t(8;14)(q24;q32), but in which the variant t(2;8)(p12;q24) also occurs; and most ALL cases with breakpoints near 2p11-12 involve the t(2;8). The t(2;8) places the protooncogene MYC under the regulation of the immunoglobulin light chain K promoter causing deregulation of MYC [16]. Patients with the t(2;8) and Burkitt lymphoma or leukemia are usually classified as FAB L3 [1] and have mature B-cell ALL, whereas the three patients we report are L1 with an early pre-B-cell ALL. The previously reported patient has L2 morphology. A second gene local-

64

ized to the short arm of c h r o m o s o m e 2 at b a n d s 2 p 1 1 - 1 3 is t r a n s f o r m i n g g r o w t h factor-a [17]. O t h e r reports of 2 p 1 1 - 1 2 a b n o r m a l i t i e s in ALL i n c l u d e t(2;12)(p11;p12), t(2;7)(p12;p14), and d e l e t i o n s of c h r o m o s o m e 2 w i t h a b r e a k p o i n t at or n e a r 2p11.2 [18]. I n v o l v e m e n t of c h r o m o s o m e 16 in ALL is rare and i n c l u d e s loss or a d d i t i o n of c h r o m o s o m e 16, b r e a k p o i n t s m o r e distal t h a n p11.2 on the short arm of c h r o m o s o m e 16, or a b n o r m a l i t i e s of the long arm of c h r o m o s o m e 16 [18]. T h e i d e n t i f i c a t i o n of this n e w n o n r a n d o m translocation, t(2;16) (p11.2;p11.2), m a y lead to a s c e r t a i n m e n t of n e w genes or o n c o g e n e s i n v o l v e d in t u m o r i g e n e s i s . It adds to the list of t r a n s l o c a t i o n s that m a y i n d i c a t e p o o r prognosis in ALL [t(4;11), t(9;22), a n d t(8;14)] [19, 20]. T h e p r e s e n c e of this t r a n s l o c a t i o n at d i a g n o s i s m a y i n d i c a t e m o r e aggressive t r e a t m e n t of s u c h patients b e c a u s e of the p o s s i b i l i t y of relapse.

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