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Cytogenetic survey of 31 patients treated with bone marrow transplantation for acute nonlymphocytic and acute lymphoblastic leukemias
Cytogenetic Survey of 31 Patients Treated with Bone Marrow Transplantation for Acute Nonlymphocytic and Acute Lymphoblastic Leukemias Giandomenico Palka, Giuseppe Calabrese, Gabriele Di Girolamo, Liborio Stuppia, Paolo Di Bartolomeo, Paolo Guanciali Franchi, Clemente Di Virgilio, Grace Patrizia Bianchi, Francesco Angrilli, Giustino Parruti, and Glauco Torlontano
ABSTRACT: The authors report on a sequential cytagenetic study carried aut on 31 patients with acute leukemia (20 with acute lymphnblastic leukemia and 11 with acute non-lymphoc:ytic leukemia) who underwent hone marrow transplantation (BMTL Engraftment was documented in all patients with sex-mismatched donors and with donor constitutianal aberrations. During the followup, ranging from 6 ta 110 months, clinical and hematologic relapse was observed in 17 patients (35.5%). Five of these cases showed a normal karyatype. 3 were tff undefined relapse origin, 2 were aneuploid karyotypes, and one was donor (maleJ metaphoses. Cytogenetic and immunologic data in the latter patient were suggestive of relapse in donor cells.
INTRODUCTION R e c e n t r e p o r t s h a v e p r o v e n t h a t b o n e m a r r o w t r a n s p l a n t a t i o n (BMT) is able to c o m p l e t e l y a n d p e r s i s t e n t l y e r a d i c a t e t h e l e u k e m i c c l o n e in p a t i e n t s w i t h a c u t e l e u k e m i a (AL) or c h r o n i c m y e l o g e n o u s l e u k e m i a (CML) [ 1 - 6 [ . Specific c h r o m o s o m e c h a n g e s at t h e t i m e of B M T are k n o w n to r e p r e s e n t a s e v e r e p r o g n o s t i c factor for p o s t - t r a n s p l a n t o u t c o m e w h e n p a t i e n t s w i t h C M L are t r a n s p l a n t e d e i t h e r in t h e a c c e l e r a t e d p h a s e or in b l a s t i c crisis [ 7 - 9 ] . A l t h o u g h p r o g n o s t i c c o r r e l a t i o n s b e t w e e n c h r o m o s o m e r e a r r a n g e m e n t s a n d AL h a v e also b e e n s u g g e s t e d [ 1 0 - 1 7 ] , few c y t o g e n e t i c data are a v a i l a b l e to p r e d i c t t h e B M T c o u r s e in p a t i e n t s d i s p l a y i n g s p e c i f i c c h r o m o s o m e c h a n g e s at t h e t i m e of B M T [7,10,11,18]. R e c u r r e n c e
Institute of Biology and Genetics. (;hair of llematology (G. D. G.. P. D. B.. 1:. A.. G. T.), University of Chieti; Division of tlemalology {G 1). G.. P. D B.. F. A.. G. T.J. Pescara flospital; Cytomorphology Institute (L. S.). CNR. Chieti. Italy. Address reprint requests to: Giandomenico Palka, Via B. Buozzi 93, 65121 Pescara, Italia l~ecewed September 22, 1989; accepted lune 4, 1990.
223 (('; 1991 Elsevier Science Publishing Co., Inc. 655 Aw:nue of the Americas, New York. NY 10010
Cancer Genel Cytogenet 223 233 (1991) 0165-4608/91/$03.50
224
G. Palka et al.
of leukemia has been reported in 2 0 - 6 0 % of patients after BMT for AI, [19,20]. Cytogenetic patterns are similar to those evidenced before BMT if conditioning regimen was insufficient. Also, the appearance of a new clone may be due to a conditioning regimen that l)roduced either a proliferative advantage in an unknown neoplastic (:ell or an alteration in normal residual (:ells [6,20]. The leukenlia relapse rarely o(:curs in donor cells after grafting. In these cases, malignancy usually resembles the pretransplant disease even if different types of leukemias have been described [21,22]. We report a cytogenetic study of 31 patients with acute n o n l y m p h o c y t i c leukemia (ANLL) and acute lymphoblasti(: leukemia (ALL) who were submitte(t to BMT, in order to discuss the importance of sequential chromosome analysis in evaluation of both stable marrow-take and early relapse.
MATERIALS AND METHODS Patient and Donor Population Between December 1976 and December 1989, 31 patients with AL {20 with ALL and 11 with ANLL) received a marrow transplant at the I)ivisione di Ematologia, Ospedale Civile, Pescara. Previous c h e m o t h e r a p y and the time of admission for BMT varied with the referring institutions. Morphologic characteristics of leukemic cells were defined according to the FAB classification. The patients' marrows were examined before transplantation and patients with less than 5% blasts in the marrow were considered in complete remission {CR). All donors were HLA-identical and MLC-non-reactive siblings. One patient was given a second marrow transplant (patient 2}.
Transplant procedure During the period covered by this report several different conditioning regimens w e r e used. Twenty-one patients received c y c l o p h o s p h a m i d e {CY) (60 mg/Kg/day for 2 days) and total body irradiation (TBI) delivered from single ~°Co source at a dose rate of less than 3 cGy/minute [patients 1-4,6,7,9-12,14,15,21-24,26-30): 2 patients received chemotherapy (cytosine arabinoside, dautmmycin, vincristine, and VP16) in addition to TBI (patients 5,8}. In the remaining 8 patients and for the set:ond BMT in patient 2, the conditioning regimen consisted of busulfan (4 mg/Kg/day for 4 days) and CY {50 mg/Kg/day for 4 days) {patient 13,16-20,25,31}. The day of marrow infusion was designated day 0. A mean dose of 4.3 × 10a/Kg body weight nucleated marrow cells was infused. In order to prevent Graft-versus-Host Disease {GvHD}, 1 patient received methotrexate (MTX) as in the Seattle schedule {patient 1), 18 patients were given cyclosporine A {CSA) for 12 months as previously described [23] {patients 2-13,21-24,26,29), and 11 patients were given a short course of MTX {3 or 4 doses i.v.) combined with a CSA long-term treatment (patients 14-20,25,27,28,31}. One patient received donor bone marrow purged with anti-T lymphocyte monoclonal antibodies {Campath 1} [24] and CSA for 12 months {patient 30). Acute and chronic GvHD were graded according to the Seattle criteria. Engraftment of donor cells was demonstrated by marrow examination and peripheral cell counts and, whenever possible, by blood genetic markers and/or cytogenetic analyses. All patients were nursed in laminar air flow or positive pressure rooms and ret:eiw,'d gastrointestinal decontamination and sterile diet.
Cytogenetics and Allogeneic BMT for ANLI. and ALL
225
Cytogenetic Studies (]ytogenetic analyses were carried out on bone marrow cells at ctiagnosis, before conctitioning, within 90 days after BMT. and at intervals of 6-12 months thereafter. For each test, at least 16 metaphases were studied by c:onventional G- anct C-banding techniques 125,26]. Cytogenetic analyses on phytohemagglutinin-stimulatect peripheral hlood cultures were performed on all of the donors. Chromosomes were classifiect ac:cording to the ISCN (1985) [27]. An abnormal clone was definect according to the criteria of FIWCL [28].
RESULTS A complete summary of the cytogenetic: data pre- and post-BMT is reported in Table 1.
Pre-BMT Only 9 of 31 patients had a cytogenetic analysis at diagnosis (patients, 1-7,29,30); the remaining 22 came from other centers where they had not been cytogenetically studied. Five of the 9 patients tested showed a normal karyotype (patients 1,2,4,5, and 7). One patient presented with chromc~somes of unciefined relapse origin (patient 3), 1 patient with a clone with a del(6q) (patient 4), and another patient with a Philadelphia chromosome (Ph) in 100% of bone marrow cells, associated with other anomalies (patient 29). Patient 30 showed a clone with a t(8;21). Before conditioning, all patients had a normal karyotype, although 4 of them were in hematologic- relapse (patients 1,24,29, and 30). In the donors' group, 28 subjects had normal karyotypes, one showed a t(2;12) (donor 7), one a del(Xq) (donor 21), and another an inv(19) (donor 28). PosI-BMT
The cytogenetic analyses carried out within 90 days from BMT showed a normal karyotype in 27 patients. Of these, 14 (10 with ALL and 4 with ANLL) who had received bone marrow from sex-mismatched donors showed cytogenetic sex conversion (patients 1, 2, 4, 6, 10, 11, 13, 15, 19, 20, 22, 23, 26, and 31) Two of these 27 patients died because of interstitial pneumonia (patients I and 4). In 3 other patients, the same constitutional chromosome change as in their donors was observed (patients 7, 21, 28). In the remaining ALL patient with sex-mismatched donor (patient 16}, BMT was unsuccessful. This patient suddenly showed clinical and hematologic signs of relapse associated with recipient diploid karyotype and died 3 months after BMT. During the cytogenetic follow-up (ranging from 6 to 110 months), the persistence of either a normal karyotype or a donor constitutional abnormal karyotype was noticed in 17 patients (10 with ALL and 7 with ANLL) in CR after BMT (patients 3, 6, 8-10, 14, 15, 18-22, 24, 25, 28, 29, and 31). In one of these, with CR 30 months after BMT, an abnormal clone was observed (patient 25). This abnormality disappeared spontaneously and the karyotype reverted to normal. One patient died from chronic GvHD during follow-up, and the last cytogenetic analysis showed the reappearance of recipient marrow cells in 25°/,, metaphases without clinical and hematologic features of relapse (patient 26). Eleven patients (35.5%, (8 with ALL and 3 with ANLL) showed clinical and hematologic relapse (patients 2, 5, 7, 11-13, 16, 17, 23, 27, and 30). Of these, 8 were transplanted with sex-matched donors (patients 5, 11-13, 17, 23, 27, and 30), 2 with sex-mismatched
M 11
V12
M;5 F'30
b','8
M,2II
F,'19
M 16
F'q
M'15
F"29
M'II
M:(i
M:I5
F;24 M!9
2
3 4
5
(i
7
8
~-I
10
II
12
t3
14
15 16
Sex, . age
1
No,
Patient
Al.l. AI.I.
AI.I.
AI.I.
AI.[.
AI,I.
AI.I.
ALl,
ALL
ALl.
4(5.XX {2(1l
46.XY 1321
4ti.XX 1381
AI.I,
AI.I.
IIRO 46.XX (301 4ls.XX.liq 171
4ls.XX 12111
2rid CR 3rd CR
lsl CR
21ul CR
2IHI CR
2rid CR
2nd ('R
2nd CR
2nd CR
2rid (]R
2n(| CR
2nd (;R
Is( CR Ist CR
3rd CR
2rid CR
4th tel
al tlia:4nosis
4ls,XY 1251
Statu~
at B M T
Patient kar',ut;'lJe
AI.I. AI.I.
AI.I.
AI.I.
Disease
46.XY 1161 41i.XX I l l i l
46.XY {lbl
46.XX [ 161
4ls.XY {lls]
7 117 12 117
11 86
8 8b
2 8B
!1 85
8.85
4ei,XX Ills) 4ls,XY Ills}
II 85
1 1'84
4ls.XX l l l i l
Ills)
1 8ls
-Ils.XX. 1(2:12} (lls]
46.XY
1 86
2 85
ls 113 10 113
2ndBMT
I 0 87
Ils]
4(I,XY Ills] 4ls.XY 1201
-lls,XY ( llsl
-16.XX [ 111l
4b.XY 1211}
4ls.XY I lhl
4ls.XX 1161
411.XX { 161
411.XY Illsl
4ls.XX. I[2;121 [161
4ls,XX Ils}
41i,XX
4ls,XY 1251 4(i.XY ( 171
.l(i.X Y 1211]
4 6 . X Y 1161
4 o . X X {lbl
12 76 1i 80
Karvotvl)e afler BMT
Dale o[ BMT
.Ils,XX 1161
"Ils,XX Ills]
4B.XY Ilti) 4B.XY IllS)
46,XY [161
4fi,XX [16 I
Donor karyolype
Table 1 Cytogenetic f i n d i n g s in transplanted patient
fi.85-12 89 4ls.XY (IbO] 5186-12 89 46.XX (17(11 3 86-12:1141 4~.XX 191)l 4 '86 46.XY 12111 II. I|6 •Ils.XY 11711 .Ils,XY. inv{2] (71 10,' 8ls I JR() 7,87-11 841 41i,XY (1501 !t,87-12 841 4(i.XY ( 12111
4 86-11 His 4(i,X X [5111 1i 8 6 - 1 2 . 8 9 4(I.XX 11411) I o. 86 4ls.XX. I(2;12111131
ls 84-12 II~1 4ls.XY (140}
4 8B 4ls.XY (1is)
ls 113 •l l i . X Y [4(1) -IT.XY. - 8 [ 121
Karyotype dilv after B M T
3 87 41;.XY inv{2) 1251
4,87 4(~,XX [11) 46.XX, I{2.12) 12!)}
I !NO
9~87-10 8!I
7:84- l(l 86 4ls.X Y 1501
4111
3 118 URO
4 '87 411.XY (9) 92.XXYY 171 46.XY, 13. * 8, t[ 1:13;14).1111:12). ?my(2) lEl
1:88
11/86
II ;Bls
1/116
7:88
12'87
4 88
-I.II1
Relapse
3 '88
1.87
4,87
7186
12:88
I I '83
10~88
2'77
I)ealh
3
, 29
~37
5
14
Ill
52
* 4!1
+61
35
+47
+58
1
78
11111
Surviwd ill Ill()Illhs at 1 2 ! 3 1 / 8 9
t',,o
M.7
F~25
M'27
F /I l l
F/IS
F'!19
M:7lt
F:20
M/13
F/38
F:34
M'3!I
M/34
Fi33
18
19
20
21
22
23
24
25
26
27
28
29
30
31
13MT, b o n e
4li.XY. t(8:21 } {l(1)
45.XY.Ph, 1 0 , - 1 5 . + M 1 [31 42.XY.Ph. - 8. -8. 12.-1;3(4)
46.XY.Ph [28)
+, aliw~ patients:
ANLL
ANI,I,
ANI,I,
ANI.I.
AN[,[,
ANLI.
ANI.I.
ANI,I.
ANLL
ANLL
ANLI,
AI,I,
AI.I.
AI.I.
AI.I.
marrow
1st CR
1st tel
1st rel
lsl (;R
1st (]R
2rid CR
2nd CR
Isl rel
2rid CR
2rid CR
l s l CR
l s l CR
2nd CR
1st CR
1st CR
transphmlalion;
46.XY [16J
46.XY Iltll
46,XY 1161
46.XX. my{ 19) 1161
46.XX [161
4(i.XX (lfi)
4tLXX 116)
46.XY {16)
-16.XY [161
,18.XY ( l b l
48.XXq -11t5)
46.XX 1161
46.XY [161
4fLX'f (lfi~
46.XY 1161
relapse origin. See Table 2 for the oomph;re disease course. " Numl~,~rs in parentheses indicate number of metaphases examined.
Abbreviations:
M.~
17
1161
leukemia;
ANLL. acute
18/89 4tI,XY. t(1;111 IJ01 10:88 1 ~/8!l 4~5.XY 160)
3; 89 46.XY 112) 4/88 48,XY 146)
9/07-I0'88 4G.XY (18)
2/88-10t88 46.XX (20J 4 6 . x x . - 16. + M 1 (21 3/88 4(I.XX [15) 4Ii.XX [5J
10:8G-3.87 ,t(I.XY 1201 46.XY.Sq [51 46,XY. 116:16) (4)
2/87 46.XX (501 10.87-12:8!t 46.XX. inv1191 (5ill 10/86-10:'89 46.XY [140)
tl 8 7 - 1 2 : 8 7 4~i.XX (50}
46.XY [13|1) 7'87 46.XX 1171
2.,87-12/8!t
46.XY [80] 10t88-12/B9 48.XY ( l l 0 ) 10:88-12'89 .16,XX {80) ~t 8G- 12 tS!t 48.XXq (90] 5/811-2:8c.1 46.XY (~t0l 3~8h 46,XY (16)
7 88-12'89 46.X'1' 170) 10 88-12189
lymphoblastic
46,XY 125J
46,XY (2[)) 4(i,XY, t(t~:16] (81
4Ii.XY (1G)
-l(i,XX, inv(19) (181
-IIi.XX [161
46,XX (20)
46.XX IIfll
46.XY [16J
46.XY (20)
4li,XY 1201
46.XXq-
4tLXX [22]
46.XY [:10)
4~I,XY (20]
-t6.XY 1221
AI,L, acute
12/87
!J.'85
10,85
4187
~l:8tl
12,8(5
9:86
2 86
10/85
21/85
8'85
4:H8
2:88
2:88
12i87
unm-lympholdastit:
1;~9 46,XY (25) 46.XY. t ( l : l 1)[9) 46.XY, t[10:15) (3)
2:87
3.'89-12.'89 .16.XX (581
leukemia;
10,8!-t
5,87
2,86
8i88
+ 24
+51
+ 50
4- 32
18
+ 3~-I
~"46
7
URO. undefined
8
6/80
5,86
+ 57
÷ 52
÷20
+22
¢ 22
~ 24
t'~ "-,1
228
(;. Palka et al.
Figure 1
Partial karyotype showin'e, inv(2)(plhll3}(paticllt 12).
donors (patients 2 and 16), and one wilth donor (:ells (:arrying the constitutional aberration t(2;12] [patient 7}. At the relapse onset, (tiploid karyotyl)eS were observed in 5 patients (patients 11,16,17.23, and 27). Four of these died 7 months after BMT on average, while one is still in relapse 24 months after BMT (patient 17). Undefined relapse origin metaphases were evidenced in 3 other patients (patients 5, 7, and 13). Two of these died 35 and 5 months, respectively, after BMT (patients 7 and 13) and one is still in relapse 25 months after BMT (patient 5). Another patient (patient 12) showed normal metaphases and a clone with inv[2)(pllq13) (Fig. 1). This (:lone showed a rapid marrow expansion and tile patient died 14 months after BMT. Patient 30 at first showed some clonal chromosome abnormalities that spontaneously (tisa|)peared with restoration of a normal karyotype. Subsequently, other (:lonal chromosome changes appeared, among them the translo(:ation t(1:11 )(p36;q23) (Fig. 2). After a short interval, in which his karyotype returned to normal, the clone with t(1;11) displayed a rapid marrow expansion and the patient developed a myelodysplasti(: syndrome (MDS). Two rnonths later, hematologic eviden(:e of ANI,I, was observed: at present he is undergoing a second BMT. In the remaining patient (patient 2), we could not define the relapse origin at the time of the first relapse (April 1981) and during the subsequent first CR. When the t)atient developed her second relapse (June 1983). two male cell lines were evidenced: 46.XY an(t 47.XY. +8. At this stage, immunologi(: studies revealed the occurrence of a B-AI,I, (70% CD38/OKT10: 84% HI,A-DR/OKDR: 20"/o OKB-CAI,I,A). She reached her se(:nnd CR after (:hemotheral)y with restoration of a male donor [normal) karyotype. In April 1987, 46 months later, during tile third relapse, cytogenetic analysis eviden(:ed only donor lnetaphases, i.e., normal. polyploid, and a small (:lone: 46.XY,-13,+8.t{1;13:14)(p11:q11:q32), t(11;12) (q13;q24), ?inv(2](p2ht11). (Fig. 3). After chemotherapy, the patient achieved the third CR (July 1987) and (:ytogeneti(: investigation showed a male (normal) karyotype. Subsequently, the patient underwent her se(:on(l BMT in O(:tober 1987. Altogether, seven cytogem;ti(: investigations have been performed between the first anti the second BMT, showing male (donor) karyotypes only in all of the 140 metaphases studied.
Figure 2
Partial karyotype showing t(1 ;11 ][p36;q23)(patieul 30).
229
('ytogenetic:s and Allogeneic BMT for ANLL and AI,I,
A
AJ n Figure 3 Partial karyotype showing chromosome aberrations at 3rd relapse, after I st BMT. (A] t(l:13;14)(pll:q11:q32), (B) t(1 l:12](q13:q24), (C) ?inv(2](p21qlll(patient 2).
Three months after the second BMT, while the patient was still in CR, a male normal karyotype was again ()[)served. In April 1988, while relapsing according to hematologic tests, she showed a male normal karyotype only. The immunologic markers proved the B (;ell origin of her leukemia (4% CD2/OKT11; 76% CD38/OKT10; 84% HLA-DR/OKDR; 90% CD24/OKB2; 48% OKB-CALLA). In October 1988, the patient died of cardio-pulmonary failure (Table 2). Eight of 11 relapsing patients died (patients 2, 7, 11-13, 16, 23, and 27), while the other 3 were alive and still in relapse in December 1989 (patients 5, 17, and 30). In summary, 11 patients died, 8 due to relapse, 2 from interstitial pneumonia, and 1 from GvHD. DISCUSSION
In the present series, cytogenetic analyses documented marrow engraftment in all patients with sex-matched donors or with donor constitutional abnormalities [3, 5]. CR associated with normal karyotype or c:onstitutional chromosome abberration was observed in 17 patients who were still alive 42 months (on average) after BMT. Eleven patients relapsed and 5 of these showed normal karyotypes. In only one of these 5 patients, transplanted with a sex-mismatched donor, cytogenetic investigatinns ctocumented the relapse in recipient cells. In three other patients with ALL the relapse origin couldn't be defined, as frequently observed in lymphoproliferative disorders [9, 29]. Unfortunately, only in the case with a donor's constitutional chromosome aberration could the cytogenetic investigations document the relapse in recipient cells. In such a patient, the undefined relapse origin was preceded by the recurfence of recipient normal cells 12 months in advance. Another ALL patient showed a clone with inv(2) and clinical and hematologic evidence of relapse at the same time. Structural rearrangements of chromosome 2 in lymphoproliferative disorders have been previously reported [30]. These changes
10/88
Death
46,XY {20) 46,XY {16)
46,XY (5O) 46,XY (4) 92.XXYY (7) 46,XY. - 13. + 8, t{1;13;14}, ?inv(2) (2) 46,XY (25)
URO I.JRO 46,XY (40) 47,XY,+ 8 [12}
46,XX (16)
46,XX (201
Bone m a r r o w karyotype
46,XY(16)
46,XY(16)
Donor karyotype
a n d c y t o g e n e t i c d a t a of p a t i e n t 2"
2% 70%
2%
2% 50%
40"/0 2°/,, 85%
95% 2% 60% 3%
Medullar blasts
CD2[OKT11 )4%; CD38(OKT10)76%;I II,A-I)R (OKI)RI84%;(]D24(OKB2190%; OKB-CALLA 48%
CD38(OKT1017O%; HI,A-DR(OKDR)84%: OKB-CAI,I,A 20%
lminunologi(: findings
Myleran + Endoxan
VCR + P + A + MTX Purinethol
VCR + P + A
C y t o x a n ~ 'I'BI COAP + TRAMPCO
VCR + P
T h e r a p y or conditioning
Abbreviations: CR. complete hematologic remission: Rel. relapse: VCR, '.'in(:ristine; TBI. total body irradiation; P. prednisone: A, asparaginase; MTX. metholrexate; UR(), undefined relapse origin. Numbers in parentheses indicated number of metaphase,s examined
1(I/87 1/88 4/88
7/87
3rd CR
2nd BMT 1st CR 1st Rel
4/87
8/83
2nd CR 3rd Rel
5/79 10/79 1/80 6/80 4/81 6/81 6/83
2/79
Date
Status of disease
Diagnosis 1st CR 1st Rel 2nd CR 1st BMT 1st Rel 1st CR 2nd Rel
Immunologic
Table 2
¢...,9
Cytogenetics and Allogeneic BMT for ANLL and ALL
231
might herald a poor response to treatment and an acceleration of the disease [30]. Also, in our case the inv(2) clone showed a rapid expansion and the patient died 8 months after this finding. Nevertheless, cytogenetic investigations were not able to identify the origin of relapse in this patient with a sex-matched donor. Patient 30 showed an interesting cytogenetic evolution. At disease onset this patient d i s p l a y e d an ANLL FAB type M2; cytogenetic investigation showed a t(8;21). After BMT we found st)me clonal chromosome abnormalities that spontaneously d i s a p p e a r e d during the follow-up. Subsequently, other clonal c h r o m o s o m e changes appeared, including a t(1;11)(p36;q23) that showed a rapid marrow expansion. The breaks on bands l p 3 6 and 11q23 have been found in patients with ANLL FAB type M4 or M5 and with MDS [31]. Nine months after first finding the t(1:11), our patient showed a clear MDS and he is undergoing his second BMT because of hematologic evolution of MDS into ANLL. In the remaining patient, at her first relapse after BMT, the hematologic data raised the suspicion that leukemia in donor cells was occuring. This was not confirmed by cytogenetic analysis, which showed undefined relapse origin metaphases in three sequential cultures. However, 36 months later further cytogenetic investigations evidenced male metaphases only. Some of these had trisomy 8, giving evidence for relapse status and the occurrence of leukemia in donor bone marrow cells. Leukemia relapse rarely occurs in donor cells after grafting. To our knowledge, only 12 cases, including the present report, have been described [21,22, 32]. Trisomy 8 is frequently found in many hematologic diseases such as AML [14]; recent data have shown this abnormality may be associated with a poor prognosis in patients treated with BMT [7]. In the present case, the patient, after a 4-year CR, developed her third relapse. At this time, a majority of normal donor metaphases was observed, associated with a donor a n e u p l o i d clone characterized by trisomy 8 and some structural changes, including a 14q + marker from a complex t(1 ;13;14). The latter abnormality, although detected in few cells, cytogenetically confirmed the lymphoproliferative origin of the disease [33], while immunologic data proved the B (:ell type of the ALL. After achieving CR, the patient underwent her second BMT, but six months later she relapsed again with a male normal karyotype only. Because of the shnrt interval hetween transplantation and relapse, we suggest that this event may be due to a defective eradication of the leukemic (:lone by the conditioning regimen rather than to a new leukemic transformation of the normal donor cells infused at second BMT. In conclusion, the present data seem to confirm the important role of serial cytogenetic studies to document (:onsistent marrow engraftment and early relapse in AL patients treated with BMT. This work was supported by a C.N.R. grant from the Rome Ontology Project, No. 88.00907.44. REFERENCES
1. Palka G, Di Bartolomeo P, iacone A. Di Girolamo G, Betti S, Calabrese G, Natale L, Stuppia L, Rieve AK, Torlontano G (1986): Cytogenetics and bone marrow transplantation. Cancer Genet Cytogenet 2 1 : 1 4 7 - 1 5 7 . 2. Cooperative study group oll chromosomes in transplanted patients. {1988): Cytogenetic follow-up of 100 patients submitted to bone marrow transplantation for Philadelphia chromosome-positive chronic myeloid leukemia. Eur J Haemato[ 4[}:50-57. 3. Zaccaria A, Rosti C, Testoui N, Arnold R, Bandini G, Becher R, Boogaerts M, Carbopnell F. Di Bartolomeo P, Ferrant A, Filippetti A, Frassoni F. Gahrton G, Haas OA, Mecucci C, Michaux L, Palka G, Pollak C, Ricci P, Rosetti A, Sessarego M, Valenti S, Van den Berghe H, Tura S (1987): Chromosome studies in patients with acute nonlymphocytic or acute lymphocytic leukemia submitted to bone marrow transplantation. Results of a European Cooperative study. Cancer Genet Cytogenet 26:51-58. 4. Spech B, Bortin MM, Champlin R, Goldman JH, Herzin RH, McGlave PB, Messner HA,
232
(;. P a l k a et al.
Wemer RS. Rimm AA [ 1984]: Aliogeneit: bone marrow transl)lantalion fnr (:hrnnic rnyelngenous h;ukaemia. I,ancet ii: 665-668. 5. Goldman ]M (1988l: Cytogenetic evolution .tier bone marrow Irausplautalioll for chronic mveloid leukaemia. Nouv Re,.' Fr He.matol. 30:31-33. 6. Calabrese (.;. Di Bartolomeo P. Stuppia I.. (;uanciali Fram:hi P. I)arruti (;. Ciancarelli M. Angrilli F. (;eraci L. Palka [19891: Cylogenc'tit:s in patients wilh chronic myelngenous leukemia treated with bone lnarrow transl)hmtati(m. Canc:er (hmet Cytogenel 41:49-59. 7. Przepiorka 1). Thomas El) (19881: Prognostic significance of cylogenelic abnormalities in patients wilh chronic myeh-~genous leukemia. Bone Marrow 'l'ransplant 3:113--119. 8. Za(:caria A, Rosti (;. Sessar(;go M. t.'rassoni 1,'. Marmnnt A, (;alimbe.rti M. Baronciani D, l"ilippetti A, Di Bartolomeo P, Di (;irolamn (;, Palka (;, Testoni N. Celso B, Bandini C. Ri(:ci P. Tassinari A, Hinterberger W. Pollak C. Haas OA. Arnohl R. Heinzc' B. Michaux 11,, Ferrant A. Me(;u(:ci C, Van den Berghe H. (;arthon (;. [,indquist R. Tufa S [19881: R(dal)se after allogeneic bone marrow transplantation for Philadelphia chromosome positive (:hronic myeloid leukemia: t:ytogeneti(: analysis of 24 patients. Bone, Marrow Transl)lant :]:41:1-42:1. 9. (;eraci 1,. Palka (;. I"iorihnfi (;. lacone A. Slupl)ia 1,. Calabrese C. Parruti (;, (;uanciali Fran(:hi P. Berardi A. Arduini A. Torlontano (_; {1987): Prognostic: value of atypical chrol'nosonlal changes during chronic mvelnid leukemia. Haematulogic:a 72:515-521. 10. Bloomfield CI.). (,;oldman AI. Alimena (.;. Berger R. Borgstr0m GH. Brandt 1,. Catovsky 11. de la Chapclle A. I)ewald GW. Garsoll OM, (,arwicz S. (}olumlJ tllVl, tinssfeld I)K. l,awler SD. Mitelman F. Nilsson P. Pierre RV. Philip P. Prigogina E, Rowley JD. Sakurai M. Sandberg AA. Seeker-Walker LM. Tricot G. Van den Berghe H. Van ()rshow;n A. Vuopio P. WhaugPeng ] [1986): Chronmsoinal abnormalities identify high risk an(l low risk patients with acute lymt)hoblastic leukemia. Blood 67:415-420. 11. Vagner-Cal)odano AM. Michel (;. Maraninchi 13. Tubiana N. (;ouzien M, Perrimond H, Carcassone Y [1988): l-'nor prognosis of acute lyrnphobh~stic hmkemia with translocation [1:191 in childhood: potential interest of allo,'4eneic bone marrow transplantation. Ann (;enet 31:53-56. 12. Palka C, I'i()ritoni (;, Lombardo M. Calabrese C, (;uan(:iali Fralmhi P, Di Marziu A, Stuppia L, Parruti (;, Geraci I, [19871: A (:ytogenetic survey of 13 patients with acute lymphocytic leukemia (AI,I,). Haematologi(:a 72:511-514. 13. Put Clt, Williams DL, Raimnndi SC, Rivera CK, l,ook AT, l)odge RK. George SL. Behm F(;, Crist WM, Murphy SB [19871: Hypodil)lt)idy is associated with a pnor prognosis ill childhood at:ute lymt)hoblasti(: leukemia. Blood 7(1:247-253. 14. Berger R, Bernheim A, Noguera ME(), Daniel MT, Valensi F. Sigaux F, Flandrin (;, Boiron M (19871: Prognoslic significance of chromosolna[ abnormalities in acute nordymphocytic leukemia: A study of 343 patients. Cancer Cenet Cytogenet 28:293-299. 15. Yunis I], Brulming RI). Howe RI). Ix)bell M (1984): High-resolution chromosomes as an independent prognostic indi¢:alor in adult acute nonlymphocyti¢: leukemia. N Engl J Med 311:812-818. 16. Palka (;. Fioritoni (;. (;era(:i L. Calabrese G. Mosca 1,. Peca S. Guanciali Franchi P. Spadano A. Arduini A. Tor[ontauo (; (1987}: Cylogenc'tics and acute non-lymphncyti(: leukemia. Ann Cenet 30:39-46. 17. Musilova ], Michalova K 11988l: Chromosolne study of 85 patients with myeIodisplastic syndrome. (]au(:er (;eilet (]ytogenet 33:39-511. 18. (]upelan EA. Kapuc)r N, Murcek M, Theil K. Tutschka PJ (19881: Marrow transplantation following busulfan and cyclophosphanfide, as treatment for translo¢:alion {4:11 ) acute leukaemia. I]rJ Ilaemato[ 711:127-128. 19. Thomas EI). Sanders JE, Fluornov N, Johnson 1,, Buckner CI), (;lift A, Fever A, Goodell BW, Storb R, Weiden PI, (1983]; Marrow transplantation for patients with acute lymi:,hoblastic leukelnia. A long-term follow-up. Blond 62:1139-1141. 20. Zaccaria A. Rosti (,. Testoni N. Arnold R. Bandini G. Becher R. Boogaerts M. Carbonell F. Di I:larlnlomeo P. Ferrant A. Filil)petti A. Frassoni F. Gahrton G. Haas OA. Mecucci C. Michaux ]1,. Palka (.;. Pollak C. Ricci P. Rosetti A. Sessaregn M. Valenti S. Van den Berghe t-1. Tura S [1987): Chromosome studies in patients with acute non lymphocytic or acute lymphocytic leukemia submitted to bone marrow transplantation. Results of an European (:ooperative study. Cant:er Genet Cytogenet 26:51-58. 21. Smith ]L. Heerema NA. Provisor AJ {1985): l,eukemic transformation of engrafted bone marrow cells. Br ] Haemat 60:415-422.
Cytogeneti(:s and Allogeneic BMT for ANLL anti ALL
233
22. Schmitz N, lnhannslln W, Sc:hmidt (_;, Villi Iter Hehn K, Loftier H {1987): Recurrence (if acute lymphoblastic leukl;mia in donor cells after allogelleic marrow [ransplantalilln assnciaic'd with a deletion of the long arln of chromosome 6. Blood 70:1099-1104. 23. Di Bartolomeo P. l)i Girolalno (;, Angrilli F, Ciancarl;lli M, Catinella V, Rolandi G. Berardi A, Di Gianfilippo R, Natah: D, Dragani A, lit:one A, Torlc)ntano G (19871: Prevention of chronic graft-w.'rsus-host disease ((.;vHl)l hy long te.rln treatlnent with cy(:lnspnrille A (CSA). Bone. Marrow Transplant 2 (SUl)pl. 1), p. 173 (ahstra(:tl. 24. Wal(tlnalm H, Polliak H, Hill(., (;. Or P,, Cividelli (.;, Weiss L. Weshler Z, Samuel S, Manor D. BrautbarC, Ra(:hmilewitz El), Slavin S. (1984): Elilninalion of (;vHl) by in-vitro (tet)letinn of alloreactive lymtlhncyles with a monll(:lnllal rat anti-human lymphocyte antihody (Campath 11. l,am:et it: 483-486. 25. Seabright M (1971 I: A rapicl tlanding terhnique for human c:hromosonles. Lancet it: 971-972. 26. Sumner AT (19721: A simple technique for dentonstraling cc,ntromeeric: heterocromatin. Exp Cell Res 75:3(14-306. 27. ISCN (1985): An International Systeln for Hnfnarl Cytogl;rletic Nomc, nclature, Harden D(;
and Klinger HP, eds.; published ill collaboralion with Cytogenet Cell Genet (Karger, Basel, 19851; also in Birth Defects: Original Article Series. Vol. 21. No. I [March of Dimes Birth Defects FllUlldation, New York, 1985). 28. FIWCI,: First lnlerlmtional Workshop on (3mnllOSolnes ill Leukemia [19771: Chrolnosomes in lenkemia: general report. Cytogenet (;ell (;enet 19:321-325. 29. Sandberg AA (19801: The chronlosonles in lmman (:am:er and leukemia. Elsevier North Holland: New York. pp. 276-294. :3(I. Yurfis II (1988): (]hronlosonlal Iranslocations and gl;ne rearrangelnents in tmll-Hodgkin lymt)holnas. Cancer I)ctection anti Prevention 12:291-296. 31. Trent ]M, Kaneko Y, Mitellnalt t" (19891: Report of lhe comnlittel; on structural chroiTlosom(; changes ill neoplasia. Human Gene Miq)t)ing 10. Cytogenet Cell Genet 51:533-569. 32. Witherspoon RP, S¢:hnbac:h W, Neilnan P, Martin P, Thomas D (1985): Donc)r cell h;ukemia developing six years after lnarrow grafting fnr ac:nle leukemia. Blood 65:1172-1174. 33. Palka G. Geraci 1,, Calahrese (;, Stlnpllia L, Guallc:iali l~'ranl:hi P, Parruti f;, I)'Antnnio A, t"ioritoni G (1988): A new case of t:hronic myelogenOllS leukemia with 14q ~ marker an¢l review of the literature. Ann Genel 31:190-192.
ABSTRACT: The authors report on a sequential cytagenetic study carried aut on 31 patients with acute leukemia (20 with acute lymphnblastic leukemia and 11 with acute non-lymphoc:ytic leukemia) who underwent hone marrow transplantation (BMTL Engraftment was documented in all patients with sex-mismatched donors and with donor constitutianal aberrations. During the followup, ranging from 6 ta 110 months, clinical and hematologic relapse was observed in 17 patients (35.5%). Five of these cases showed a normal karyatype. 3 were tff undefined relapse origin, 2 were aneuploid karyotypes, and one was donor (maleJ metaphoses. Cytogenetic and immunologic data in the latter patient were suggestive of relapse in donor cells.
INTRODUCTION R e c e n t r e p o r t s h a v e p r o v e n t h a t b o n e m a r r o w t r a n s p l a n t a t i o n (BMT) is able to c o m p l e t e l y a n d p e r s i s t e n t l y e r a d i c a t e t h e l e u k e m i c c l o n e in p a t i e n t s w i t h a c u t e l e u k e m i a (AL) or c h r o n i c m y e l o g e n o u s l e u k e m i a (CML) [ 1 - 6 [ . Specific c h r o m o s o m e c h a n g e s at t h e t i m e of B M T are k n o w n to r e p r e s e n t a s e v e r e p r o g n o s t i c factor for p o s t - t r a n s p l a n t o u t c o m e w h e n p a t i e n t s w i t h C M L are t r a n s p l a n t e d e i t h e r in t h e a c c e l e r a t e d p h a s e or in b l a s t i c crisis [ 7 - 9 ] . A l t h o u g h p r o g n o s t i c c o r r e l a t i o n s b e t w e e n c h r o m o s o m e r e a r r a n g e m e n t s a n d AL h a v e also b e e n s u g g e s t e d [ 1 0 - 1 7 ] , few c y t o g e n e t i c data are a v a i l a b l e to p r e d i c t t h e B M T c o u r s e in p a t i e n t s d i s p l a y i n g s p e c i f i c c h r o m o s o m e c h a n g e s at t h e t i m e of B M T [7,10,11,18]. R e c u r r e n c e
Institute of Biology and Genetics. (;hair of llematology (G. D. G.. P. D. B.. 1:. A.. G. T.), University of Chieti; Division of tlemalology {G 1). G.. P. D B.. F. A.. G. T.J. Pescara flospital; Cytomorphology Institute (L. S.). CNR. Chieti. Italy. Address reprint requests to: Giandomenico Palka, Via B. Buozzi 93, 65121 Pescara, Italia l~ecewed September 22, 1989; accepted lune 4, 1990.
223 (('; 1991 Elsevier Science Publishing Co., Inc. 655 Aw:nue of the Americas, New York. NY 10010
Cancer Genel Cytogenet 223 233 (1991) 0165-4608/91/$03.50
224
G. Palka et al.
of leukemia has been reported in 2 0 - 6 0 % of patients after BMT for AI, [19,20]. Cytogenetic patterns are similar to those evidenced before BMT if conditioning regimen was insufficient. Also, the appearance of a new clone may be due to a conditioning regimen that l)roduced either a proliferative advantage in an unknown neoplastic (:ell or an alteration in normal residual (:ells [6,20]. The leukenlia relapse rarely o(:curs in donor cells after grafting. In these cases, malignancy usually resembles the pretransplant disease even if different types of leukemias have been described [21,22]. We report a cytogenetic study of 31 patients with acute n o n l y m p h o c y t i c leukemia (ANLL) and acute lymphoblasti(: leukemia (ALL) who were submitte(t to BMT, in order to discuss the importance of sequential chromosome analysis in evaluation of both stable marrow-take and early relapse.
MATERIALS AND METHODS Patient and Donor Population Between December 1976 and December 1989, 31 patients with AL {20 with ALL and 11 with ANLL) received a marrow transplant at the I)ivisione di Ematologia, Ospedale Civile, Pescara. Previous c h e m o t h e r a p y and the time of admission for BMT varied with the referring institutions. Morphologic characteristics of leukemic cells were defined according to the FAB classification. The patients' marrows were examined before transplantation and patients with less than 5% blasts in the marrow were considered in complete remission {CR). All donors were HLA-identical and MLC-non-reactive siblings. One patient was given a second marrow transplant (patient 2}.
Transplant procedure During the period covered by this report several different conditioning regimens w e r e used. Twenty-one patients received c y c l o p h o s p h a m i d e {CY) (60 mg/Kg/day for 2 days) and total body irradiation (TBI) delivered from single ~°Co source at a dose rate of less than 3 cGy/minute [patients 1-4,6,7,9-12,14,15,21-24,26-30): 2 patients received chemotherapy (cytosine arabinoside, dautmmycin, vincristine, and VP16) in addition to TBI (patients 5,8}. In the remaining 8 patients and for the set:ond BMT in patient 2, the conditioning regimen consisted of busulfan (4 mg/Kg/day for 4 days) and CY {50 mg/Kg/day for 4 days) {patient 13,16-20,25,31}. The day of marrow infusion was designated day 0. A mean dose of 4.3 × 10a/Kg body weight nucleated marrow cells was infused. In order to prevent Graft-versus-Host Disease {GvHD}, 1 patient received methotrexate (MTX) as in the Seattle schedule {patient 1), 18 patients were given cyclosporine A {CSA) for 12 months as previously described [23] {patients 2-13,21-24,26,29), and 11 patients were given a short course of MTX {3 or 4 doses i.v.) combined with a CSA long-term treatment (patients 14-20,25,27,28,31}. One patient received donor bone marrow purged with anti-T lymphocyte monoclonal antibodies {Campath 1} [24] and CSA for 12 months {patient 30). Acute and chronic GvHD were graded according to the Seattle criteria. Engraftment of donor cells was demonstrated by marrow examination and peripheral cell counts and, whenever possible, by blood genetic markers and/or cytogenetic analyses. All patients were nursed in laminar air flow or positive pressure rooms and ret:eiw,'d gastrointestinal decontamination and sterile diet.
Cytogenetics and Allogeneic BMT for ANLI. and ALL
225
Cytogenetic Studies (]ytogenetic analyses were carried out on bone marrow cells at ctiagnosis, before conctitioning, within 90 days after BMT. and at intervals of 6-12 months thereafter. For each test, at least 16 metaphases were studied by c:onventional G- anct C-banding techniques 125,26]. Cytogenetic analyses on phytohemagglutinin-stimulatect peripheral hlood cultures were performed on all of the donors. Chromosomes were classifiect ac:cording to the ISCN (1985) [27]. An abnormal clone was definect according to the criteria of FIWCL [28].
RESULTS A complete summary of the cytogenetic: data pre- and post-BMT is reported in Table 1.
Pre-BMT Only 9 of 31 patients had a cytogenetic analysis at diagnosis (patients, 1-7,29,30); the remaining 22 came from other centers where they had not been cytogenetically studied. Five of the 9 patients tested showed a normal karyotype (patients 1,2,4,5, and 7). One patient presented with chromc~somes of unciefined relapse origin (patient 3), 1 patient with a clone with a del(6q) (patient 4), and another patient with a Philadelphia chromosome (Ph) in 100% of bone marrow cells, associated with other anomalies (patient 29). Patient 30 showed a clone with a t(8;21). Before conditioning, all patients had a normal karyotype, although 4 of them were in hematologic- relapse (patients 1,24,29, and 30). In the donors' group, 28 subjects had normal karyotypes, one showed a t(2;12) (donor 7), one a del(Xq) (donor 21), and another an inv(19) (donor 28). PosI-BMT
The cytogenetic analyses carried out within 90 days from BMT showed a normal karyotype in 27 patients. Of these, 14 (10 with ALL and 4 with ANLL) who had received bone marrow from sex-mismatched donors showed cytogenetic sex conversion (patients 1, 2, 4, 6, 10, 11, 13, 15, 19, 20, 22, 23, 26, and 31) Two of these 27 patients died because of interstitial pneumonia (patients I and 4). In 3 other patients, the same constitutional chromosome change as in their donors was observed (patients 7, 21, 28). In the remaining ALL patient with sex-mismatched donor (patient 16}, BMT was unsuccessful. This patient suddenly showed clinical and hematologic signs of relapse associated with recipient diploid karyotype and died 3 months after BMT. During the cytogenetic follow-up (ranging from 6 to 110 months), the persistence of either a normal karyotype or a donor constitutional abnormal karyotype was noticed in 17 patients (10 with ALL and 7 with ANLL) in CR after BMT (patients 3, 6, 8-10, 14, 15, 18-22, 24, 25, 28, 29, and 31). In one of these, with CR 30 months after BMT, an abnormal clone was observed (patient 25). This abnormality disappeared spontaneously and the karyotype reverted to normal. One patient died from chronic GvHD during follow-up, and the last cytogenetic analysis showed the reappearance of recipient marrow cells in 25°/,, metaphases without clinical and hematologic features of relapse (patient 26). Eleven patients (35.5%, (8 with ALL and 3 with ANLL) showed clinical and hematologic relapse (patients 2, 5, 7, 11-13, 16, 17, 23, 27, and 30). Of these, 8 were transplanted with sex-matched donors (patients 5, 11-13, 17, 23, 27, and 30), 2 with sex-mismatched
M 11
V12
M;5 F'30
b','8
M,2II
F,'19
M 16
F'q
M'15
F"29
M'II
M:(i
M:I5
F;24 M!9
2
3 4
5
(i
7
8
~-I
10
II
12
t3
14
15 16
Sex, . age
1
No,
Patient
Al.l. AI.I.
AI.I.
AI.I.
AI.[.
AI,I.
AI.I.
ALl,
ALL
ALl.
4(5.XX {2(1l
46.XY 1321
4ti.XX 1381
AI.I,
AI.I.
IIRO 46.XX (301 4ls.XX.liq 171
4ls.XX 12111
2rid CR 3rd CR
lsl CR
21ul CR
2IHI CR
2rid CR
2nd ('R
2nd CR
2nd CR
2rid (]R
2n(| CR
2nd (;R
Is( CR Ist CR
3rd CR
2rid CR
4th tel
al tlia:4nosis
4ls,XY 1251
Statu~
at B M T
Patient kar',ut;'lJe
AI.I. AI.I.
AI.I.
AI.I.
Disease
46.XY 1161 41i.XX I l l i l
46.XY {lbl
46.XX [ 161
4ls.XY {lls]
7 117 12 117
11 86
8 8b
2 8B
!1 85
8.85
4ei,XX Ills) 4ls,XY Ills}
II 85
1 1'84
4ls.XX l l l i l
Ills)
1 8ls
-Ils.XX. 1(2:12} (lls]
46.XY
1 86
2 85
ls 113 10 113
2ndBMT
I 0 87
Ils]
4(I,XY Ills] 4ls.XY 1201
-lls,XY ( llsl
-16.XX [ 111l
4b.XY 1211}
4ls.XY I lhl
4ls.XX 1161
411.XX { 161
411.XY Illsl
4ls.XX. I[2;121 [161
4ls,XX Ils}
41i,XX
4ls,XY 1251 4(i.XY ( 171
.l(i.X Y 1211]
4 6 . X Y 1161
4 o . X X {lbl
12 76 1i 80
Karvotvl)e afler BMT
Dale o[ BMT
.Ils,XX 1161
"Ils,XX Ills]
4B.XY Ilti) 4B.XY IllS)
46,XY [161
4fi,XX [16 I
Donor karyolype
Table 1 Cytogenetic f i n d i n g s in transplanted patient
fi.85-12 89 4ls.XY (IbO] 5186-12 89 46.XX (17(11 3 86-12:1141 4~.XX 191)l 4 '86 46.XY 12111 II. I|6 •Ils.XY 11711 .Ils,XY. inv{2] (71 10,' 8ls I JR() 7,87-11 841 41i,XY (1501 !t,87-12 841 4(i.XY ( 12111
4 86-11 His 4(i,X X [5111 1i 8 6 - 1 2 . 8 9 4(I.XX 11411) I o. 86 4ls.XX. I(2;12111131
ls 84-12 II~1 4ls.XY (140}
4 8B 4ls.XY (1is)
ls 113 •l l i . X Y [4(1) -IT.XY. - 8 [ 121
Karyotype dilv after B M T
3 87 41;.XY inv{2) 1251
4,87 4(~,XX [11) 46.XX, I{2.12) 12!)}
I !NO
9~87-10 8!I
7:84- l(l 86 4ls.X Y 1501
4111
3 118 URO
4 '87 411.XY (9) 92.XXYY 171 46.XY, 13. * 8, t[ 1:13;14).1111:12). ?my(2) lEl
1:88
11/86
II ;Bls
1/116
7:88
12'87
4 88
-I.II1
Relapse
3 '88
1.87
4,87
7186
12:88
I I '83
10~88
2'77
I)ealh
3
, 29
~37
5
14
Ill
52
* 4!1
+61
35
+47
+58
1
78
11111
Surviwd ill Ill()Illhs at 1 2 ! 3 1 / 8 9
t',,o
M.7
F~25
M'27
F /I l l
F/IS
F'!19
M:7lt
F:20
M/13
F/38
F:34
M'3!I
M/34
Fi33
18
19
20
21
22
23
24
25
26
27
28
29
30
31
13MT, b o n e
4li.XY. t(8:21 } {l(1)
45.XY.Ph, 1 0 , - 1 5 . + M 1 [31 42.XY.Ph. - 8. -8. 12.-1;3(4)
46.XY.Ph [28)
+, aliw~ patients:
ANLL
ANI,I,
ANI,I,
ANI.I.
AN[,[,
ANLI.
ANI.I.
ANI,I.
ANLL
ANLL
ANLI,
AI,I,
AI.I.
AI.I.
AI.I.
marrow
1st CR
1st tel
1st rel
lsl (;R
1st (]R
2rid CR
2nd CR
Isl rel
2rid CR
2rid CR
l s l CR
l s l CR
2nd CR
1st CR
1st CR
transphmlalion;
46.XY [16J
46.XY Iltll
46,XY 1161
46.XX. my{ 19) 1161
46.XX [161
4(i.XX (lfi)
4tLXX 116)
46.XY {16)
-16.XY [161
,18.XY ( l b l
48.XXq -11t5)
46.XX 1161
46.XY [161
4fLX'f (lfi~
46.XY 1161
relapse origin. See Table 2 for the oomph;re disease course. " Numl~,~rs in parentheses indicate number of metaphases examined.
Abbreviations:
M.~
17
1161
leukemia;
ANLL. acute
18/89 4tI,XY. t(1;111 IJ01 10:88 1 ~/8!l 4~5.XY 160)
3; 89 46.XY 112) 4/88 48,XY 146)
9/07-I0'88 4G.XY (18)
2/88-10t88 46.XX (20J 4 6 . x x . - 16. + M 1 (21 3/88 4(I.XX [15) 4Ii.XX [5J
10:8G-3.87 ,t(I.XY 1201 46.XY.Sq [51 46,XY. 116:16) (4)
2/87 46.XX (501 10.87-12:8!t 46.XX. inv1191 (5ill 10/86-10:'89 46.XY [140)
tl 8 7 - 1 2 : 8 7 4~i.XX (50}
46.XY [13|1) 7'87 46.XX 1171
2.,87-12/8!t
46.XY [80] 10t88-12/B9 48.XY ( l l 0 ) 10:88-12'89 .16,XX {80) ~t 8G- 12 tS!t 48.XXq (90] 5/811-2:8c.1 46.XY (~t0l 3~8h 46,XY (16)
7 88-12'89 46.X'1' 170) 10 88-12189
lymphoblastic
46,XY 125J
46,XY (2[)) 4(i,XY, t(t~:16] (81
4Ii.XY (1G)
-l(i,XX, inv(19) (181
-IIi.XX [161
46,XX (20)
46.XX IIfll
46.XY [16J
46.XY (20)
4li,XY 1201
46.XXq-
4tLXX [22]
46.XY [:10)
4~I,XY (20]
-t6.XY 1221
AI,L, acute
12/87
!J.'85
10,85
4187
~l:8tl
12,8(5
9:86
2 86
10/85
21/85
8'85
4:H8
2:88
2:88
12i87
unm-lympholdastit:
1;~9 46,XY (25) 46.XY. t ( l : l 1)[9) 46.XY, t[10:15) (3)
2:87
3.'89-12.'89 .16.XX (581
leukemia;
10,8!-t
5,87
2,86
8i88
+ 24
+51
+ 50
4- 32
18
+ 3~-I
~"46
7
URO. undefined
8
6/80
5,86
+ 57
÷ 52
÷20
+22
¢ 22
~ 24
t'~ "-,1
228
(;. Palka et al.
Figure 1
Partial karyotype showin'e, inv(2)(plhll3}(paticllt 12).
donors (patients 2 and 16), and one wilth donor (:ells (:arrying the constitutional aberration t(2;12] [patient 7}. At the relapse onset, (tiploid karyotyl)eS were observed in 5 patients (patients 11,16,17.23, and 27). Four of these died 7 months after BMT on average, while one is still in relapse 24 months after BMT (patient 17). Undefined relapse origin metaphases were evidenced in 3 other patients (patients 5, 7, and 13). Two of these died 35 and 5 months, respectively, after BMT (patients 7 and 13) and one is still in relapse 25 months after BMT (patient 5). Another patient (patient 12) showed normal metaphases and a clone with inv[2)(pllq13) (Fig. 1). This (:lone showed a rapid marrow expansion and tile patient died 14 months after BMT. Patient 30 at first showed some clonal chromosome abnormalities that spontaneously (tisa|)peared with restoration of a normal karyotype. Subsequently, other (:lonal chromosome changes appeared, among them the translo(:ation t(1:11 )(p36;q23) (Fig. 2). After a short interval, in which his karyotype returned to normal, the clone with t(1;11) displayed a rapid marrow expansion and the patient developed a myelodysplasti(: syndrome (MDS). Two rnonths later, hematologic eviden(:e of ANI,I, was observed: at present he is undergoing a second BMT. In the remaining patient (patient 2), we could not define the relapse origin at the time of the first relapse (April 1981) and during the subsequent first CR. When the t)atient developed her second relapse (June 1983). two male cell lines were evidenced: 46.XY an(t 47.XY. +8. At this stage, immunologi(: studies revealed the occurrence of a B-AI,I, (70% CD38/OKT10: 84% HI,A-DR/OKDR: 20"/o OKB-CAI,I,A). She reached her se(:nnd CR after (:hemotheral)y with restoration of a male donor [normal) karyotype. In April 1987, 46 months later, during tile third relapse, cytogenetic analysis eviden(:ed only donor lnetaphases, i.e., normal. polyploid, and a small (:lone: 46.XY,-13,+8.t{1;13:14)(p11:q11:q32), t(11;12) (q13;q24), ?inv(2](p2ht11). (Fig. 3). After chemotherapy, the patient achieved the third CR (July 1987) and (:ytogeneti(: investigation showed a male (normal) karyotype. Subsequently, the patient underwent her se(:on(l BMT in O(:tober 1987. Altogether, seven cytogem;ti(: investigations have been performed between the first anti the second BMT, showing male (donor) karyotypes only in all of the 140 metaphases studied.
Figure 2
Partial karyotype showing t(1 ;11 ][p36;q23)(patieul 30).
229
('ytogenetic:s and Allogeneic BMT for ANLL and AI,I,
A
AJ n Figure 3 Partial karyotype showing chromosome aberrations at 3rd relapse, after I st BMT. (A] t(l:13;14)(pll:q11:q32), (B) t(1 l:12](q13:q24), (C) ?inv(2](p21qlll(patient 2).
Three months after the second BMT, while the patient was still in CR, a male normal karyotype was again ()[)served. In April 1988, while relapsing according to hematologic tests, she showed a male normal karyotype only. The immunologic markers proved the B (;ell origin of her leukemia (4% CD2/OKT11; 76% CD38/OKT10; 84% HLA-DR/OKDR; 90% CD24/OKB2; 48% OKB-CALLA). In October 1988, the patient died of cardio-pulmonary failure (Table 2). Eight of 11 relapsing patients died (patients 2, 7, 11-13, 16, 23, and 27), while the other 3 were alive and still in relapse in December 1989 (patients 5, 17, and 30). In summary, 11 patients died, 8 due to relapse, 2 from interstitial pneumonia, and 1 from GvHD. DISCUSSION
In the present series, cytogenetic analyses documented marrow engraftment in all patients with sex-matched donors or with donor constitutional abnormalities [3, 5]. CR associated with normal karyotype or c:onstitutional chromosome abberration was observed in 17 patients who were still alive 42 months (on average) after BMT. Eleven patients relapsed and 5 of these showed normal karyotypes. In only one of these 5 patients, transplanted with a sex-mismatched donor, cytogenetic investigatinns ctocumented the relapse in recipient cells. In three other patients with ALL the relapse origin couldn't be defined, as frequently observed in lymphoproliferative disorders [9, 29]. Unfortunately, only in the case with a donor's constitutional chromosome aberration could the cytogenetic investigations document the relapse in recipient cells. In such a patient, the undefined relapse origin was preceded by the recurfence of recipient normal cells 12 months in advance. Another ALL patient showed a clone with inv(2) and clinical and hematologic evidence of relapse at the same time. Structural rearrangements of chromosome 2 in lymphoproliferative disorders have been previously reported [30]. These changes
10/88
Death
46,XY {20) 46,XY {16)
46,XY (5O) 46,XY (4) 92.XXYY (7) 46,XY. - 13. + 8, t{1;13;14}, ?inv(2) (2) 46,XY (25)
URO I.JRO 46,XY (40) 47,XY,+ 8 [12}
46,XX (16)
46,XX (201
Bone m a r r o w karyotype
46,XY(16)
46,XY(16)
Donor karyotype
a n d c y t o g e n e t i c d a t a of p a t i e n t 2"
2% 70%
2%
2% 50%
40"/0 2°/,, 85%
95% 2% 60% 3%
Medullar blasts
CD2[OKT11 )4%; CD38(OKT10)76%;I II,A-I)R (OKI)RI84%;(]D24(OKB2190%; OKB-CALLA 48%
CD38(OKT1017O%; HI,A-DR(OKDR)84%: OKB-CAI,I,A 20%
lminunologi(: findings
Myleran + Endoxan
VCR + P + A + MTX Purinethol
VCR + P + A
C y t o x a n ~ 'I'BI COAP + TRAMPCO
VCR + P
T h e r a p y or conditioning
Abbreviations: CR. complete hematologic remission: Rel. relapse: VCR, '.'in(:ristine; TBI. total body irradiation; P. prednisone: A, asparaginase; MTX. metholrexate; UR(), undefined relapse origin. Numbers in parentheses indicated number of metaphase,s examined
1(I/87 1/88 4/88
7/87
3rd CR
2nd BMT 1st CR 1st Rel
4/87
8/83
2nd CR 3rd Rel
5/79 10/79 1/80 6/80 4/81 6/81 6/83
2/79
Date
Status of disease
Diagnosis 1st CR 1st Rel 2nd CR 1st BMT 1st Rel 1st CR 2nd Rel
Immunologic
Table 2
¢...,9
Cytogenetics and Allogeneic BMT for ANLL and ALL
231
might herald a poor response to treatment and an acceleration of the disease [30]. Also, in our case the inv(2) clone showed a rapid expansion and the patient died 8 months after this finding. Nevertheless, cytogenetic investigations were not able to identify the origin of relapse in this patient with a sex-matched donor. Patient 30 showed an interesting cytogenetic evolution. At disease onset this patient d i s p l a y e d an ANLL FAB type M2; cytogenetic investigation showed a t(8;21). After BMT we found st)me clonal chromosome abnormalities that spontaneously d i s a p p e a r e d during the follow-up. Subsequently, other clonal c h r o m o s o m e changes appeared, including a t(1;11)(p36;q23) that showed a rapid marrow expansion. The breaks on bands l p 3 6 and 11q23 have been found in patients with ANLL FAB type M4 or M5 and with MDS [31]. Nine months after first finding the t(1:11), our patient showed a clear MDS and he is undergoing his second BMT because of hematologic evolution of MDS into ANLL. In the remaining patient, at her first relapse after BMT, the hematologic data raised the suspicion that leukemia in donor cells was occuring. This was not confirmed by cytogenetic analysis, which showed undefined relapse origin metaphases in three sequential cultures. However, 36 months later further cytogenetic investigations evidenced male metaphases only. Some of these had trisomy 8, giving evidence for relapse status and the occurrence of leukemia in donor bone marrow cells. Leukemia relapse rarely occurs in donor cells after grafting. To our knowledge, only 12 cases, including the present report, have been described [21,22, 32]. Trisomy 8 is frequently found in many hematologic diseases such as AML [14]; recent data have shown this abnormality may be associated with a poor prognosis in patients treated with BMT [7]. In the present case, the patient, after a 4-year CR, developed her third relapse. At this time, a majority of normal donor metaphases was observed, associated with a donor a n e u p l o i d clone characterized by trisomy 8 and some structural changes, including a 14q + marker from a complex t(1 ;13;14). The latter abnormality, although detected in few cells, cytogenetically confirmed the lymphoproliferative origin of the disease [33], while immunologic data proved the B (:ell type of the ALL. After achieving CR, the patient underwent her second BMT, but six months later she relapsed again with a male normal karyotype only. Because of the shnrt interval hetween transplantation and relapse, we suggest that this event may be due to a defective eradication of the leukemic (:lone by the conditioning regimen rather than to a new leukemic transformation of the normal donor cells infused at second BMT. In conclusion, the present data seem to confirm the important role of serial cytogenetic studies to document (:onsistent marrow engraftment and early relapse in AL patients treated with BMT. This work was supported by a C.N.R. grant from the Rome Ontology Project, No. 88.00907.44. REFERENCES
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