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Cytogenetics of chronic myelomonocytic leukemia
Cytogenetics of Chronic Myelomonocytic Leukemia Groupe Fran~ais de Cytog~n~tique H6matologique
In a retrospective multicenter study by the Groupe Franqais de Cytog~n~tique H~matologique, chromosome investigation was undertaken in 120 cases of chronic myelomonocytic leukemia, which was diagnosed in accordance with the French-American-British (FAB) criteria. Chromosome abnormalities of the clonal type were present at diagnosis in 30% of the patients. Median age of these patients was lower than for these without karyotypic abnormalities, and prognosis was less favorable. The most frequently encountered characteristic chromosome change was monosomy 7; chronic myelomonocytic leukemia (CMLL) with monosomy 7 occurs in younger age groups and has a very poor prognosis. Next in frequency were trisomy 8, iso(17q), and a 12p anomaly. The latter may have to be classified among the so-called primary characteristic chromosome changes in leukemia. All chromosome changes were of the type usually found in myeloid proliferation, and no anomaly specific for CMML was discovered. Isochromosome 17q was found only during blastic phase. Several of the CMML cases with chromosome anomalies were secondary leukemias, and among these was one case with a homogeneously staining region (HSR), which is rarely reported in leukemia. A paraproteinemia was found in 12% of the patients. No correlation of its occurrence with presence or type of karyotypic anomaly could be found.
ABSTRACT:
INTRODUCTION Chronic m y e l o m o n o c y t i c leukemia (CMML) is a leukemic disease, belonging to the group of c o m m o n progenitor stem cell disorders [1-4]. For many years, its nature was rather ill-determined. As a disease entity, the disorder was recognized essentially on the basis of clinical and cytologic criteria, w h i c h were only vaguely delineated. With the aim of establishing a better classification, the French-American-British Cooperative Group (FAB) recently i n c l u d e d CMML in the large group of myelodysplastic syndromes (MDS) [5] and defined some simple, but strict, criteria for its definition. These FAB criteria were applied in a recently published study [6] in w h i c h full description of the disorder is given and its clinically p l e i o m o r p h character confirmed. However, the cytogenetic aspects of the disorder are still m u c h less well defined. From a series of mostly single observations [2-4, 7-9], it appears that a Philadelphia c h r o m o s o m e is rarely or never seen. No characteristic chromosome anomalies have yet been associated with CMML, but large and systematically stud-
For a complete list of the participants in the Groupe Fran§ais de Cytogen~n~tique H~matologique see Appendix 1. Address requests for reprints to Dr. Jean-Louis Michaux, Service d'H~matologie, Cliniques Universitaires St-Luc, Avenue Hippocrate 10, B-1200 Brussels, Belgium. Received February 4, 1985; accepted May 7, 1985.
11 © 1986 Elsevier Science Publishing Co., Inc. 52 Vanderbilt Ave., New York, NY 10017
Cancer Genet Cytogenet 21:11 30 (1986) 0165-4608/86/$03.50
12
Groupe Fran§ais de Cytog@n@tique H6matologique
ied series have not been reported. The Groupe Fran~ais de Cytog~n~tique H~matologique therefore decided to conduct a multicenter study based on the FAB morphological criteria and aiming at a better definition of the chromosome anomalies in CMML.
MATERIALS AND METHODS The present study is a retrospective one, and 16 centers (15 French and 1 Belgian) contributed data that were in accordance with the FAB diagnostic criteria. Information on 120 patients was collected; included were anamnestic, clinical, hematologic and immunologic data, all of which were reviewed by J. L. M. Bone marrow and peripheral blood cytology were reviewed by two investigators (G. F. and P. F.). Cytogenetic investigations had to i n c l u d e the analysis of at least 15 metaphases of the bone marrow cultured for not less than 48 hr. All cases had to be banded, and all karyotypes were reviewed first on the local level. Twelve cases were excluded because of insufficient data. Finally, a small group of cytogeneticists reviewed all other karyotypes. For the purpose of this study, the 120 cases were subdivided into four types, each describing a particular stage or aspect of the disease at the time of cytogenetic investigation: Type 1: Classical morphological and hematologic features, as described by FAB; monocytosis in the blood ranged between 1 and 5 x 109/L. Type 2: As type 1, but with monocytosis higher than 5 x 109/L. Type 3: As types 1 and 2, but with some morphological peculiarities, e.g., eosinophilia (two cases) or megaloblastosis (one case). Type 4: Transformation into acute leukemia, with more than 30% blasts in the bone marrow. Of the 120 cases, 44.2% belonged to type 1, 49.2% to type 2, 2.5% to type 3, and 4.2% to type 4. RESULTS
Clinical Aspects Of the 120 patients, 79 were m e n and 41 were women, yielding a sex ratio (M/F) of 2:1. Median age for m e n was 69 years (extremes were 23.9 and 86.6) and for w o m e n 72.8 years (extremes 49.3 and 91.9). The mean time lapse between onset of symptoms and diagnosis was 8.1 months. The m a i n clinical and hematologic features of the patients are summarized in Table 1. There were no striking differences between the four subtypes as defined in this study. Splenomegaly, however, was significantly more frequent in type 2 as compared with type 1, and in addition, exposure to toxic agents or to chemotherapy and radiation for a previous malignancy was more frequent in type 2.
Hematologic Characteristics Table 1 and Figures 1 and 2 show that 50% of the patients had moderate anemia, with hemoglobin (Hb) values less than 110 g/L, as well as thrombopenia, with platelet values lower than 100 x 109/L. The white cell count varied with the subtypes defined. Differences were outspoken and significant between types 1 and 2 with regard to leukocytosis, monocytosis,
Table 1
G e n e r a l a n d b i o l o g i c d a t a o n 120 p a t i e n t s w i t h C M M L Total
Type 1
Type 2
Type 3
Type 4 a
N u m b e r and percentage of patients Sex ratio (M/F) Age (year) Median Mean
120, 100% 79/41
53, 44.2% 31/22
59, 49.2% 43/16
3, 2.5% 2/1
5, 4.2% 3/2
70.5 68.3
70 68.2
70.7 67.9
73.7 73.9
69 69.8
Fever Weight loss Fatigue Night sweating Infections Bleeding t e n d e n c y
25.9% 39.5% 76.6% 16.2% 25.9% 27.6%
8 (50) 18 (48) 34 (48) 6 (44) 12 (49) 13 (50)
10 (58) 20 (54) 45 (56) 7 (49) 14 (57) 15 (58)
2 2 2 2 1 1
3 3 4 1 2 3
Splenomegaly Hepatomegaly
45.2% 39.8%
18 (49) b 20 (51)
30 (58) ~ 21 (52)
2 (3) 1 (3)
2 (5) 2 (5)
L y m p h node enlargement Gingival h y p e r t r o p h y Cutaneous lesions
17.1% 3.7% 5.3%
10 (52) 2 (51) 1 (48)
8 (58) 2 (55) 3 (58)
1 (3) 0 (3) 0 (3)
1 (4) 0 (4) 2 (5)
Previous n e o p l a s m s ( n u m b e r of patients) Toxic or therapeutic e x p o s u r e ( n u m b e r of patients)
12 (100) 7 (85)
3 (45) 1 (40)
7 (51) 6 (42)
1 (2) 0 (2)
1 (2) 0 (1)
109 141 28.565 7.229 88 (112) 32 (105)
110 136 13.265 d 3.229 d 31 (48) c 8 (46) b
109 142 41.7784 10.830 d 51 (57) ~ 20 (51) ~
116 110 18.367 6.767 2 (3) 1 (3)
96 219 20.400 7.524 4 (5) 3 (5)
87 62.15 38 12 (98)
37 63.3
45 78.4
2 17
2 83
2 (42)
7 (49)
0 (3)
3 (4)
104 15.6 14.4
45 15.1
51 14.5
3 20.5
5 28.4
C h r o m o s o m e investigations (see also Results section) Hypodiploidy Hyperdiploidy Structural anomalies Complex anomalies Normal karyotype
16 13 13 3 84
10 5 7 1 33
4 7 6 1 46
1 --1 2
1 1 --3
Survival (median in m o n t h s )
27.4
37.3
20.7
38
48.9
Hematologic data Hb (g/L) Platelets ( x 109/L) WBC (× 109/L) Monocytes (× 109/L) I m m a t u r e forms in blood ( n u m b e r of cases) Presence of blasts in blood ( n u m b e r of cases) S e r u m lysozymes (ms/L) N u m b e r of cases Mean Median Presence of clonal Ig ( n u m b e r of cases) I m m u n o g l o b u l i n level (g/L) N u m b e r of cases Mean Median
(3) (3) (3) (3) (3) (3)
Numbers in parentheses represent the number of cases on which information was available. Percentages in the first column are cumulative percentages of the presence of the feature in the four types. ~For explanation see Materials and Methods. bDifference between type 1 and type 2 is significant, p < 0.05. ~Difference between type 1 and type 2 is significant, p ~ 0.01. dDifference between type 1 and type 2 is significant, p < 0.0001.
(4) (4) (4) (3) (3) (5)
:i.... {ii
Figure I
215
i c.
.~ i i~ ~
cLq
Hematologic data. T I 2 3 4:: Median values in different types of CMML.
I111
4
PLAIELETS
x I09/L
4~
Cytogenetics of CMML
TI t
15
T
Figure 2 Blood lysozyme and serum IgG levels. 1' 1 2 3 4: Median values in different types of CMML. ( ~ ) Type 1', ( ~ ) t y p e
B L 0 0 [I
?
~
Ii
':
17
L Y S 0 Z ¥ r~ E
2; ( ~ ) t y p e
3;
~:c~:~:-
,!
immature forms, and blasts. Type 4 was naturally markedly different from the other types because of the blast crisis presented by the patients belonging to that category. Bone marrow aspiration and biopsy generally showed hypercellular bone marrow with predominant myeloid proliferation and increased monocytosis. At times, the monocytoid elements were difficult to distinguish from immature myeloid elements. The myeloid elements very often showed morphological anomalies characterized by diminution of primary granules and poor segmentation of mature forms. The erythroid series was often depressed and showed marked morphological ab-
16
Groupe Fran~ais de Cytog6n6tique H6matologique normalities: macroblastosis and megaloblastosis, sideroblasts, as well as ringed cells. Nuclear anomalies were frequently seen. Megakaryocytes were often r e d u c e d in number, small, and hypolobulated, and giant platelets could be found in the blood. In patients who also s h o w e d a clonal gammapathy, infiltration of the bone marrow by plasma cells was observed. This proliferation, however, was not accompanied by morphological changes of the p l a s m a cells, as is seen in m u l t i p l e myeloma. The leukocyte alkaline p h o s p h a t a s e varied considerably from case to case, and this variation had no bearing on the stage or progression of the disorder.
Other Biologic Findings, Including Gammopathy Serum lyzozymes were high and variable in all patients, but no differences could be found among the four types. Serum i m m u n o g l o b u l i n levels were usually higher than normal; about 50% of the patients had values above 14 g/L, and all i m m u n o globulin classes could be involved. A monoclonal c o m p o n e n t was found in 12 patients: 5 IgG, 3 IgM, 2 IgA, and 2 cases w i t h light chains (Table 2). They were especially present in types 2 and 4. In none of these patients, however, was any indication of m u l t i p l e m y e l o m a found. No correlation between the existence of a paraprotein and the frequency or type of karyotypic anomaly could be demonstrated. The problem of p a r a p r o t e i n e m i a in CMML is especially interesting. Table 1 shows that 12% (12 of 96) of patients had paraproteinemia. The type of paraprotein and the correlation with the status of the karyotype are given in Table 2. It appears from this table that p a r a p r o t e i n e m i a is found more often in cases with r a p i d l y advancing disease (types 2 and 4 of our classification) and that no correlation with frequency or type of karyotypic a n o m a l y could be demonstrated.
Prevalence of Karyotypic Abnormalities in 120 CMML Cases (Appendix 2) All patients were investigated at diagnosis; however, in those patients whose karyotype r e m a i n e d normal, the diagnosis was not confirmed until a few months after the initial karyotypic investigation. Thus, the karyotype was abnormal in 36 of 120 patients (30%) at diagnosis. In four patients, the karyotype became abnormal during subsequent evolution (Table 3). It is possible that with further evolution, the karyotype may also become abnormal in some of those patients who are still alive.
Principal Chromosome Abnormalities (Table 4) A m o n g the n u m e r i c a l changes, m o n o s o m y 7 was the most frequent chromosome anomaly in this series, occurring either as the sole a n o m a l y (8/40 or 20%) or in combination with c o m p l e x abnormalities (2/40). In the latter two cases, a chromosome # 5 was also abnormal (see below). In total, m o n o s o m y 7 was found in 25% of cases with abnormal karyotype. Next in frequency was trisomy 8, w h i c h occurred in 5/40 patients (12.5%) as the sole anomaly. It was found also twice in combination with other changes. A n u m b e r of structural anomalies were observed, some of w h i c h d e m a n d particular attention. The short arm of chromosome #12 was found to be abnormal five times. In three cases, a deletion with breakpoints in p11-12 was the sole anomaly; in two other cases, 12p was involved in a translocation, and in each of these cases, breakpoints were again in p12. An isochromosome of the 17q was the sole a n o m a l y in two cases and was present in two other cases in combination with other changes. In one of these cases, a
1
2
3
Light chains
IgM
--
2
IgA
--
1
5
2
12
IgG
Number of cases
Total
Number of cases
Total
--
--
--
46,XX,del(12)(q15q22)
Karyotypic anomalies
Type 1
4 6 , X Y , + 19, - 22 None
1
--
--
Karyotypic anomalies
1
1
1
3
7
Number of cases
Type 2
A s s o c i a t i o n of c l o n a l i m m u n o g l o b u l i n s a n d k a r y o t y p i c a n o m a l i e s i n C M M L
Clonal immunoglobulin
Table 2
m
m
m
of c a s e s
Number
m
m
anomalies
Karyotypic
Type 3
1
3 1
of c a s e s
Number
47, x x , + 8
45,XY, - 7
anomalies
Karyotypic
Type 4
18
G r o u p e F r a n ~ a i s de C y t o g 6 n 6 t i q u e H e m a t o l o g i q u e
Table 3 Sex
E v o l u t i o n of k a r y o t y p e i n s e v e n c a s e s of C M M L
Age
Type of CMML
Chronic phase
Acceleration
Blastic phase
Case 1 M 53
CMML 2
46,XY
Irrel.
45,XY, - 7
Case 2 M 61
CMML 2
46,XY
Irrel.
47,XY, + 8 48,XY,+ 8,+ 8
Case 3 M 75
CMML 1
46,XY
Irrel.
45,XY, - 17 46,XY,inv(9p),i(17q) 46,XY
Case 4 M 56
CMML 1
50,XY, + 8, + 9, +19,+21
Irrel.
49,XY,+ 8,+ 9,+ 19 50,XY,+ 8, + 9,+ 19,+ 21 51,XY, + 8, + 9, + 19, + 21, + mar
Case 5 M 60
CMML 1
47,XY, + 21
46,XY,i(17q)
Case 6 M 60
CMML 2
47,XY,del(7q)(q22) 46,XY
Irrel.
48,XY,del(4q),t(7p;HSR;4q), i(17q), + 7, + 22 49,XY,del(4q),t(Tp;HSR;4q), i(17q),+ 7,+ 22,+ min 46,XY
Case 7 M 58
CMML 2
46,XY
Irrel.
46,XY,i(17q)
cell l i n e w a s p r e s e n t w i t h o u t a n iso(17q), b u t a # 1 7 c h r o m o s o m e w a s m i s s i n g , A # 1 7 w a s also m i s s i n g i n o n e o t h e r p a t i e n t , t h u s b r i n g i n g t h e t o t a l n u m b e r of pat i e n t s w i t h m o n o s o m y 17p to five. Iso(17q) cases w e r e all f o u n d d u r i n g b l a s t i c phase and were not present during chronic phase. A s t r u c t u r a l a n o m a l y of c h r o m o s o m e # 5 w a s p r e s e n t i n t w o p a t i e n t s . In e a c h of t h e s e cases, a c h r o m o s o m e # 7 w a s also m i s s i n g (see a b o v e ) a n d still o t h e r a n o m a lies w e r e p r e s e n t . T w o c a s e s i n t h i s series p r e s e n t e d a s t r u c t u r a l a n o m a l y of c h r o m o s o m e # 3 . T h e y h a d t h e s a m e b r e a k p o i n t i n t h e l o n g a r m at q22: o n e w a s a l i n e a r d e l e t i o n a n d t h e o t h e r a t r a n s l o c a t i o n , t(1;3)(p36;q22). A n o m a l i e s of c h r o m o s o m e # 1 1 w e r e p r e s e n t i n t w o p a t i e n t s . In o n e case, t h e s h o r t a r m (p11) w a s i n v o l v e d i n a c o m p l e x t r a n s l o c a t i o n ; i n t h e o t h e r , t h e n a t u r e of t h e a n o m a l y , w h i c h w a s f o u n d i n a s s o c i a t i o n w i t h a s t r u c t u r a l a n o m a l y of # 5 and a missing #7, could not be determined with certainty. F i n a l l y , t h e s h o r t a r m of # 9 w a s i n v o l v e d t w i c e : o n e case del(20)(q12) as t h e sole a n o m a l y w a s n o t e d , as w e l l as o n e case w i t h a h o m o g e n e o u s l y s t a i n i n g r e g i o n (HSR).
N a t u r a l History a n d S u r v i v a l (Table 1) CMML, b y d e f i n i t i o n , is a c h r o n i c d i s e a s e , a n d as a rule, o c c u r s i n e l d e r l y p e o p l e . Life e x p e c t a n c y , t h e r e f o r e , is t h a t of t h e age g r o u p to w h i c h t h e y b e l o n g . T h e dis-
19 Table 4
Sex
Age
Karyotypic anomalies N u m b e r of n o r m a l cells
in 40 patients with CMML
N u m b e r of a b n o r m a l cells
H y p o d i p l o i d y (n = 17) ( i n c l u d i n g As the sole a n o m a l y (n = 12) M o n o s o m y 7 (n = 8) M 53 6 M 54 0 M 50 3 M 50 0 M 32 0 M 69 5 M 69 6 F 51 0 Y C h r o m o s o m e loss (n = 3) M 60 3 M 71 0 M 24 0 M o n o s o m y 15 (n = 1) F 72 43
Karyotype
2 c o m p l e x cases)
7 14 16 35 26 10 12 11
45,XY, 7 45,XY,-7 45,XY,-7 45,XY,-7 45,XY,-7 45,XY,-7 45,XY,-7 45,XX,-7
97 16 36
45,X(Y) 45,X(-Y) 45,X(-Y)
2 1
(a) 45,XX, 15 (b) 42,XX, - 4 , - 1 5 ,
18,-19
In c o m b i n a t i o n w i t h o t h e r a n o m a l i e s (n = 5) M 74 1 7 4 5 , X Y , - 4, - 5, - 10, - 1 1 , - 21, + m a r l , + mar2, + mar3, + mar4 F 69 2 10 (a) 45,XX, - 5, - 7, + t(5;7)(q21;q11), - 6 , - 1 5 , - 21, + ring, + m a r l , + mar2 [34] 3 (b) i d e m as a) + 2 2 F 7O 12 4 (a) 45,X( - X) 2 (b) 47,XX, + 22 M 52 0 25 46,XY, 2 2 , + 1 9 M 77 2 3 (a) 4 5 , X Y , - 17 16 (b) 46,XY,inv(p9),i(17q) H y p e r d i p l o i d y (n - 14) ( i n c l u d i n g 2 c o m p l e x As the sole a n o m a l y (n - 8) T r i s o m y 8 (n = 5) M 60 10 5 9 M 65 17 ~' 10 M 70 1 17 1 F 68 0 14 F 73 0 9 Oth er t r i s o m y (n - 3) M 60 0 30 M 63 0 29 F 84 14 16
cases)
a) 47,XY, + 8 b) 48,XY, + 8 , + 8 47,XY, + 8 a) 4 7 , X Y , + 8 b) 48,XY, + 8, + 8 47,XX,+ 8 47,XX, + 8 47,XY, + 21 47,XY, + del?(13)(q?) 47,XX, + m i n
In c o m b i n a t i o n w i t h other a n o m a l i e s (n = 6) ( i n c l u d i n g 2 c o m p l e x cases) M 56 1 30 50,XY,+ 8 , + 9 , + 1 9 , + 21 M 56 1 7 (a) 47,XY, + 8,t(9;12)(p23;p12) 5 (b) 46,XY,t(9;12)(p23;p12) M 52 0 25 4 6 , X Y , + 1 9 , - 22 F 7O 12 2 (a) 47,XX, + 22 4 {b) 4 5 , X ( - X) F 69 2 10 (a) 4 5 , X Y , - 5 , 7,+t(5;7)(q21;q11), -6, 15,-21,+ring,+marl,+mar2
[34]
20
Groupe Franqais de Cytog6n6tique H6matologique
K a r y o t y p i c a n o m a l i e s i n 40 p a t i e n t s w i t h C M M L
Table 4
Sex
Age
Number of normal cells
Number of abnormal cells
M
60
3
11 12
3
Structural anomalies (n = 17) As the sole anomaly (n = 12) Anomaly of 12 (n = 5) F 60 29 F 66 12 F 61 0 M 77 11 F 69 0 Anomaly of other chromosome M 60 2 M 58 1 M 60 0 F 82 3 M 74 0 F M
M M
M M M
49 71
0 10
30 11 19 20 39 (n = 7) 12 9 12 10 36 10 18 20
(continued)
Karyotype (b) idem as (a) +22 (a) 48,XY,del(4q),t(7p;HSR;4q),i(17q), + 7, + 22 (b) idem as (a) + m i n
46,XX,del(12)(p12) [22] 46,XX,del(12)(pl 1) 46,XX,del(12)(p12) 46,XY,del(12)(p12) [22] 46,XX,del(12)(qlSq22) 46,XY,del(7q)(q22) 46,XY,i(17q) 46,XY,i(17q) 46,XX,del(20q)(q12) (a) 46,XY,t(1;6)(q21;p24) (b) 46,XY,t(1;6)(q21 ;p24),del(3)(q22) 46,XX,t(1;3)(p36;q22) 46,XY,t(11;12;13)(p11;p12;q21) [22]
In combination with other anomalies (n = 5) (including 1 complex case) (a) 47,XY,+8,t(9;12)(p23;p12) [22] 56 1 7 (b) 46,XY,t(9;12)(p23pl 2} 5 (a) 4 5 , X Y , 1 4 q + , - 17 79 14 1 (b) 4 5 , X Y , 1 4 q + , - 15 1 (c) 40,XY,-4, 6, 1 0 , - 1 3 , - 1 3 , 1 4 q + , - 1 7 1 (a) 48,XY,del(4q),t(7p;HSR;4q),i(17q}, + 7, + 22 60 3 11 (b) idem as (a) + m i n 12 (a} 46,XY,inv(9p),i(17q) 77 2 16 (b) 45,XY,- 17 3 46,XY, - 17, + mar 82 5 3
°Exclusive of a constitutional anomaly: 46,XY,t(2;11)(q14;q14).
ease n e v e r t h e l e s s is l i f e - t h r e a t e n i n g , as i l l u s t r a t e d b y t h e d u r a t i o n of life after diagnosis. In a d d i t i o n , s u r v i v a l is n o t s i m i l a r for all p a t i e n t s . T h i s is c l e a r l y e v i d e n c e d b y c o m p a r i n g m e d i a n s u r v i v a l of p a t i e n t s b e l o n g i n g to o u r t y p e s 1 a n d 2; b o t h g r o u p s are v e r y s i m i l a r w i t h r e s p e c t to age at d i a g n o s i s , w i t h s o m e w h a t m o r e m e n i n t y p e 2 t h a n i n t y p e 1. T h e y are d i s s i m i l a r w i t h r e g a r d to s u r v i v a l : 37.3 m o n t h s for t y p e 1 v e r s u s 20.7 m o n t h s for t y p e 2 (0.30 ~ p ~ 0.20). T h i s d i f f e r e n c e , h o w ever, is n o t s t a t i s t i c a l l y s i g n i f i c a n t . Age of o n s e t , e v o l u t i o n , a n d s u r v i v a l w e r e also a n a l y z e d s e p a r a t e l y for t h e m o s t i m p o r t a n t k a r y o t y p i c s u b g r o u p s ( T a b l e 5). Cases w i t h m o n o s o m y 7 w e r e c h a r a c t e r i z e d b y a m u c h l o w e r age of o n s e t ( m e d i a n 51 years, m e a n age 53) a n d b y a m o r e unfavorable prognosis. O n e p a t i e n t p r e s e n t e d i n t r a n s f o r m a t i o n a n d d i e d w i t h i n 13 m o n t h s ; f o u r pat i e n t s w e n t i n t o t r a n s f o r m a t i o n , a n d t h r e e of t h e s e d i e d w i t h i n 11, 13, a n d 18 m o n t h s , r e s p e c t i v e l y , after d i a g n o s i s . T h e f o u r t h t r a n s f o r m a t i o n o c c u r r e d w i t h i n 14 m o n t h s . O n e p a t i e n t d i e d of t h e d i s e a s e w h i l e i n c h r o n i c p h a s e after 2 m o n t h s , a n d o n e after 27 m o n t h s . F i n a l l y , o n e p a t i e n t is a l i v e 22 m o n t h s after t h e d i a g n o s i s , b u t
21
Cytogenetics of CMML
Table 5
Survival of patients with normal and abnormal karyotypes Number of cases
Normal karyotype at diagnosis Abnormal karyotype at diagnosis Specific subgroups Monosomy 7 (sole anomaly) Trisomy 8 (sole anomaly) Loss of Y Anomaly of 12p Sole anomaly Combination iso(17q) Sole anomaly Combination
Median age at diagnosis (years) Extremes
Median survival in months
84 36
72" 67 ~
41-92 24-84
8 5 3
51 68 60
33 69 60-73 24-71
28.3 26.3 Deceased Alive 2, 11, 13, 18, 22, 27 14, 22 2, 9, 11, 16 12 1, 31, 43 --
4 2
60 56 and 71
56-77 --
13,54 6
3, 14 3
2 2
58 and 60 60 and 76
---
21, 27 11, 28
---
"Mean age normal karyotype 70.2 years, and abnormal karyotype 63.5; statistical difference p > 0.01.
has progressive disease (type 2). CMML with m o n o s o m y 7 evidently is one of the dysmyelopoietic syndromes with the poorest possible prognosis. Median age of onset in trisomy 8 was 68 years, w h i c h is m u c h higher than for m o n o s o m y 7. Median survival, on the other hand, was equally short. CMML with trisomy 8 is characterized by a progressive disorder from the beginning; rapidly occurring acute transformation took place in 2/5 patients, with death from the disease (2/5) after 2 and 11 months, respectively. One patient is alive after 12 months. Of the three patients with Y c h r o m o s o m e loss as the sole anomaly, one was only 24 years old at diagnosis and died in acute transformation after 12 months. The ages of the other two patients were 60 and 71 years, with survival of 43 months and 1 month, respectively. With regard to iso(17q), one patient, aged 58, had progressive disease with normal karyotype at diagnosis. The iso(17q) appeared during acute transformation, wh i ch occurred 18 months after diagnosis; total survival was 21 months. A second patient, aged 60, had trisomy 21 at diagnosis and entered into acute phase after 12 months; at that time, the 21 trisomy cells had disappeared, and all metaphases showed an iso(17q) as the sole anomaly. Survival was 27 months. A third patient, 76 years old at diagnosis, had a normal karyotype. Acute transformation occurred after 22 months, with loss of a # 1 7 in some cells, inv(9p) and iso(17q). Death occurred after 28 months. The fourth patient, a woman, 60 years of age, had been treated for a solid tumor some years prior to diagnosis of CMML. In this secondary leukemia, a del(7)(q22) was present as the sole anomaly. M4-1ike acute transformation occurred within 10 months, at w h i c h time an iso(17q) appeared together with other anomalies. Death occurred 1 m o n t h later. The last karyotypic subgroup consists of the five patients with 12p anomaly, of w h i c h three were previously reported [22]. One female patient, age 60, had been treated before with c y c l o p h o s p h a m i d e because of hemolytic illness. Her disease was rapidly progressive. A second patient had been regularly exposed to pesticides as a farmer; diagnosis was made at the age of 77; the disease was still chronic 13 months later. A third patient, a steelworker in the automobile industry, may also have been exposed to toxic agents; diagnosed at the age of 70, the disease was rapidly progressive and death occurred during i n d u ct i o n of treatment. One patient was 66 w h e n CMML was diagnosed; his disease is chronic and stable after 54 months. The fifth patient, a 62-year-old woman, showed progressive disease at diagnosis and is alive 3 months later.
22
Groupe Fran~ais de Cytog~n~tique H6matologique
DISCUSSION This retrospective study of the chromosome changes in 120 patients with CMML (FAB classification) yielded some interesting results. Generally, the abnormalities found were reputed to be markers of myeioid proliferative disease: trisomy 8, monosomy 7, iso(17q), and anomalies of 12p. In contrast, chromosome changes characteristically associated with monocytoid disease were rare or absent; two cases were found with anomaly of chromosome #11, one of l l p , and one not further identified. The monocytic proliferation in CMML thus seems to occur i n d e p e n d e n t l y of a discernable lesion of chromosome #11. On the other hand, chromosome #7, occurring as the sole anomaly, was present in 20% of the cases with an abnormal karyotype. It is well k n o w n to occur in de novo and secondary acute myelogenous leukemia, with the stem cell as a target cell. It is also by far the most frequently occurring anomaly in juvenile chronic myelogenous leukemia (JCML), in which monocytosis is usually present, again in the absence of anomalies of chromosome #11 [10]. In CMML and JCML, moreover, in vitro colonies show a p r e d o m i n a n t outgrowth of monocytic cells [11, 12]. The data all lead to the assumption that CMML and JCML are due to proliferation of a comm o n progenitor cell. It has been proposed that both diseases, one of which occurs early in life and the other toward the end of a normal lifespan, may be one and the same [13-16]. The data indirectly indicate that in the association between 11q22 anomalies and acute monocytoid proliferation, we are dealing with a totally different event. Anomalies of chromosome #5 (monosomy 5 or 5 q - ) , which are so prevalent otherwise in dysmyelopoietic syndromes, were found in only two cases, each time presenting with m o n o s o m y 7. This association is well known, and the Fourth International Workshop on Chromosomes in Leukemia (FWCL) has noted a remarkable overrepresentation of it in patients with acute n o n l y m p h o c y t i c leukemia (ANLL), who have been exposed to chemicals and are more than 30 years old [17]. With regard to the other karyotypic anomalies found in this series, it is noteworthy that one case was found of a t(1;3)(p36;q22), a novel anomaly recently described in three patients with MDS, of which one had CMML [18]. The same breakpoint, 3q22, was also involved in a deletion of chromosome # 3 found in another patient of our series. An anomaly of 9p was observed twice, and a del(20)(q12) was seen once. The most surprising result u n d o u b t e d l y has been the frequent occurrence in this series of anomalies of 12p: three cases with del(12)(p11 or 12) as the sole anomaly and two cases in which the 12p was involved in a translocation with one or more chromosomes. The breakpoint in all five cases was p l l or p12. The n o n r a n d o m occurrence of 12p anomalies in hematologic disorders was clearly demonstrated for the first time by the FWCL [19]. Seventeen cases had been collected, all with ANLL, in accordance with the theme of the Workshop. It was found in de novo as well as in secondary leukemias, and all FAB types, except M3, were represented. Very recently, a 12p12 anomaly was also described in acute lymphocytic leukemia (ALL) [20]. The present study confirms that anomalies of 12p occur n o n r a n d o m l y in hematologic malignancies, p r e d o m i n a n t l y in myeloid disorders. The study specifically shows that 12p anomalies occur not only in acute, but also in chronic myetoproliferative disorders, particularly in CMML [22, 23]. In addition, as they were found as the sole anomaly, and more than occasionally as a simple terminal deletion, it may very well be that the 12p anomaly, with breakpoint in p12 (or p11-p13, depending probably on the b a n d i n g technique used), is to be added to the list of so-called primary [24, 25] characteristic changes. Some of these characteristic chromosome anomalies have been shown to play a role in oncogene activation [26], and a series of oncogenes has been located on various chromosomes near one of the breakpoints involved in those structural changes [27]. Thus, an oncogene of the ras
Cytogenetics of CMML
23
family, namely K ras-2, has been located in 12p (in segment p12-pter). As for m a n y other examples, however, activation of the oncogene in those circumstances and the possible role of the chromosome rearrangement have not yet been demonstrated. The chromosome changes in leukemia and l y m p h o m a have also been tentatively correlated with the existence of so-called fragile sites [28, 29]. No fragile site has been located so far in 12p12. A final c o m m e n t concerning the nature of the chromosome changes found in our series of CMML patients concerns the case with an HSR in a rearranged chromosome #7. HSR have been found with particularly high frequency in solid tumors, especially neuroblastoma. In de novo leukemias, however, they have been much more rarely reported: in acute myelomonocytic leukemia by Li et al. [30] and in ANLL-M2 by Yunis et al. [31]. To our knowledge, the case presented in the present series is the first to be reported in a chronic myeloproliferative disorder. It is to be emphasized, however, that the disorder in this patient was a secondary leukemia, occurring 5 years after radiologic and cytostatic treatment for a solid tumor. When HSR, and especially double minutes, appear in the bone marrow cells, they are preferentially found in secondary leukemias [7]. The present study also addressed itself to the relation between the presence and nature of chromosome abnormalities and some general aspects of the disorder in which they were found, particularly age, diagnosis, progression, transformation, and survival. Some numerical data are found in Table 1. When comparing age of onset and survival of cases with and without chromosome changes, it is very clear that patients with an abnormal karyotype in leukemic cells start the disease earlier in life and that their survival is shorter than in cases with a normal karyotype. We also analyzed those parameters for the most frequent karyotypic subgroups: m o n o s o m y 7, trisomy 8, iso(17q), Y chromosome loss, and 12p anomaly (Table 5). The n u m b e r of patients per karyotypic subgroup is too small to allow for definite conclusions; one group, however, clearly distinguished itself by disease onset at a younger age and a very poor prognosis, i.e., m o n o s o m y 7. This picture of monosomy 7 in CMML makes it totally clear that w i t h i n each disease category in which it is found (ANLL, refractory anemia and so-called preleukemia, JCML, and now also CMML), m o n o s o m y 7 is associated with a more aggressive disease and with poor survival. In fact, survival of m o n o s o m y 7 disease seems to be invariably short, whatever the type of leukemia in which it is found. Monosomy 7 and deletion of its long arm are more c o m m o n in secondary leukemias and in leukemias occurring in patients with k n o w n exposure to mutagenic agents [17]. tn the present series, several cases of secondary leukemia with chromosome # 7 anomaly could be found; but this was also the case for some of the other karyotypic anomalies, i n c l u d i n g the 12p anomaly, the occurrence of which in secondary leukemia was already reported previously [17, 19] and has been recently further confirmed [21]. With regard to the gammopathy found in CMML, a diffuse increase of gammaglobulins in the serum is part of the picture of this disorder. In some cases, a monoclonal c o m p o n e n t or paraprotein has been found. It is to be noted, however, that such paraproteins can be found in normal people, in a frequency (increasing with age) varying from 1% to 6% above the age of 50 [32]. Paraproteinemia in CMML, according to Barnard et al. [33] is not accompanied by increased bone marrow plasmacytosis. Our findings are at variance with those of Barnard et al., because in some of the patients with paraproteinemia of our series, up to 10% of all marrow cells were plasmacytes. In no case, however, was there any indication for the existence of a malignant plasma cell proliferation. This observation, and the frequent occurrence of a gammopathy in elderly people, withhold us from speculating that in CMML, as in CML, lymphoid cells may be involved in the proliferative process.
24
Groupe Fran~ais de Cytog~n~tique H~matologique
CONCLUSIONS The present mutticenter study has presented, for the first time, a clear picture of the cytogenetics of CMML. Prevalence of chromosome anomalies at diagnosis was 30%. No anomalies specific for CMML could be found. All chromosome changes encountered were k n o w n to occur in other myeloproliferative disorders, but important differences were nevertheless to be noted. Not a single instance was found in characteristic myeloid anomalies, such as Ph t(9;22), t(8;21), or t(15;17), which rarely or never occur in so-called preleukemic conditions or DMS. Neither were anomalies of 11q22 or a t(4;11) found, which are k n o w n to occur in disorders that have a strong monocytoid component, totally or partially. The most frequently occurring characteristic chromosome anomaly was monosomy 7 (25% of all cases with abnormal karyotype and 8.3% of all CMML). This type of CMML occurred in younger age groups and is associated with aggressive disease and poor prognosis, a finding not different from all other conditions with m o n o s o m y 7. Next in frequency were trisomy 8, iso(17q), and, somewhat surprisingly, a 12p anomaly (breakpoint in or close to p12). This 12p abnormality, in most cases, was the sole anomaly, and in analogy with other characteristic chromosome changes [t(9;22) a.o.] may well be classified among the so-called "primary" characteristic chromosome changes in h u m a n leukemia. The iso(17q), a marker of blastic phase in chronic myeloid leukemia (CML), in CMML also was only found during blastic phase. Other chromosome changes found in more than one patient include - 5 / 5 q - , 9p anomalies, missing Y as the sole anomaly, and a structural anomaly of chromosome # 3 involving band q22. Sequential occurrence of unrelated clonal chromosome anomalies was noted. A n HSR was found in one patient, proximally of band q22 in the long arm of chromosome #7 in a secondary CMML. Several of the karyotypically abnormal CMML were indeed secondary leukemias following chemotherapy treatment; in others, exposure to mutagenic substances was documented or strongly suspected, although no systematic investigation could be done in this respect in this retrospective study. In general, CMML with karyotypic anomalies at diagnosis occur in younger age groups, and prognosis is less favorable than CMML without chromosome changes. About 12% of our CMML patients had a paraprotein, and in those cases, the n u m b e r of plasmacytes in the marrow could be elevated, an observation that is at variance with other studies. Never was there any indication found of the existence of a malignant plasma cell proliferation. There was no correlation between the presence of a paraprotein and the presence or type of karyotypic changes.
R E F E R E N C E S
1. Saarni MI, Linman JW (1971): Myelomonocytic leukaemia: Disorderly proliferation of all marrow cells. Cancer 2 7 : 1 2 2 1 - 1 2 3 0 . 2. Miescher PA, Farquet JJ (1974): Chronic myelomonocytic leukemia in adults. Semin Hematol 11:129-139. 3. Geary CG, Catovsky D, Wiltshaw E, Milner GR, Scholes MC, Van Noorden S, Wadsworth LD, Muldal S, Maciver JE, Galton DAG (1975): Chronic myelomonocytic leukemia. Br J Haematol 30:289. 4. Zittoun R (1976): Subacute and chronic myelomonocytic leukaemia: A distinct haematological entity (annotation). Br J Haematol 32:1. 5. Bennett JM, Catovsky D, Daniel MT, Flandrin G, Galton DAG, Sultan C, The French-American-British (FAB)-co-operative Group (1982): Proposals for the classification of the myelodysplastic syndromes. Br J Haematol 51:189-199. 6. Solal-Celigny Ph, Desaint B, Herrera A, Chastang C, Amar M, Vroclans M, Brousse N,
C y t o g e n e t i c s of C M M L
7. 8. 9.
10. 11. 12. 13. 14.
15. 16.
17.
18. 19. 20.
21.
22. 23. 24. 25.
26. 27. 28. 29. 30.
25
Mancilla F, Renoux M, Bernard JF, Boivin P (1984): Chronic myelomonocytic leukemia according to FAB classification: Analysis of 35 cases. Blood 63:634-638. Sandberg AA (1980): The Chromosome in Human Cancer and Leukemia. Elsevier NorthHolland, New York. Degnan T, Weiselber L, Schulman Ph, Budman DR (1984): Dysmyelopoietic syndrome. Current concepts. Am J Med 76:122-128. Ohyashiki K, Ohyashiki J, Oshimura M, Miyasaka Y, Sakai N, Osamura S, Tonomura A, Ito H (1984): Cytogenetic and in vitro culture studies on chronic myelomonocytic leukemia. Cancer 54:2468-2474. Ghione F, Mecucci C, Symann M, Michaux JL, Casteels-Van Daele M, Van Den Berghe H (1985): Cytogenetic investigations in childhood chronic myelocytic leukemia (in press). Chatelain Ch: (personal communication). Altman AJ, Baehner RL (1975): In vitro colony-forming characteristics of chronic granulocytic leukemia in childhood. J Pediatr 86:221-284. Weisgerber C, Schaison G, Chavelet F, Seligmann M, Bernard J (1972): Les leuc~mies my~lomonocytaires de l'enfant. Arch Fr Pediatr 29:11-30. Altman AJ, Palmeer CG, Baehner RL (1974): Juvenile chronic granulocytic leukemia: A panmyelopathy with prominent monocytic involvement and circulating monocyte colonyforming cells. Blood 43:341-350. Thomas WJ, North RB, Poplack DG, Slease RB, Duval-Arnould B (1981): Chronic myelomonocytic leukemia in childhood. Am J Hematol 10:181-194. Castro-Malaspina H, Schaison G, Passe S, Pasquier A, Berger R, Bayle-Weisgerber C, Miller D, Seligmann M, Bernard J (1984): Subacute and chronic myelomonocytic leukemia in children (juvenile CML). Cancer 54:675-686. Fourth International Workshop on Chromosomes in Leukemia, 1982 (1984): The correlation of karyotype and occupational exposure to potential mutagenic/carcinogenic agents in acute nonlymphocytic leukemia. Cancer Genet Cytogenet 11:326-331. Moir DJ, Jones PAE, Pearson J, Duncan JR, Cook P, Buckle VJ (1984): A new translocation, t(1;3)(p36;q21), in myelodysplastic disorders. Blood 64:553-555. Fourth International Workshop on Chromosomes in Leukemia, 1982 (1984): Transloca° tions and additions to chromosome 12p. Cancer Genet Cytogenet 11:308-309. Raimondi SC, Williams DL, Harris LA, Stass S, Melvin SL, Rivera G (1984): Nonrandom occurrence of the 12p12 abnormality in childhood ALL and its clinical correlations. Blood 65(Suppl 1):204b, abstr 729. Wilmoth D, Feder M, Finan J, Nowel P (1985): Preleukemia and leukemia with 1 2 p - and 19q + chromosome alterations following Alkeran therapy. Cancer Genet Cytogenet 15:9598. Lessard M, Tanzer J (1984): Chromosome 12 short arm rearrangement in adults with chronic myelomonocytic leukemia (CMML). Blood 65(Suppl 1):204a, abstr 725. Kardon N, Schulman P, Degnan TJ, Budman DR, Davis J, Vinciguerra V (1982): Cytogenetic findings in the dysmyelopoietic syndrome. Cancer 50:2834-2838. Berger R, Bernheim A, Daniel MT, Valensi F, Flandrin G (1983): Cytological types of mitoses and chromosome abnormalities in acute leukemia. Leuk Res 7:221-236. Sandberg AA (1984): Chromosome changes and cancer causation: Chromatin reawaking. In: Accomplishments in Cancer Research, G. Fortner, J., Rhoads, eds., G.B. Lippincott, Philadelphia, pp 157-169. Klein G (198~): The role of gene dosage and genetic transpositions in carcinogenesis. Nature 294:313-318. de la Chapelle A, Berger R (1984): Report of the committee on chromosome rearrangements in neoplasia and on fragile sites. Cytogenet Cell Genet 37:274-311. Hecht F, Sutherland GR (1984): Fragile sites and cancer breakpoints. Cancer Genet Cytogenet 12:179-181. Yunis GG, Foreng AL (1984): Constitutive fragile sites and cancer. Science 226:1199-1204. Li YS, Khalid G, Hayhoe FGJ (1983): Correlation between chromosomal pattern, cytological subtypes, response to therapy, and survival in acute myeloid leukemia. Scand J Haematol 30:265-277.
26
G r o u p e F r a n ~ a i s de C y t o g 6 n 6 t i q u e H 6 m a t o l o g i q u e
31. Yunis JJ, Brunning RD, Howe RB, Lobell M (1984): High-reso[ution chromosome as an independent prognostic indicator in adult acute nonlymphocytic leukemia. N Engl J Med 311:812-818. 32. Axelsson U, Bachmann R, H~llen J (1966): Frequency of pathological proteins (M-components) in 6.995 sera from an adult population. Acta Med Scand 179:235-247. 33. Barnard DL, Burns GF, Gordon J, Cawley JC, Barker CR, Hayhoe FGJ, Smith JL (1979): Chronic myelomonocytic leukemia with paraproteinemia but no detectable plasmacytosis. A detailed cytological and immunological study. Cancer 44:927-935. 34. Groupe Fran~ais de Cytog6n6tique H6matologique (1984): Chromosome analysis of 63 cases of secondary non lymphoid blood disorders. A cooperative study. Cancer Genet Cytogenet 12:95 104.
APPENDIX 1:
G r o u p e F r a n § a i s de C y t o g 6 n 6 t i q u e H 6 m a t o l o g i q u e
Centers
Cities
Names of Participants
St-Luc-U.C.L. and Centre of Human Genetics-K.U.L.
Bruxelles and Leuven
J. Binon, A. Bosly, C. Mecucci, Jean-Louis Michaux, J. Rodhain, Herman Van Den Berghe
St-Louis
Paris
R. Berger, A. Bernheim, M. T. Daniel, G. Flandrin
Henri Mondor
Cr6teil
M. Imbert, H. Jouault, M. C. Lescs, F. Razavi, O. Raoul
St-Antoine
Paris
M. Krulik, N. Smadja
Service de Pathologie Cellulaire et de G6n6tique, Facult~ de M~decine
Nice
N. Ayraud, J. Bayle, S. Raynaud
C.R.T.S. Boisguillaume
Rouen
C. Bastard
C.H.R. Bordeaux
Pessac
A. Broustet, Ph. Bernard, D. Dachary, J. Reiffers
C.H.U. Timone
Marseille
A. M. Capodano, M.Gouzien, A. Stahl
H6pital Calmette, Laboratoire de Cytog6n6tique
Lille
A. Cosson, M. Deminatti, J. L., Lai, P. Lepelley, M. Zandecki
C.H.U.R. D6partement d'H6matologie
St-Etienne
M. F. Bertheas, C. P. Brizard, J. Fraisse, J. Jaubert, C. Vasselon
C.R.T.S. de Brabois
Nancy
J. Buisine, S. Gilgenkrantz, M. J. Gr6goire, J. C. Humbert
C.H.U. La Tronche
Grenoble
D. Leroux, D. Seigneurin, L. Kolodie, P. Jalbert
D6partement d'H6matologie
Poitiers
M. Lessard, J. Tanzer
Facult6 de M6decine
Dijon
F. Mugneret, C. Turc-Carel
C.H.U. Morvan
Brest
M. N. Blanchet, J. Bri~re, M. J. Le BrisQuill6v6r6, M. C. L6glise, D. Rivi~re
C.H. Lyon Sud
Pierre B6nite
P. Felman
M M M
75
79 67
76 63 6O
71 68 71
55
77 60 72 52 76 71 90 72 69 77 75 81 76 69 77 62 76 61 78 74 63
4. B F
5. BJ
6. B M
7. B A 8. C P 9. D A
10. D M 11. D L 12. D H
13. DJ
14. H E 15. JL 16. JL
34. VJ
32. PJ 33. S A
31. N A
29. G P 30. N Y
27. C E 28. G R
25. A J 26. B Y
23. V A 24. W I
20. P M 21. S N 22. S E
17. L L 18. L R 19. O P
M
66
M
M M
M
M F
M M
M F
M F
F F M
M M M
F M M
F M M
M
F
F
F
M
3. B L
M
72
66
Sex
Age
1. A L
2
2. B A
Case/Initials
APPENDIX
M
M M
M
M M
M M
M M
M M
B M M
M M M
M M M
M
M M M
M M M
M
M
M
M
M
M
M/B
48
23 34
31
12 6O
19 23
46 23
15 15
15 15 21
15 5 15
24 25 27
15
4O 10 28
16 10 15
15
3
10
10
10
15
Cells
0 0 0 1 2 1 2 1
19 23 12 59 29 22 32 47
0
23
0 0
15 21 0 0 0
0 0 0
5 15 15
15 15 46
0 0 0 0
0
15 24 25 27 15
0 0 0
4O 10 28
0 0 0
0 0
3 15 16 10 15
0
0
0
0
Abnormal cells
10
10
10
15
Normal cells
46,XY 46,XY 46,XY
46,XX 46,XY
46,XY 46,XY
46,XX 46,XY
46,XY
46,XY 46,XX
46,XY
46,XY 46,XY 46,XX 46,XX
46,XY 46,XY
46 XY 46,XY 46,XY
46 XY 46 XY
46 XY 46 XY 46 XX
46 XY 46 XX
46 XX
46,XX
46,XX
46,XY
46,XY
Karyotype
Acute --
6 4
-Acute ---
80 +20
--
----
Acute
--
--
198 7
20
8 1 2
40
+23 +37
5
-Acute
-3 21
- -
- -
2
15
---
---
--
Therapy ---
--
--
Therapy
---
--
--
-----
---
----
Therapy --
--
--
--
--
--
Exposure
--
1
-----
----
26 54 +5
3 2 13 61
---
--
--
--
--
--
Transformation
11 +2
+23
6
59
+26
12
Survival
2 4 1
2
2
3 2 2 1
2
2 1
2
3 2 2
1 1
1
1 2 2
4 4 1
2
2 2 2
1
1
1
1
2
Group
[',a "-1
70
73
69
48. DP
49.
51
75
81
64
65. BM
66. BL
72
64. VR
69
59. LF
60. LR
63. PF
75
58. LA
76
67
57. LA
55
73
56. HJ
61. LY
M
70
55. DM
62. PL
M
55
54. DN
F
M
M
F
M
M
F
M
M
M
F
F
M
56
84
M
53. DF
76
51. BR
F
M
M
F
F
M
F
F
M
F
M
M
M
M
F
F
Sex
52. DM
74
50. VM
SJ
78
4 7 . BJ
69
42. MF
46. MH
70
41. LM
81
75
40. GS
45. LP
74
39. DC
74
67
38. DA
92
76
37. DH
44. BH
78
43. ZV
82
36. CY
Age
M
M
M
M
M
M
M
M
M
B
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M/B
2 (continued)
35. BS
Case/Initials
APPENDIX
7
12
28
22
17
16
28
24
27
17
19
39
16
22
16
24
20
32
28
33
20
15
16
23
33
13
16
17
17
25
25
20
Cells
5
12
28
21
17
16
28
24
27
16
19
39
16
22
16
24
19
32
28
33
20
15
16
22
33
13
16
17
17
25
23
20
cells
Normal
2
0
0
1
0
0
0
0
0
1
0
0
0
0
0
0
1
0
0
0
0
0
0
1
0
0
0
0
0
0
2
0
cells
Abnormal
46,XY
46,XY
46,XX
46,XY
46,XX 46,XY
46,XY
46,XY
46,XY 46,XY
46,XY
46,XX
46,XY 46,XX
46,XX
46,XX 46,XY
46,XY
46,XY
46,XX
46,XX
46,XY
46,XX
46,XX
46,XY
46,XX
46,XY
46,XY
46,XY 46,XY
46,XX
46,XX
Karyotype
3
3
+ 26
15
+ 37
2
+ 3 + 10
+ 1
+ 24
8 + 5
+
10 12
18
14 + 2
12
12
7
14
2
19
+ 63
12
+ 63
+ 51
+ 48
28 7
3
72
Survival
--
Acute
--
Acute
---
--
--
Acute --
--
--
---
--
Acute --
--
--
--
--
--
--
--
--
--
--
--
Acute --
--
--
Transformation
--
--
--
--
Cancer --
--
--
---
--
--
Cancer --
--
Medical --
_
--
--
--
--
--
--
--
--
--
--
---
--
--
Exposure
1
2
1
2
2
1
2
2
2
1
2
2
2
1
1
2
1
1
1 1
2
2
1
2
2
1
1
1
1
1 1
2
Group
[',3 C¢
61 85 86 58 76 74 82 61 80 69 64 60 56 54 32 69 69 51 50 50 52 71 60 24 70
74
69
72 70
BJ CF GJ GV ML SJ SJ MC PP FM MP BR AJ BF GV GM VM DJ LH VM MO DP RG RJ LA
92. FR
93. LM
94. LS 95. SG
67. 68. 69. 70. 71. 72. 73. 74. 75. 76. 77. 78. 79. 80. 81. 82. 83. 84. 85. 86. 87. 88. 89. 90. 91.
F M
F
M
M M M M M M M M F M M F M M M M M F M M M M M M F
M M
M
M
M M M M M M M M M M M M M M M M M M M M M M M M M
46 19
15
8
10 !5 12 7 11 14 10 19 16 42 21 16 31 16 32 15 18 11 35 19 25 16 100 36 19
2
1
7 11 9 8 19 16 42 21 16 1 0 0 5 6 0 35 16 0 0 3 36 12
10 15
3 45 17 1
10
0 0 0 0 0 5 2 0 0 0 0 0 30 14 26 10 12 11 0 3 25 16 97 0 4 2 7
46 XY 46 XY 46 XY 46 XY 46 XY 46 XY 46 XY 46 XY 46 XX 46 XY 46 XY 46 XX 5 0 , X Y , 3 8 , 3 9 , 3 1 9 , 3 21 45,XY,- 7 45,XY,- 7 45,XY, 7 45,XY,- 7 45,XX,- 7 45,XY,- 7 45,XY,- 7 46,XY, - 22, 3 19 45,X(-Y) 45,X(-Y) 45,X(-Y) 45,X( - X) 47,XX, 3 22 4 5 , X Y , - 4 , - 5 , - 1 0 , - 11, - 21, 3 m a r l , ÷ m a r 2 , ÷ m a r 3 , 3 mar4 4 5 , X X , - 5 , - 7, ÷ t(5;7)(q21;q11), -6,-15, 21, ÷ ring, + m a r l , + m a r 2 ~: i d e m + 22 45,XX, - 15 47,XY, ÷ 8 48,XY,38,÷ 8 51 10
32
16 1 2 21 337 322 26 39 7 392 33 26 13 322 27 2 13 14 11 18 8 1 43 19 344
Acute
Acute
Acute Acute Acute Acute
Acute Acute
Acute
Acute
m
Therapy
Cancer
Professional
m
m
m
b3 ¢J:)
(continued)
56
66 77 61 81 79
109. RA
CS RO RP HC AF
LY KM MA PF VA VY
110. 111. 112. 113. 114.
115. 116. 117. 118. 119. 120.
M F F M F M
F M F M M
M
M
F F M M M F F M F F F M
M M M M M M
M M M M M
M
M
M M M M M M M M M M M M
16 16 15 18 13 15
23 31 19 8 17
13
30
14 9 27 30 3O 3O 13 14 18 59 39 46
16 16 14 17 13 15
12 11 0 5 14
1
10
0 0 17 0 0 14 3 2 0 29 0 0
Normal cells
I'Ref. 22.
0 0 1 1 0 0
1 1
7 5 11 20 19 3 1
20
14 9 10 30 29 16 10 12 18 30 39 36 10
Abnormal cells
<'Exclusive of a constitutional alioma|y: 46,XY,t12:11)(q14;q14).
53 75 72 61 75 75
71
AC JR DS DJ MC HE AM MM BM
68 73 65 60 63 84 82 6O 49 60 69 74
108. BP
99. 100. 101. 102. 103. 104. 105. 106. 107.
98. vj
96. M M 97. LM
Case/Initials Age Sex M/B Cells
APPENDIX 2
Acute
Acute
Therapy
Acute
Therapy
Professional
Professional
Exposure
Acute
Acute
Survival Transformation
47,XX, + 8 9 47,XX, + 8 14 47,XY, + 8,t(2;11)(q14;q14) ° 11 47,XY, + 21 27 47,XY, + del?(13)(q?) + 10 47,XX, + m i n 4 46,XX,del(20)(q12) + 14 46,XY,del(7)(q22) 11 46,XX,t(1;3)(p36;q22) +43 46,XX,del(12)(p12) ~ 12 46,XX,del(12)(q15q22) 31 46,XY,t(1;6)(q21;p24}, +4 46,XY,t(1;6)(q21;p24) del(3)(q22) 46,XY,t(11;12;13) 7 (pll;p12;q21/' 47,XY, + 8,t(9;12)(p23;p12) b 1 46,XY,t(9;12)(p23;p12) 46,XX,del(12)(p11) 54 46,XY,del(12)(p12/' + 13 46,XX,del(12)(pter) + 3 46,XY, - 17, + m a r +8 45,XY,14q + , - 17 5 45,XY,14q + , - 15 40,XY,-4,-6,1 0 , - 13, - 1 3 , 1 4 q + , - 17 46,XY 22 46,XX 12 46,XX 2 46,XY 23 46,XX + 27 46,XY + 2O
Karyotype
2 1 2 2 2 1
2 2 1 2
1
2
2
4 2 2 1 2 1 1 2 1 2 1 1
Group
In a retrospective multicenter study by the Groupe Franqais de Cytog~n~tique H~matologique, chromosome investigation was undertaken in 120 cases of chronic myelomonocytic leukemia, which was diagnosed in accordance with the French-American-British (FAB) criteria. Chromosome abnormalities of the clonal type were present at diagnosis in 30% of the patients. Median age of these patients was lower than for these without karyotypic abnormalities, and prognosis was less favorable. The most frequently encountered characteristic chromosome change was monosomy 7; chronic myelomonocytic leukemia (CMLL) with monosomy 7 occurs in younger age groups and has a very poor prognosis. Next in frequency were trisomy 8, iso(17q), and a 12p anomaly. The latter may have to be classified among the so-called primary characteristic chromosome changes in leukemia. All chromosome changes were of the type usually found in myeloid proliferation, and no anomaly specific for CMML was discovered. Isochromosome 17q was found only during blastic phase. Several of the CMML cases with chromosome anomalies were secondary leukemias, and among these was one case with a homogeneously staining region (HSR), which is rarely reported in leukemia. A paraproteinemia was found in 12% of the patients. No correlation of its occurrence with presence or type of karyotypic anomaly could be found.
ABSTRACT:
INTRODUCTION Chronic m y e l o m o n o c y t i c leukemia (CMML) is a leukemic disease, belonging to the group of c o m m o n progenitor stem cell disorders [1-4]. For many years, its nature was rather ill-determined. As a disease entity, the disorder was recognized essentially on the basis of clinical and cytologic criteria, w h i c h were only vaguely delineated. With the aim of establishing a better classification, the French-American-British Cooperative Group (FAB) recently i n c l u d e d CMML in the large group of myelodysplastic syndromes (MDS) [5] and defined some simple, but strict, criteria for its definition. These FAB criteria were applied in a recently published study [6] in w h i c h full description of the disorder is given and its clinically p l e i o m o r p h character confirmed. However, the cytogenetic aspects of the disorder are still m u c h less well defined. From a series of mostly single observations [2-4, 7-9], it appears that a Philadelphia c h r o m o s o m e is rarely or never seen. No characteristic chromosome anomalies have yet been associated with CMML, but large and systematically stud-
For a complete list of the participants in the Groupe Fran§ais de Cytogen~n~tique H~matologique see Appendix 1. Address requests for reprints to Dr. Jean-Louis Michaux, Service d'H~matologie, Cliniques Universitaires St-Luc, Avenue Hippocrate 10, B-1200 Brussels, Belgium. Received February 4, 1985; accepted May 7, 1985.
11 © 1986 Elsevier Science Publishing Co., Inc. 52 Vanderbilt Ave., New York, NY 10017
Cancer Genet Cytogenet 21:11 30 (1986) 0165-4608/86/$03.50
12
Groupe Fran§ais de Cytog@n@tique H6matologique
ied series have not been reported. The Groupe Fran~ais de Cytog~n~tique H~matologique therefore decided to conduct a multicenter study based on the FAB morphological criteria and aiming at a better definition of the chromosome anomalies in CMML.
MATERIALS AND METHODS The present study is a retrospective one, and 16 centers (15 French and 1 Belgian) contributed data that were in accordance with the FAB diagnostic criteria. Information on 120 patients was collected; included were anamnestic, clinical, hematologic and immunologic data, all of which were reviewed by J. L. M. Bone marrow and peripheral blood cytology were reviewed by two investigators (G. F. and P. F.). Cytogenetic investigations had to i n c l u d e the analysis of at least 15 metaphases of the bone marrow cultured for not less than 48 hr. All cases had to be banded, and all karyotypes were reviewed first on the local level. Twelve cases were excluded because of insufficient data. Finally, a small group of cytogeneticists reviewed all other karyotypes. For the purpose of this study, the 120 cases were subdivided into four types, each describing a particular stage or aspect of the disease at the time of cytogenetic investigation: Type 1: Classical morphological and hematologic features, as described by FAB; monocytosis in the blood ranged between 1 and 5 x 109/L. Type 2: As type 1, but with monocytosis higher than 5 x 109/L. Type 3: As types 1 and 2, but with some morphological peculiarities, e.g., eosinophilia (two cases) or megaloblastosis (one case). Type 4: Transformation into acute leukemia, with more than 30% blasts in the bone marrow. Of the 120 cases, 44.2% belonged to type 1, 49.2% to type 2, 2.5% to type 3, and 4.2% to type 4. RESULTS
Clinical Aspects Of the 120 patients, 79 were m e n and 41 were women, yielding a sex ratio (M/F) of 2:1. Median age for m e n was 69 years (extremes were 23.9 and 86.6) and for w o m e n 72.8 years (extremes 49.3 and 91.9). The mean time lapse between onset of symptoms and diagnosis was 8.1 months. The m a i n clinical and hematologic features of the patients are summarized in Table 1. There were no striking differences between the four subtypes as defined in this study. Splenomegaly, however, was significantly more frequent in type 2 as compared with type 1, and in addition, exposure to toxic agents or to chemotherapy and radiation for a previous malignancy was more frequent in type 2.
Hematologic Characteristics Table 1 and Figures 1 and 2 show that 50% of the patients had moderate anemia, with hemoglobin (Hb) values less than 110 g/L, as well as thrombopenia, with platelet values lower than 100 x 109/L. The white cell count varied with the subtypes defined. Differences were outspoken and significant between types 1 and 2 with regard to leukocytosis, monocytosis,
Table 1
G e n e r a l a n d b i o l o g i c d a t a o n 120 p a t i e n t s w i t h C M M L Total
Type 1
Type 2
Type 3
Type 4 a
N u m b e r and percentage of patients Sex ratio (M/F) Age (year) Median Mean
120, 100% 79/41
53, 44.2% 31/22
59, 49.2% 43/16
3, 2.5% 2/1
5, 4.2% 3/2
70.5 68.3
70 68.2
70.7 67.9
73.7 73.9
69 69.8
Fever Weight loss Fatigue Night sweating Infections Bleeding t e n d e n c y
25.9% 39.5% 76.6% 16.2% 25.9% 27.6%
8 (50) 18 (48) 34 (48) 6 (44) 12 (49) 13 (50)
10 (58) 20 (54) 45 (56) 7 (49) 14 (57) 15 (58)
2 2 2 2 1 1
3 3 4 1 2 3
Splenomegaly Hepatomegaly
45.2% 39.8%
18 (49) b 20 (51)
30 (58) ~ 21 (52)
2 (3) 1 (3)
2 (5) 2 (5)
L y m p h node enlargement Gingival h y p e r t r o p h y Cutaneous lesions
17.1% 3.7% 5.3%
10 (52) 2 (51) 1 (48)
8 (58) 2 (55) 3 (58)
1 (3) 0 (3) 0 (3)
1 (4) 0 (4) 2 (5)
Previous n e o p l a s m s ( n u m b e r of patients) Toxic or therapeutic e x p o s u r e ( n u m b e r of patients)
12 (100) 7 (85)
3 (45) 1 (40)
7 (51) 6 (42)
1 (2) 0 (2)
1 (2) 0 (1)
109 141 28.565 7.229 88 (112) 32 (105)
110 136 13.265 d 3.229 d 31 (48) c 8 (46) b
109 142 41.7784 10.830 d 51 (57) ~ 20 (51) ~
116 110 18.367 6.767 2 (3) 1 (3)
96 219 20.400 7.524 4 (5) 3 (5)
87 62.15 38 12 (98)
37 63.3
45 78.4
2 17
2 83
2 (42)
7 (49)
0 (3)
3 (4)
104 15.6 14.4
45 15.1
51 14.5
3 20.5
5 28.4
C h r o m o s o m e investigations (see also Results section) Hypodiploidy Hyperdiploidy Structural anomalies Complex anomalies Normal karyotype
16 13 13 3 84
10 5 7 1 33
4 7 6 1 46
1 --1 2
1 1 --3
Survival (median in m o n t h s )
27.4
37.3
20.7
38
48.9
Hematologic data Hb (g/L) Platelets ( x 109/L) WBC (× 109/L) Monocytes (× 109/L) I m m a t u r e forms in blood ( n u m b e r of cases) Presence of blasts in blood ( n u m b e r of cases) S e r u m lysozymes (ms/L) N u m b e r of cases Mean Median Presence of clonal Ig ( n u m b e r of cases) I m m u n o g l o b u l i n level (g/L) N u m b e r of cases Mean Median
(3) (3) (3) (3) (3) (3)
Numbers in parentheses represent the number of cases on which information was available. Percentages in the first column are cumulative percentages of the presence of the feature in the four types. ~For explanation see Materials and Methods. bDifference between type 1 and type 2 is significant, p < 0.05. ~Difference between type 1 and type 2 is significant, p ~ 0.01. dDifference between type 1 and type 2 is significant, p < 0.0001.
(4) (4) (4) (3) (3) (5)
:i.... {ii
Figure I
215
i c.
.~ i i~ ~
cLq
Hematologic data. T I 2 3 4:: Median values in different types of CMML.
I111
4
PLAIELETS
x I09/L
4~
Cytogenetics of CMML
TI t
15
T
Figure 2 Blood lysozyme and serum IgG levels. 1' 1 2 3 4: Median values in different types of CMML. ( ~ ) Type 1', ( ~ ) t y p e
B L 0 0 [I
?
~
Ii
':
17
L Y S 0 Z ¥ r~ E
2; ( ~ ) t y p e
3;
~:c~:~:-
,!
immature forms, and blasts. Type 4 was naturally markedly different from the other types because of the blast crisis presented by the patients belonging to that category. Bone marrow aspiration and biopsy generally showed hypercellular bone marrow with predominant myeloid proliferation and increased monocytosis. At times, the monocytoid elements were difficult to distinguish from immature myeloid elements. The myeloid elements very often showed morphological anomalies characterized by diminution of primary granules and poor segmentation of mature forms. The erythroid series was often depressed and showed marked morphological ab-
16
Groupe Fran~ais de Cytog6n6tique H6matologique normalities: macroblastosis and megaloblastosis, sideroblasts, as well as ringed cells. Nuclear anomalies were frequently seen. Megakaryocytes were often r e d u c e d in number, small, and hypolobulated, and giant platelets could be found in the blood. In patients who also s h o w e d a clonal gammapathy, infiltration of the bone marrow by plasma cells was observed. This proliferation, however, was not accompanied by morphological changes of the p l a s m a cells, as is seen in m u l t i p l e myeloma. The leukocyte alkaline p h o s p h a t a s e varied considerably from case to case, and this variation had no bearing on the stage or progression of the disorder.
Other Biologic Findings, Including Gammopathy Serum lyzozymes were high and variable in all patients, but no differences could be found among the four types. Serum i m m u n o g l o b u l i n levels were usually higher than normal; about 50% of the patients had values above 14 g/L, and all i m m u n o globulin classes could be involved. A monoclonal c o m p o n e n t was found in 12 patients: 5 IgG, 3 IgM, 2 IgA, and 2 cases w i t h light chains (Table 2). They were especially present in types 2 and 4. In none of these patients, however, was any indication of m u l t i p l e m y e l o m a found. No correlation between the existence of a paraprotein and the frequency or type of karyotypic anomaly could be demonstrated. The problem of p a r a p r o t e i n e m i a in CMML is especially interesting. Table 1 shows that 12% (12 of 96) of patients had paraproteinemia. The type of paraprotein and the correlation with the status of the karyotype are given in Table 2. It appears from this table that p a r a p r o t e i n e m i a is found more often in cases with r a p i d l y advancing disease (types 2 and 4 of our classification) and that no correlation with frequency or type of karyotypic a n o m a l y could be demonstrated.
Prevalence of Karyotypic Abnormalities in 120 CMML Cases (Appendix 2) All patients were investigated at diagnosis; however, in those patients whose karyotype r e m a i n e d normal, the diagnosis was not confirmed until a few months after the initial karyotypic investigation. Thus, the karyotype was abnormal in 36 of 120 patients (30%) at diagnosis. In four patients, the karyotype became abnormal during subsequent evolution (Table 3). It is possible that with further evolution, the karyotype may also become abnormal in some of those patients who are still alive.
Principal Chromosome Abnormalities (Table 4) A m o n g the n u m e r i c a l changes, m o n o s o m y 7 was the most frequent chromosome anomaly in this series, occurring either as the sole a n o m a l y (8/40 or 20%) or in combination with c o m p l e x abnormalities (2/40). In the latter two cases, a chromosome # 5 was also abnormal (see below). In total, m o n o s o m y 7 was found in 25% of cases with abnormal karyotype. Next in frequency was trisomy 8, w h i c h occurred in 5/40 patients (12.5%) as the sole anomaly. It was found also twice in combination with other changes. A n u m b e r of structural anomalies were observed, some of w h i c h d e m a n d particular attention. The short arm of chromosome #12 was found to be abnormal five times. In three cases, a deletion with breakpoints in p11-12 was the sole anomaly; in two other cases, 12p was involved in a translocation, and in each of these cases, breakpoints were again in p12. An isochromosome of the 17q was the sole a n o m a l y in two cases and was present in two other cases in combination with other changes. In one of these cases, a
1
2
3
Light chains
IgM
--
2
IgA
--
1
5
2
12
IgG
Number of cases
Total
Number of cases
Total
--
--
--
46,XX,del(12)(q15q22)
Karyotypic anomalies
Type 1
4 6 , X Y , + 19, - 22 None
1
--
--
Karyotypic anomalies
1
1
1
3
7
Number of cases
Type 2
A s s o c i a t i o n of c l o n a l i m m u n o g l o b u l i n s a n d k a r y o t y p i c a n o m a l i e s i n C M M L
Clonal immunoglobulin
Table 2
m
m
m
of c a s e s
Number
m
m
anomalies
Karyotypic
Type 3
1
3 1
of c a s e s
Number
47, x x , + 8
45,XY, - 7
anomalies
Karyotypic
Type 4
18
G r o u p e F r a n ~ a i s de C y t o g 6 n 6 t i q u e H e m a t o l o g i q u e
Table 3 Sex
E v o l u t i o n of k a r y o t y p e i n s e v e n c a s e s of C M M L
Age
Type of CMML
Chronic phase
Acceleration
Blastic phase
Case 1 M 53
CMML 2
46,XY
Irrel.
45,XY, - 7
Case 2 M 61
CMML 2
46,XY
Irrel.
47,XY, + 8 48,XY,+ 8,+ 8
Case 3 M 75
CMML 1
46,XY
Irrel.
45,XY, - 17 46,XY,inv(9p),i(17q) 46,XY
Case 4 M 56
CMML 1
50,XY, + 8, + 9, +19,+21
Irrel.
49,XY,+ 8,+ 9,+ 19 50,XY,+ 8, + 9,+ 19,+ 21 51,XY, + 8, + 9, + 19, + 21, + mar
Case 5 M 60
CMML 1
47,XY, + 21
46,XY,i(17q)
Case 6 M 60
CMML 2
47,XY,del(7q)(q22) 46,XY
Irrel.
48,XY,del(4q),t(7p;HSR;4q), i(17q), + 7, + 22 49,XY,del(4q),t(Tp;HSR;4q), i(17q),+ 7,+ 22,+ min 46,XY
Case 7 M 58
CMML 2
46,XY
Irrel.
46,XY,i(17q)
cell l i n e w a s p r e s e n t w i t h o u t a n iso(17q), b u t a # 1 7 c h r o m o s o m e w a s m i s s i n g , A # 1 7 w a s also m i s s i n g i n o n e o t h e r p a t i e n t , t h u s b r i n g i n g t h e t o t a l n u m b e r of pat i e n t s w i t h m o n o s o m y 17p to five. Iso(17q) cases w e r e all f o u n d d u r i n g b l a s t i c phase and were not present during chronic phase. A s t r u c t u r a l a n o m a l y of c h r o m o s o m e # 5 w a s p r e s e n t i n t w o p a t i e n t s . In e a c h of t h e s e cases, a c h r o m o s o m e # 7 w a s also m i s s i n g (see a b o v e ) a n d still o t h e r a n o m a lies w e r e p r e s e n t . T w o c a s e s i n t h i s series p r e s e n t e d a s t r u c t u r a l a n o m a l y of c h r o m o s o m e # 3 . T h e y h a d t h e s a m e b r e a k p o i n t i n t h e l o n g a r m at q22: o n e w a s a l i n e a r d e l e t i o n a n d t h e o t h e r a t r a n s l o c a t i o n , t(1;3)(p36;q22). A n o m a l i e s of c h r o m o s o m e # 1 1 w e r e p r e s e n t i n t w o p a t i e n t s . In o n e case, t h e s h o r t a r m (p11) w a s i n v o l v e d i n a c o m p l e x t r a n s l o c a t i o n ; i n t h e o t h e r , t h e n a t u r e of t h e a n o m a l y , w h i c h w a s f o u n d i n a s s o c i a t i o n w i t h a s t r u c t u r a l a n o m a l y of # 5 and a missing #7, could not be determined with certainty. F i n a l l y , t h e s h o r t a r m of # 9 w a s i n v o l v e d t w i c e : o n e case del(20)(q12) as t h e sole a n o m a l y w a s n o t e d , as w e l l as o n e case w i t h a h o m o g e n e o u s l y s t a i n i n g r e g i o n (HSR).
N a t u r a l History a n d S u r v i v a l (Table 1) CMML, b y d e f i n i t i o n , is a c h r o n i c d i s e a s e , a n d as a rule, o c c u r s i n e l d e r l y p e o p l e . Life e x p e c t a n c y , t h e r e f o r e , is t h a t of t h e age g r o u p to w h i c h t h e y b e l o n g . T h e dis-
19 Table 4
Sex
Age
Karyotypic anomalies N u m b e r of n o r m a l cells
in 40 patients with CMML
N u m b e r of a b n o r m a l cells
H y p o d i p l o i d y (n = 17) ( i n c l u d i n g As the sole a n o m a l y (n = 12) M o n o s o m y 7 (n = 8) M 53 6 M 54 0 M 50 3 M 50 0 M 32 0 M 69 5 M 69 6 F 51 0 Y C h r o m o s o m e loss (n = 3) M 60 3 M 71 0 M 24 0 M o n o s o m y 15 (n = 1) F 72 43
Karyotype
2 c o m p l e x cases)
7 14 16 35 26 10 12 11
45,XY, 7 45,XY,-7 45,XY,-7 45,XY,-7 45,XY,-7 45,XY,-7 45,XY,-7 45,XX,-7
97 16 36
45,X(Y) 45,X(-Y) 45,X(-Y)
2 1
(a) 45,XX, 15 (b) 42,XX, - 4 , - 1 5 ,
18,-19
In c o m b i n a t i o n w i t h o t h e r a n o m a l i e s (n = 5) M 74 1 7 4 5 , X Y , - 4, - 5, - 10, - 1 1 , - 21, + m a r l , + mar2, + mar3, + mar4 F 69 2 10 (a) 45,XX, - 5, - 7, + t(5;7)(q21;q11), - 6 , - 1 5 , - 21, + ring, + m a r l , + mar2 [34] 3 (b) i d e m as a) + 2 2 F 7O 12 4 (a) 45,X( - X) 2 (b) 47,XX, + 22 M 52 0 25 46,XY, 2 2 , + 1 9 M 77 2 3 (a) 4 5 , X Y , - 17 16 (b) 46,XY,inv(p9),i(17q) H y p e r d i p l o i d y (n - 14) ( i n c l u d i n g 2 c o m p l e x As the sole a n o m a l y (n - 8) T r i s o m y 8 (n = 5) M 60 10 5 9 M 65 17 ~' 10 M 70 1 17 1 F 68 0 14 F 73 0 9 Oth er t r i s o m y (n - 3) M 60 0 30 M 63 0 29 F 84 14 16
cases)
a) 47,XY, + 8 b) 48,XY, + 8 , + 8 47,XY, + 8 a) 4 7 , X Y , + 8 b) 48,XY, + 8, + 8 47,XX,+ 8 47,XX, + 8 47,XY, + 21 47,XY, + del?(13)(q?) 47,XX, + m i n
In c o m b i n a t i o n w i t h other a n o m a l i e s (n = 6) ( i n c l u d i n g 2 c o m p l e x cases) M 56 1 30 50,XY,+ 8 , + 9 , + 1 9 , + 21 M 56 1 7 (a) 47,XY, + 8,t(9;12)(p23;p12) 5 (b) 46,XY,t(9;12)(p23;p12) M 52 0 25 4 6 , X Y , + 1 9 , - 22 F 7O 12 2 (a) 47,XX, + 22 4 {b) 4 5 , X ( - X) F 69 2 10 (a) 4 5 , X Y , - 5 , 7,+t(5;7)(q21;q11), -6, 15,-21,+ring,+marl,+mar2
[34]
20
Groupe Franqais de Cytog6n6tique H6matologique
K a r y o t y p i c a n o m a l i e s i n 40 p a t i e n t s w i t h C M M L
Table 4
Sex
Age
Number of normal cells
Number of abnormal cells
M
60
3
11 12
3
Structural anomalies (n = 17) As the sole anomaly (n = 12) Anomaly of 12 (n = 5) F 60 29 F 66 12 F 61 0 M 77 11 F 69 0 Anomaly of other chromosome M 60 2 M 58 1 M 60 0 F 82 3 M 74 0 F M
M M
M M M
49 71
0 10
30 11 19 20 39 (n = 7) 12 9 12 10 36 10 18 20
(continued)
Karyotype (b) idem as (a) +22 (a) 48,XY,del(4q),t(7p;HSR;4q),i(17q), + 7, + 22 (b) idem as (a) + m i n
46,XX,del(12)(p12) [22] 46,XX,del(12)(pl 1) 46,XX,del(12)(p12) 46,XY,del(12)(p12) [22] 46,XX,del(12)(qlSq22) 46,XY,del(7q)(q22) 46,XY,i(17q) 46,XY,i(17q) 46,XX,del(20q)(q12) (a) 46,XY,t(1;6)(q21;p24) (b) 46,XY,t(1;6)(q21 ;p24),del(3)(q22) 46,XX,t(1;3)(p36;q22) 46,XY,t(11;12;13)(p11;p12;q21) [22]
In combination with other anomalies (n = 5) (including 1 complex case) (a) 47,XY,+8,t(9;12)(p23;p12) [22] 56 1 7 (b) 46,XY,t(9;12)(p23pl 2} 5 (a) 4 5 , X Y , 1 4 q + , - 17 79 14 1 (b) 4 5 , X Y , 1 4 q + , - 15 1 (c) 40,XY,-4, 6, 1 0 , - 1 3 , - 1 3 , 1 4 q + , - 1 7 1 (a) 48,XY,del(4q),t(7p;HSR;4q),i(17q}, + 7, + 22 60 3 11 (b) idem as (a) + m i n 12 (a} 46,XY,inv(9p),i(17q) 77 2 16 (b) 45,XY,- 17 3 46,XY, - 17, + mar 82 5 3
°Exclusive of a constitutional anomaly: 46,XY,t(2;11)(q14;q14).
ease n e v e r t h e l e s s is l i f e - t h r e a t e n i n g , as i l l u s t r a t e d b y t h e d u r a t i o n of life after diagnosis. In a d d i t i o n , s u r v i v a l is n o t s i m i l a r for all p a t i e n t s . T h i s is c l e a r l y e v i d e n c e d b y c o m p a r i n g m e d i a n s u r v i v a l of p a t i e n t s b e l o n g i n g to o u r t y p e s 1 a n d 2; b o t h g r o u p s are v e r y s i m i l a r w i t h r e s p e c t to age at d i a g n o s i s , w i t h s o m e w h a t m o r e m e n i n t y p e 2 t h a n i n t y p e 1. T h e y are d i s s i m i l a r w i t h r e g a r d to s u r v i v a l : 37.3 m o n t h s for t y p e 1 v e r s u s 20.7 m o n t h s for t y p e 2 (0.30 ~ p ~ 0.20). T h i s d i f f e r e n c e , h o w ever, is n o t s t a t i s t i c a l l y s i g n i f i c a n t . Age of o n s e t , e v o l u t i o n , a n d s u r v i v a l w e r e also a n a l y z e d s e p a r a t e l y for t h e m o s t i m p o r t a n t k a r y o t y p i c s u b g r o u p s ( T a b l e 5). Cases w i t h m o n o s o m y 7 w e r e c h a r a c t e r i z e d b y a m u c h l o w e r age of o n s e t ( m e d i a n 51 years, m e a n age 53) a n d b y a m o r e unfavorable prognosis. O n e p a t i e n t p r e s e n t e d i n t r a n s f o r m a t i o n a n d d i e d w i t h i n 13 m o n t h s ; f o u r pat i e n t s w e n t i n t o t r a n s f o r m a t i o n , a n d t h r e e of t h e s e d i e d w i t h i n 11, 13, a n d 18 m o n t h s , r e s p e c t i v e l y , after d i a g n o s i s . T h e f o u r t h t r a n s f o r m a t i o n o c c u r r e d w i t h i n 14 m o n t h s . O n e p a t i e n t d i e d of t h e d i s e a s e w h i l e i n c h r o n i c p h a s e after 2 m o n t h s , a n d o n e after 27 m o n t h s . F i n a l l y , o n e p a t i e n t is a l i v e 22 m o n t h s after t h e d i a g n o s i s , b u t
21
Cytogenetics of CMML
Table 5
Survival of patients with normal and abnormal karyotypes Number of cases
Normal karyotype at diagnosis Abnormal karyotype at diagnosis Specific subgroups Monosomy 7 (sole anomaly) Trisomy 8 (sole anomaly) Loss of Y Anomaly of 12p Sole anomaly Combination iso(17q) Sole anomaly Combination
Median age at diagnosis (years) Extremes
Median survival in months
84 36
72" 67 ~
41-92 24-84
8 5 3
51 68 60
33 69 60-73 24-71
28.3 26.3 Deceased Alive 2, 11, 13, 18, 22, 27 14, 22 2, 9, 11, 16 12 1, 31, 43 --
4 2
60 56 and 71
56-77 --
13,54 6
3, 14 3
2 2
58 and 60 60 and 76
---
21, 27 11, 28
---
"Mean age normal karyotype 70.2 years, and abnormal karyotype 63.5; statistical difference p > 0.01.
has progressive disease (type 2). CMML with m o n o s o m y 7 evidently is one of the dysmyelopoietic syndromes with the poorest possible prognosis. Median age of onset in trisomy 8 was 68 years, w h i c h is m u c h higher than for m o n o s o m y 7. Median survival, on the other hand, was equally short. CMML with trisomy 8 is characterized by a progressive disorder from the beginning; rapidly occurring acute transformation took place in 2/5 patients, with death from the disease (2/5) after 2 and 11 months, respectively. One patient is alive after 12 months. Of the three patients with Y c h r o m o s o m e loss as the sole anomaly, one was only 24 years old at diagnosis and died in acute transformation after 12 months. The ages of the other two patients were 60 and 71 years, with survival of 43 months and 1 month, respectively. With regard to iso(17q), one patient, aged 58, had progressive disease with normal karyotype at diagnosis. The iso(17q) appeared during acute transformation, wh i ch occurred 18 months after diagnosis; total survival was 21 months. A second patient, aged 60, had trisomy 21 at diagnosis and entered into acute phase after 12 months; at that time, the 21 trisomy cells had disappeared, and all metaphases showed an iso(17q) as the sole anomaly. Survival was 27 months. A third patient, 76 years old at diagnosis, had a normal karyotype. Acute transformation occurred after 22 months, with loss of a # 1 7 in some cells, inv(9p) and iso(17q). Death occurred after 28 months. The fourth patient, a woman, 60 years of age, had been treated for a solid tumor some years prior to diagnosis of CMML. In this secondary leukemia, a del(7)(q22) was present as the sole anomaly. M4-1ike acute transformation occurred within 10 months, at w h i c h time an iso(17q) appeared together with other anomalies. Death occurred 1 m o n t h later. The last karyotypic subgroup consists of the five patients with 12p anomaly, of w h i c h three were previously reported [22]. One female patient, age 60, had been treated before with c y c l o p h o s p h a m i d e because of hemolytic illness. Her disease was rapidly progressive. A second patient had been regularly exposed to pesticides as a farmer; diagnosis was made at the age of 77; the disease was still chronic 13 months later. A third patient, a steelworker in the automobile industry, may also have been exposed to toxic agents; diagnosed at the age of 70, the disease was rapidly progressive and death occurred during i n d u ct i o n of treatment. One patient was 66 w h e n CMML was diagnosed; his disease is chronic and stable after 54 months. The fifth patient, a 62-year-old woman, showed progressive disease at diagnosis and is alive 3 months later.
22
Groupe Fran~ais de Cytog~n~tique H6matologique
DISCUSSION This retrospective study of the chromosome changes in 120 patients with CMML (FAB classification) yielded some interesting results. Generally, the abnormalities found were reputed to be markers of myeioid proliferative disease: trisomy 8, monosomy 7, iso(17q), and anomalies of 12p. In contrast, chromosome changes characteristically associated with monocytoid disease were rare or absent; two cases were found with anomaly of chromosome #11, one of l l p , and one not further identified. The monocytic proliferation in CMML thus seems to occur i n d e p e n d e n t l y of a discernable lesion of chromosome #11. On the other hand, chromosome #7, occurring as the sole anomaly, was present in 20% of the cases with an abnormal karyotype. It is well k n o w n to occur in de novo and secondary acute myelogenous leukemia, with the stem cell as a target cell. It is also by far the most frequently occurring anomaly in juvenile chronic myelogenous leukemia (JCML), in which monocytosis is usually present, again in the absence of anomalies of chromosome #11 [10]. In CMML and JCML, moreover, in vitro colonies show a p r e d o m i n a n t outgrowth of monocytic cells [11, 12]. The data all lead to the assumption that CMML and JCML are due to proliferation of a comm o n progenitor cell. It has been proposed that both diseases, one of which occurs early in life and the other toward the end of a normal lifespan, may be one and the same [13-16]. The data indirectly indicate that in the association between 11q22 anomalies and acute monocytoid proliferation, we are dealing with a totally different event. Anomalies of chromosome #5 (monosomy 5 or 5 q - ) , which are so prevalent otherwise in dysmyelopoietic syndromes, were found in only two cases, each time presenting with m o n o s o m y 7. This association is well known, and the Fourth International Workshop on Chromosomes in Leukemia (FWCL) has noted a remarkable overrepresentation of it in patients with acute n o n l y m p h o c y t i c leukemia (ANLL), who have been exposed to chemicals and are more than 30 years old [17]. With regard to the other karyotypic anomalies found in this series, it is noteworthy that one case was found of a t(1;3)(p36;q22), a novel anomaly recently described in three patients with MDS, of which one had CMML [18]. The same breakpoint, 3q22, was also involved in a deletion of chromosome # 3 found in another patient of our series. An anomaly of 9p was observed twice, and a del(20)(q12) was seen once. The most surprising result u n d o u b t e d l y has been the frequent occurrence in this series of anomalies of 12p: three cases with del(12)(p11 or 12) as the sole anomaly and two cases in which the 12p was involved in a translocation with one or more chromosomes. The breakpoint in all five cases was p l l or p12. The n o n r a n d o m occurrence of 12p anomalies in hematologic disorders was clearly demonstrated for the first time by the FWCL [19]. Seventeen cases had been collected, all with ANLL, in accordance with the theme of the Workshop. It was found in de novo as well as in secondary leukemias, and all FAB types, except M3, were represented. Very recently, a 12p12 anomaly was also described in acute lymphocytic leukemia (ALL) [20]. The present study confirms that anomalies of 12p occur n o n r a n d o m l y in hematologic malignancies, p r e d o m i n a n t l y in myeloid disorders. The study specifically shows that 12p anomalies occur not only in acute, but also in chronic myetoproliferative disorders, particularly in CMML [22, 23]. In addition, as they were found as the sole anomaly, and more than occasionally as a simple terminal deletion, it may very well be that the 12p anomaly, with breakpoint in p12 (or p11-p13, depending probably on the b a n d i n g technique used), is to be added to the list of so-called primary [24, 25] characteristic changes. Some of these characteristic chromosome anomalies have been shown to play a role in oncogene activation [26], and a series of oncogenes has been located on various chromosomes near one of the breakpoints involved in those structural changes [27]. Thus, an oncogene of the ras
Cytogenetics of CMML
23
family, namely K ras-2, has been located in 12p (in segment p12-pter). As for m a n y other examples, however, activation of the oncogene in those circumstances and the possible role of the chromosome rearrangement have not yet been demonstrated. The chromosome changes in leukemia and l y m p h o m a have also been tentatively correlated with the existence of so-called fragile sites [28, 29]. No fragile site has been located so far in 12p12. A final c o m m e n t concerning the nature of the chromosome changes found in our series of CMML patients concerns the case with an HSR in a rearranged chromosome #7. HSR have been found with particularly high frequency in solid tumors, especially neuroblastoma. In de novo leukemias, however, they have been much more rarely reported: in acute myelomonocytic leukemia by Li et al. [30] and in ANLL-M2 by Yunis et al. [31]. To our knowledge, the case presented in the present series is the first to be reported in a chronic myeloproliferative disorder. It is to be emphasized, however, that the disorder in this patient was a secondary leukemia, occurring 5 years after radiologic and cytostatic treatment for a solid tumor. When HSR, and especially double minutes, appear in the bone marrow cells, they are preferentially found in secondary leukemias [7]. The present study also addressed itself to the relation between the presence and nature of chromosome abnormalities and some general aspects of the disorder in which they were found, particularly age, diagnosis, progression, transformation, and survival. Some numerical data are found in Table 1. When comparing age of onset and survival of cases with and without chromosome changes, it is very clear that patients with an abnormal karyotype in leukemic cells start the disease earlier in life and that their survival is shorter than in cases with a normal karyotype. We also analyzed those parameters for the most frequent karyotypic subgroups: m o n o s o m y 7, trisomy 8, iso(17q), Y chromosome loss, and 12p anomaly (Table 5). The n u m b e r of patients per karyotypic subgroup is too small to allow for definite conclusions; one group, however, clearly distinguished itself by disease onset at a younger age and a very poor prognosis, i.e., m o n o s o m y 7. This picture of monosomy 7 in CMML makes it totally clear that w i t h i n each disease category in which it is found (ANLL, refractory anemia and so-called preleukemia, JCML, and now also CMML), m o n o s o m y 7 is associated with a more aggressive disease and with poor survival. In fact, survival of m o n o s o m y 7 disease seems to be invariably short, whatever the type of leukemia in which it is found. Monosomy 7 and deletion of its long arm are more c o m m o n in secondary leukemias and in leukemias occurring in patients with k n o w n exposure to mutagenic agents [17]. tn the present series, several cases of secondary leukemia with chromosome # 7 anomaly could be found; but this was also the case for some of the other karyotypic anomalies, i n c l u d i n g the 12p anomaly, the occurrence of which in secondary leukemia was already reported previously [17, 19] and has been recently further confirmed [21]. With regard to the gammopathy found in CMML, a diffuse increase of gammaglobulins in the serum is part of the picture of this disorder. In some cases, a monoclonal c o m p o n e n t or paraprotein has been found. It is to be noted, however, that such paraproteins can be found in normal people, in a frequency (increasing with age) varying from 1% to 6% above the age of 50 [32]. Paraproteinemia in CMML, according to Barnard et al. [33] is not accompanied by increased bone marrow plasmacytosis. Our findings are at variance with those of Barnard et al., because in some of the patients with paraproteinemia of our series, up to 10% of all marrow cells were plasmacytes. In no case, however, was there any indication for the existence of a malignant plasma cell proliferation. This observation, and the frequent occurrence of a gammopathy in elderly people, withhold us from speculating that in CMML, as in CML, lymphoid cells may be involved in the proliferative process.
24
Groupe Fran~ais de Cytog~n~tique H~matologique
CONCLUSIONS The present mutticenter study has presented, for the first time, a clear picture of the cytogenetics of CMML. Prevalence of chromosome anomalies at diagnosis was 30%. No anomalies specific for CMML could be found. All chromosome changes encountered were k n o w n to occur in other myeloproliferative disorders, but important differences were nevertheless to be noted. Not a single instance was found in characteristic myeloid anomalies, such as Ph t(9;22), t(8;21), or t(15;17), which rarely or never occur in so-called preleukemic conditions or DMS. Neither were anomalies of 11q22 or a t(4;11) found, which are k n o w n to occur in disorders that have a strong monocytoid component, totally or partially. The most frequently occurring characteristic chromosome anomaly was monosomy 7 (25% of all cases with abnormal karyotype and 8.3% of all CMML). This type of CMML occurred in younger age groups and is associated with aggressive disease and poor prognosis, a finding not different from all other conditions with m o n o s o m y 7. Next in frequency were trisomy 8, iso(17q), and, somewhat surprisingly, a 12p anomaly (breakpoint in or close to p12). This 12p abnormality, in most cases, was the sole anomaly, and in analogy with other characteristic chromosome changes [t(9;22) a.o.] may well be classified among the so-called "primary" characteristic chromosome changes in h u m a n leukemia. The iso(17q), a marker of blastic phase in chronic myeloid leukemia (CML), in CMML also was only found during blastic phase. Other chromosome changes found in more than one patient include - 5 / 5 q - , 9p anomalies, missing Y as the sole anomaly, and a structural anomaly of chromosome # 3 involving band q22. Sequential occurrence of unrelated clonal chromosome anomalies was noted. A n HSR was found in one patient, proximally of band q22 in the long arm of chromosome #7 in a secondary CMML. Several of the karyotypically abnormal CMML were indeed secondary leukemias following chemotherapy treatment; in others, exposure to mutagenic substances was documented or strongly suspected, although no systematic investigation could be done in this respect in this retrospective study. In general, CMML with karyotypic anomalies at diagnosis occur in younger age groups, and prognosis is less favorable than CMML without chromosome changes. About 12% of our CMML patients had a paraprotein, and in those cases, the n u m b e r of plasmacytes in the marrow could be elevated, an observation that is at variance with other studies. Never was there any indication found of the existence of a malignant plasma cell proliferation. There was no correlation between the presence of a paraprotein and the presence or type of karyotypic changes.
R E F E R E N C E S
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10. 11. 12. 13. 14.
15. 16.
17.
18. 19. 20.
21.
22. 23. 24. 25.
26. 27. 28. 29. 30.
25
Mancilla F, Renoux M, Bernard JF, Boivin P (1984): Chronic myelomonocytic leukemia according to FAB classification: Analysis of 35 cases. Blood 63:634-638. Sandberg AA (1980): The Chromosome in Human Cancer and Leukemia. Elsevier NorthHolland, New York. Degnan T, Weiselber L, Schulman Ph, Budman DR (1984): Dysmyelopoietic syndrome. Current concepts. Am J Med 76:122-128. Ohyashiki K, Ohyashiki J, Oshimura M, Miyasaka Y, Sakai N, Osamura S, Tonomura A, Ito H (1984): Cytogenetic and in vitro culture studies on chronic myelomonocytic leukemia. Cancer 54:2468-2474. Ghione F, Mecucci C, Symann M, Michaux JL, Casteels-Van Daele M, Van Den Berghe H (1985): Cytogenetic investigations in childhood chronic myelocytic leukemia (in press). Chatelain Ch: (personal communication). Altman AJ, Baehner RL (1975): In vitro colony-forming characteristics of chronic granulocytic leukemia in childhood. J Pediatr 86:221-284. Weisgerber C, Schaison G, Chavelet F, Seligmann M, Bernard J (1972): Les leuc~mies my~lomonocytaires de l'enfant. Arch Fr Pediatr 29:11-30. Altman AJ, Palmeer CG, Baehner RL (1974): Juvenile chronic granulocytic leukemia: A panmyelopathy with prominent monocytic involvement and circulating monocyte colonyforming cells. Blood 43:341-350. Thomas WJ, North RB, Poplack DG, Slease RB, Duval-Arnould B (1981): Chronic myelomonocytic leukemia in childhood. Am J Hematol 10:181-194. Castro-Malaspina H, Schaison G, Passe S, Pasquier A, Berger R, Bayle-Weisgerber C, Miller D, Seligmann M, Bernard J (1984): Subacute and chronic myelomonocytic leukemia in children (juvenile CML). Cancer 54:675-686. Fourth International Workshop on Chromosomes in Leukemia, 1982 (1984): The correlation of karyotype and occupational exposure to potential mutagenic/carcinogenic agents in acute nonlymphocytic leukemia. Cancer Genet Cytogenet 11:326-331. Moir DJ, Jones PAE, Pearson J, Duncan JR, Cook P, Buckle VJ (1984): A new translocation, t(1;3)(p36;q21), in myelodysplastic disorders. Blood 64:553-555. Fourth International Workshop on Chromosomes in Leukemia, 1982 (1984): Transloca° tions and additions to chromosome 12p. Cancer Genet Cytogenet 11:308-309. Raimondi SC, Williams DL, Harris LA, Stass S, Melvin SL, Rivera G (1984): Nonrandom occurrence of the 12p12 abnormality in childhood ALL and its clinical correlations. Blood 65(Suppl 1):204b, abstr 729. Wilmoth D, Feder M, Finan J, Nowel P (1985): Preleukemia and leukemia with 1 2 p - and 19q + chromosome alterations following Alkeran therapy. Cancer Genet Cytogenet 15:9598. Lessard M, Tanzer J (1984): Chromosome 12 short arm rearrangement in adults with chronic myelomonocytic leukemia (CMML). Blood 65(Suppl 1):204a, abstr 725. Kardon N, Schulman P, Degnan TJ, Budman DR, Davis J, Vinciguerra V (1982): Cytogenetic findings in the dysmyelopoietic syndrome. Cancer 50:2834-2838. Berger R, Bernheim A, Daniel MT, Valensi F, Flandrin G (1983): Cytological types of mitoses and chromosome abnormalities in acute leukemia. Leuk Res 7:221-236. Sandberg AA (1984): Chromosome changes and cancer causation: Chromatin reawaking. In: Accomplishments in Cancer Research, G. Fortner, J., Rhoads, eds., G.B. Lippincott, Philadelphia, pp 157-169. Klein G (198~): The role of gene dosage and genetic transpositions in carcinogenesis. Nature 294:313-318. de la Chapelle A, Berger R (1984): Report of the committee on chromosome rearrangements in neoplasia and on fragile sites. Cytogenet Cell Genet 37:274-311. Hecht F, Sutherland GR (1984): Fragile sites and cancer breakpoints. Cancer Genet Cytogenet 12:179-181. Yunis GG, Foreng AL (1984): Constitutive fragile sites and cancer. Science 226:1199-1204. Li YS, Khalid G, Hayhoe FGJ (1983): Correlation between chromosomal pattern, cytological subtypes, response to therapy, and survival in acute myeloid leukemia. Scand J Haematol 30:265-277.
26
G r o u p e F r a n ~ a i s de C y t o g 6 n 6 t i q u e H 6 m a t o l o g i q u e
31. Yunis JJ, Brunning RD, Howe RB, Lobell M (1984): High-reso[ution chromosome as an independent prognostic indicator in adult acute nonlymphocytic leukemia. N Engl J Med 311:812-818. 32. Axelsson U, Bachmann R, H~llen J (1966): Frequency of pathological proteins (M-components) in 6.995 sera from an adult population. Acta Med Scand 179:235-247. 33. Barnard DL, Burns GF, Gordon J, Cawley JC, Barker CR, Hayhoe FGJ, Smith JL (1979): Chronic myelomonocytic leukemia with paraproteinemia but no detectable plasmacytosis. A detailed cytological and immunological study. Cancer 44:927-935. 34. Groupe Fran~ais de Cytog6n6tique H6matologique (1984): Chromosome analysis of 63 cases of secondary non lymphoid blood disorders. A cooperative study. Cancer Genet Cytogenet 12:95 104.
APPENDIX 1:
G r o u p e F r a n § a i s de C y t o g 6 n 6 t i q u e H 6 m a t o l o g i q u e
Centers
Cities
Names of Participants
St-Luc-U.C.L. and Centre of Human Genetics-K.U.L.
Bruxelles and Leuven
J. Binon, A. Bosly, C. Mecucci, Jean-Louis Michaux, J. Rodhain, Herman Van Den Berghe
St-Louis
Paris
R. Berger, A. Bernheim, M. T. Daniel, G. Flandrin
Henri Mondor
Cr6teil
M. Imbert, H. Jouault, M. C. Lescs, F. Razavi, O. Raoul
St-Antoine
Paris
M. Krulik, N. Smadja
Service de Pathologie Cellulaire et de G6n6tique, Facult~ de M~decine
Nice
N. Ayraud, J. Bayle, S. Raynaud
C.R.T.S. Boisguillaume
Rouen
C. Bastard
C.H.R. Bordeaux
Pessac
A. Broustet, Ph. Bernard, D. Dachary, J. Reiffers
C.H.U. Timone
Marseille
A. M. Capodano, M.Gouzien, A. Stahl
H6pital Calmette, Laboratoire de Cytog6n6tique
Lille
A. Cosson, M. Deminatti, J. L., Lai, P. Lepelley, M. Zandecki
C.H.U.R. D6partement d'H6matologie
St-Etienne
M. F. Bertheas, C. P. Brizard, J. Fraisse, J. Jaubert, C. Vasselon
C.R.T.S. de Brabois
Nancy
J. Buisine, S. Gilgenkrantz, M. J. Gr6goire, J. C. Humbert
C.H.U. La Tronche
Grenoble
D. Leroux, D. Seigneurin, L. Kolodie, P. Jalbert
D6partement d'H6matologie
Poitiers
M. Lessard, J. Tanzer
Facult6 de M6decine
Dijon
F. Mugneret, C. Turc-Carel
C.H.U. Morvan
Brest
M. N. Blanchet, J. Bri~re, M. J. Le BrisQuill6v6r6, M. C. L6glise, D. Rivi~re
C.H. Lyon Sud
Pierre B6nite
P. Felman
M M M
75
79 67
76 63 6O
71 68 71
55
77 60 72 52 76 71 90 72 69 77 75 81 76 69 77 62 76 61 78 74 63
4. B F
5. BJ
6. B M
7. B A 8. C P 9. D A
10. D M 11. D L 12. D H
13. DJ
14. H E 15. JL 16. JL
34. VJ
32. PJ 33. S A
31. N A
29. G P 30. N Y
27. C E 28. G R
25. A J 26. B Y
23. V A 24. W I
20. P M 21. S N 22. S E
17. L L 18. L R 19. O P
M
66
M
M M
M
M F
M M
M F
M F
F F M
M M M
F M M
F M M
M
F
F
F
M
3. B L
M
72
66
Sex
Age
1. A L
2
2. B A
Case/Initials
APPENDIX
M
M M
M
M M
M M
M M
M M
B M M
M M M
M M M
M
M M M
M M M
M
M
M
M
M
M
M/B
48
23 34
31
12 6O
19 23
46 23
15 15
15 15 21
15 5 15
24 25 27
15
4O 10 28
16 10 15
15
3
10
10
10
15
Cells
0 0 0 1 2 1 2 1
19 23 12 59 29 22 32 47
0
23
0 0
15 21 0 0 0
0 0 0
5 15 15
15 15 46
0 0 0 0
0
15 24 25 27 15
0 0 0
4O 10 28
0 0 0
0 0
3 15 16 10 15
0
0
0
0
Abnormal cells
10
10
10
15
Normal cells
46,XY 46,XY 46,XY
46,XX 46,XY
46,XY 46,XY
46,XX 46,XY
46,XY
46,XY 46,XX
46,XY
46,XY 46,XY 46,XX 46,XX
46,XY 46,XY
46 XY 46,XY 46,XY
46 XY 46 XY
46 XY 46 XY 46 XX
46 XY 46 XX
46 XX
46,XX
46,XX
46,XY
46,XY
Karyotype
Acute --
6 4
-Acute ---
80 +20
--
----
Acute
--
--
198 7
20
8 1 2
40
+23 +37
5
-Acute
-3 21
- -
- -
2
15
---
---
--
Therapy ---
--
--
Therapy
---
--
--
-----
---
----
Therapy --
--
--
--
--
--
Exposure
--
1
-----
----
26 54 +5
3 2 13 61
---
--
--
--
--
--
Transformation
11 +2
+23
6
59
+26
12
Survival
2 4 1
2
2
3 2 2 1
2
2 1
2
3 2 2
1 1
1
1 2 2
4 4 1
2
2 2 2
1
1
1
1
2
Group
[',a "-1
70
73
69
48. DP
49.
51
75
81
64
65. BM
66. BL
72
64. VR
69
59. LF
60. LR
63. PF
75
58. LA
76
67
57. LA
55
73
56. HJ
61. LY
M
70
55. DM
62. PL
M
55
54. DN
F
M
M
F
M
M
F
M
M
M
F
F
M
56
84
M
53. DF
76
51. BR
F
M
M
F
F
M
F
F
M
F
M
M
M
M
F
F
Sex
52. DM
74
50. VM
SJ
78
4 7 . BJ
69
42. MF
46. MH
70
41. LM
81
75
40. GS
45. LP
74
39. DC
74
67
38. DA
92
76
37. DH
44. BH
78
43. ZV
82
36. CY
Age
M
M
M
M
M
M
M
M
M
B
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M/B
2 (continued)
35. BS
Case/Initials
APPENDIX
7
12
28
22
17
16
28
24
27
17
19
39
16
22
16
24
20
32
28
33
20
15
16
23
33
13
16
17
17
25
25
20
Cells
5
12
28
21
17
16
28
24
27
16
19
39
16
22
16
24
19
32
28
33
20
15
16
22
33
13
16
17
17
25
23
20
cells
Normal
2
0
0
1
0
0
0
0
0
1
0
0
0
0
0
0
1
0
0
0
0
0
0
1
0
0
0
0
0
0
2
0
cells
Abnormal
46,XY
46,XY
46,XX
46,XY
46,XX 46,XY
46,XY
46,XY
46,XY 46,XY
46,XY
46,XX
46,XY 46,XX
46,XX
46,XX 46,XY
46,XY
46,XY
46,XX
46,XX
46,XY
46,XX
46,XX
46,XY
46,XX
46,XY
46,XY
46,XY 46,XY
46,XX
46,XX
Karyotype
3
3
+ 26
15
+ 37
2
+ 3 + 10
+ 1
+ 24
8 + 5
+
10 12
18
14 + 2
12
12
7
14
2
19
+ 63
12
+ 63
+ 51
+ 48
28 7
3
72
Survival
--
Acute
--
Acute
---
--
--
Acute --
--
--
---
--
Acute --
--
--
--
--
--
--
--
--
--
--
--
Acute --
--
--
Transformation
--
--
--
--
Cancer --
--
--
---
--
--
Cancer --
--
Medical --
_
--
--
--
--
--
--
--
--
--
--
---
--
--
Exposure
1
2
1
2
2
1
2
2
2
1
2
2
2
1
1
2
1
1
1 1
2
2
1
2
2
1
1
1
1
1 1
2
Group
[',3 C¢
61 85 86 58 76 74 82 61 80 69 64 60 56 54 32 69 69 51 50 50 52 71 60 24 70
74
69
72 70
BJ CF GJ GV ML SJ SJ MC PP FM MP BR AJ BF GV GM VM DJ LH VM MO DP RG RJ LA
92. FR
93. LM
94. LS 95. SG
67. 68. 69. 70. 71. 72. 73. 74. 75. 76. 77. 78. 79. 80. 81. 82. 83. 84. 85. 86. 87. 88. 89. 90. 91.
F M
F
M
M M M M M M M M F M M F M M M M M F M M M M M M F
M M
M
M
M M M M M M M M M M M M M M M M M M M M M M M M M
46 19
15
8
10 !5 12 7 11 14 10 19 16 42 21 16 31 16 32 15 18 11 35 19 25 16 100 36 19
2
1
7 11 9 8 19 16 42 21 16 1 0 0 5 6 0 35 16 0 0 3 36 12
10 15
3 45 17 1
10
0 0 0 0 0 5 2 0 0 0 0 0 30 14 26 10 12 11 0 3 25 16 97 0 4 2 7
46 XY 46 XY 46 XY 46 XY 46 XY 46 XY 46 XY 46 XY 46 XX 46 XY 46 XY 46 XX 5 0 , X Y , 3 8 , 3 9 , 3 1 9 , 3 21 45,XY,- 7 45,XY,- 7 45,XY, 7 45,XY,- 7 45,XX,- 7 45,XY,- 7 45,XY,- 7 46,XY, - 22, 3 19 45,X(-Y) 45,X(-Y) 45,X(-Y) 45,X( - X) 47,XX, 3 22 4 5 , X Y , - 4 , - 5 , - 1 0 , - 11, - 21, 3 m a r l , ÷ m a r 2 , ÷ m a r 3 , 3 mar4 4 5 , X X , - 5 , - 7, ÷ t(5;7)(q21;q11), -6,-15, 21, ÷ ring, + m a r l , + m a r 2 ~: i d e m + 22 45,XX, - 15 47,XY, ÷ 8 48,XY,38,÷ 8 51 10
32
16 1 2 21 337 322 26 39 7 392 33 26 13 322 27 2 13 14 11 18 8 1 43 19 344
Acute
Acute
Acute Acute Acute Acute
Acute Acute
Acute
Acute
m
Therapy
Cancer
Professional
m
m
m
b3 ¢J:)
(continued)
56
66 77 61 81 79
109. RA
CS RO RP HC AF
LY KM MA PF VA VY
110. 111. 112. 113. 114.
115. 116. 117. 118. 119. 120.
M F F M F M
F M F M M
M
M
F F M M M F F M F F F M
M M M M M M
M M M M M
M
M
M M M M M M M M M M M M
16 16 15 18 13 15
23 31 19 8 17
13
30
14 9 27 30 3O 3O 13 14 18 59 39 46
16 16 14 17 13 15
12 11 0 5 14
1
10
0 0 17 0 0 14 3 2 0 29 0 0
Normal cells
I'Ref. 22.
0 0 1 1 0 0
1 1
7 5 11 20 19 3 1
20
14 9 10 30 29 16 10 12 18 30 39 36 10
Abnormal cells
<'Exclusive of a constitutional alioma|y: 46,XY,t12:11)(q14;q14).
53 75 72 61 75 75
71
AC JR DS DJ MC HE AM MM BM
68 73 65 60 63 84 82 6O 49 60 69 74
108. BP
99. 100. 101. 102. 103. 104. 105. 106. 107.
98. vj
96. M M 97. LM
Case/Initials Age Sex M/B Cells
APPENDIX 2
Acute
Acute
Therapy
Acute
Therapy
Professional
Professional
Exposure
Acute
Acute
Survival Transformation
47,XX, + 8 9 47,XX, + 8 14 47,XY, + 8,t(2;11)(q14;q14) ° 11 47,XY, + 21 27 47,XY, + del?(13)(q?) + 10 47,XX, + m i n 4 46,XX,del(20)(q12) + 14 46,XY,del(7)(q22) 11 46,XX,t(1;3)(p36;q22) +43 46,XX,del(12)(p12) ~ 12 46,XX,del(12)(q15q22) 31 46,XY,t(1;6)(q21;p24}, +4 46,XY,t(1;6)(q21;p24) del(3)(q22) 46,XY,t(11;12;13) 7 (pll;p12;q21/' 47,XY, + 8,t(9;12)(p23;p12) b 1 46,XY,t(9;12)(p23;p12) 46,XX,del(12)(p11) 54 46,XY,del(12)(p12/' + 13 46,XX,del(12)(pter) + 3 46,XY, - 17, + m a r +8 45,XY,14q + , - 17 5 45,XY,14q + , - 15 40,XY,-4,-6,1 0 , - 13, - 1 3 , 1 4 q + , - 17 46,XY 22 46,XX 12 46,XX 2 46,XY 23 46,XX + 27 46,XY + 2O
Karyotype
2 1 2 2 2 1
2 2 1 2
1
2
2
4 2 2 1 2 1 1 2 1 2 1 1
Group