- Email: [email protected]
myeloid acute leukemia
Evolution of Complex Chromosomal Rearrangements in a Case of Biphenotypic Pre-B/Myeloid Acute Leukemia Marion Wood, Jeanette H. Palmer, Faith Wright, Daoroong Kangwanpong, and Lorna M. Secker-Walker
ABSTRACT: A case of acute biphenotypic leukemia, in which blast cells coexpress antigens of both lymphoid and myeloid lineages, was seen in a 24-year-old female. The clonal karyotype was complex but did not include any of the abnormalities previously found in biphenotypic leukemia. Chromosome abnormalities included breakpoints seen in both acute lymphoblastic and acute myeloid leukemias as well as a number of known fragile sites, namely the rare heritable fragile site at 10q24, and the common, aphidicolin-induced sites on chromosome 7.
INTRODUCrION
Acute biphenotypic leukemia, in which blast cells coexpress antigens of both lymphoid and myeloid lineage, is now recognized as a distinct clinical entity. Some associated keryotypic abnormalities have been described, notably the Philadelphia translocation and abnormalities involving breakpoints at llq23-q24 [1-5]. The case presented is era patient with acute biphenotypic leukemia and a novel complex karyotype of the leukemic blasts. CASE REPORT
A 24-year-old Indian woman presented in Thailand with lymphadenopathy, bruising, and an episode of fainting. Her full blood count showed Hb 10 g/dl, WBC 36.1 x 109/L (94% blasts}, platelets 30 x 109/L. Following bone marrow examination a diagnosis of probable ALL was made and she commenced treatment consisting of weekly intravenous vincristine 2 mg and adriamycin 40 mg, with oral prednisolone 100 mg/day. After 3 weeks her lymphadenopathy had resolved but bone marrow examination showed persistent disease. She was referred to this hospital for further management. Repeat marrow examination showed 95% blasts with morphologic and cytochemical features of ALL-L1. Blast cell immunophenotype was 90% positive for stem-cell markers HLA-Class II, CD34, and TdT, 90% for B-lineage markers CD10, CD19, CD22,
From the Department of Haematology [M. W., ]. H. P., E W., L. M. S.-W.), The Royal Free Hospital and School of Medicine, London; and the Human Genetics Unit (19.K.), Department of Pathology, Faculty of Medicine, Ram~thibodi Hospital, Bangkok, Thailand. Address reprint requests to: Prof. L. M. Secker-Walker, Department of Haematology, Royal Free Hospital Pond Street, London NW3 2QG, U.K. Received December 8, 1992; accepted May 6, 1993.
and cigar, and 90% for the myeloid marker, CD33, together with 89% myeloperoxidase positivity by monoclonal antibody. These results indicated a biphenotypic pre-B/myeloid acute leukemia. High-dose timed sequential chemotherapy was given consisting of cytambine 3.2G/24 hours continuous infusion for 3 days, dannorubicin 72 mg i.v. bolus on days 1, 2, and 3 (starting 12 hours after commencement of cytarabine), and etoposide 640 mg/day as a 6-hour infusion on days 8, 9, and 10. Oral prednisolone was continued for 2 weeks and a further two doses of vincristine were given at weekly intervals. The subsequent phase of pancytopenia was complicated by pyrexia that failed to respond to antibacterial, antiviral, and antifungal agents. Six weeks later, as her blood counts began to recover, she developed a cavitating pulmonary lesion. A mycotic lung sequestrum, which was positive on culture for Aspergillus, was resected. Repeat marrow aspirate 10 weeks after her referral showed morphologic remission and a second course of chemotherapy was begun. However, pneumonia developed and, in spite of antibiotics, antifungals, and full ventilatory support, the patient deteriorated and died I week later, 14 weeks after diagnosis. Cytogenetic Analysis Cytogenetic preparation from a bone marrow culture at diagnosis gave a poor mitotic yield and chromosomes of poor morphology. Three weeks later, on referral to The Royal Free Hospital with refractory disease, the bone marrow was prepared for cytogenetic analysis by 24-hour culture in RPMI 1640 with 20% fetal calf serum, harvested with standard techniques, and stained with Giemsa banding. Comparison of the metaphase spreads from the two investigations suggested that the diagnostic sample showed 46,XX,t(5;6)(p13;p23}, der(7)inv(7) (p13q36)inv[7) (p13q22),del(9) (p12),inv{10) (q24q26) [16]/46,XX[4]. On referral three clonally related cell lines were 129
© 1993 Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, New York, NY 10010
Cancer Genet Cytogenet 09:129-131 (1993) 0105-4608/93/$06.00
130
M. Wood et al.
Figure 1 Karyogram of the most complex cell line seen in the bone marrow 3 weeks from diagnosis following failure to respond to treatment: ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ del(l~)(q~~),der(2O)t(l~;2O)(2Opl3~2Oqll::llql3~llqter). Loss of 18 was not cloned.
found, i.e., 46,XX,inv(lO)(q24q26)[2]/46,XX,t(5;6)(pl3;p23), der(7)inv(7)(pl3q36)imr(71(p13q22),de1(9)(p12),iw(lO)(q24q26) [31/46,xX, t(5;6),der(~)imr(~,de1(9),imr(l0),del(ll)(qll),der(20) t(11;20)(20p13~20q11::1lq13+11qter) [15]. A karyogram of the most complex cell line is shown in Figure 1. DISCUSSION Some confusion exists about nomenclature for cases of acute leukemia with lymphoid and myeloid characteristics that are of two kinds. Bilineage cases express lymphoid and myeloid antigens on different populations of blasts. In contrast, biphenotypic cases coexpress lymphoid and myeloid antigens on the same cells. Ours was a case of biphenotypic acute leukemia in which > 90% blasts coexpressed markers of early B-lineage and myeloid cells. Chromosomal rearrangements resulted from breakage at a total of 11 different chromosomal sites. The concurrence of breakpoints commonly found in ALL, as well as in AML, was a notable feature of this case. One of the breakpoints, 74136,band location of the beta chain of the T-cell receptor gene TCRB, has been previously described in a bilineage acute leukemia with t(7;8)(q35-q36; q22); however, that case differed from ours in having blasts of M4 morphology coexpressing CM9 and CD13 but nega-
tive for CD10 and CD33 [l]. De1(9)(p12) and breakage at 7pl3 occur in both common and T ALL. Two of the remaining breakpoints, 5~13 and lOq24 have each been found as a primary change in adult T-cell leukemia/lymphoma or TALL. Involvement of sites commonly involved in T-cell malignancies was an unusual feature of this case. Breakpoints 6~23 occur and breakpoints ip22 are frequent in AML [6]. It is now recommended that immunophenotyping with monoclonal antibodies should be considered along with cytogenetics in the identification of biphenotypic leukemia [il. None of the abnormalities commonly associated with biphenotypic leukemia, t(4;11)(q21;q23) [2], translocations involving tllq23 [l, 3-51, or t(9;22)(q34;qll) [2-41 were found in the present case. Of potential interest in this case was the involvement of four chromosomal bands in which fragile sites are known to be located, including both the rare heritable sites at lOq24 and the common fragile sites at 7p13, Q22, and iQ36, which are induced by aphidicolin [8]. The patient was not investigated for fragile lOq24 and the role of heritable fragile sites in the acquisition of chromosomal abnormalities in malignancies is far from clear. Neither was there any evidence of exposure to toxic agents in this case. Nevertheless, complexity and location of the chromosomal changes raises the pos-
Biphenotypic Leukemia
sibility that environmental or therapeutic agents acting on genetically sensitive sites may have been involved i n the etiology of this chromosomally unique biphenotypic leukemia. Our patient achieved remission with intensive chemotherapy but unfortunately died of infection following consolidation chemotherapy. However, cases of acute leukemia associated with multiple karyotypic abnormalities such as this have generally had particularly poor prognoses [9], suggesting that there was a high probability that this patient would suffer an early relapse.
131 3. Guyotat D, Campos L, Shi ZH, Charrin C, Treille D, Magaud JE Fiere D (1990): Myeloid surface antigen expression in adult acute lymphoblastic leukemia. Leukemia 4:664-666. 4. Sulak LE, Clare CN, Morale BA, Hansen KL, Montiel MM (1990): Biphenotypic acute leukemia in adults. Am J Clin Pathol 94:54-58. 5. Cuneo A, Michaux J-L, Ferrant A, Van Hove L, Bosley A, Stul M, Dal Cin P, Vandenberghe E, Cassiman J-J, Negrini M, Piva N, Castoldi G, Van den Berghe H (1992):Correlation of cytogenetic patterns and clinicobiological features in adult acute myeloid leukemia expressing lymphoid markers. Blood 79:720-727.
We are grateful to the Kay Kendall Leukaemia Fund for their support.
6. Mitelman F, Kaneko Y, Trent J (1991): Report of the committee on chromosome changes in neoplasia, Human Gene Mapping 11 (1991). Cytogenet Cell Genet 58:1053-1079.
REFERENCES
7. Catovsky D, Matutes E (1992): The classification of acute leukaemia. Leukemia 6 (Suppl 2):1-6.
1. Hayashi Y, Sugita K, Nakazawa S, Abe T, Kojima S, Inaba T, Hanada R, YanmmotoK (1990): Karyotypic patterns in acute mixed lineage leukemia. Leukemia 4:121-126. 2. Altman AJ (1990): Clinical features and biological implications of acute mixed lineage (hybrid) leukemias. Am J Ped Hemat-Oncol 12:123-133.
8. Sutherland GR, Hecht F (1985): Fragile sites on human chromosomes. Oxford University Press, New York. 9. Yunis JJ, Brnnning RD (1986): Prognostic significance of chromosomal abnormalities in acute leukaemias and myelodysplastic syndromes. Clin Haematol 15:597-619.
ABSTRACT: A case of acute biphenotypic leukemia, in which blast cells coexpress antigens of both lymphoid and myeloid lineages, was seen in a 24-year-old female. The clonal karyotype was complex but did not include any of the abnormalities previously found in biphenotypic leukemia. Chromosome abnormalities included breakpoints seen in both acute lymphoblastic and acute myeloid leukemias as well as a number of known fragile sites, namely the rare heritable fragile site at 10q24, and the common, aphidicolin-induced sites on chromosome 7.
INTRODUCrION
Acute biphenotypic leukemia, in which blast cells coexpress antigens of both lymphoid and myeloid lineage, is now recognized as a distinct clinical entity. Some associated keryotypic abnormalities have been described, notably the Philadelphia translocation and abnormalities involving breakpoints at llq23-q24 [1-5]. The case presented is era patient with acute biphenotypic leukemia and a novel complex karyotype of the leukemic blasts. CASE REPORT
A 24-year-old Indian woman presented in Thailand with lymphadenopathy, bruising, and an episode of fainting. Her full blood count showed Hb 10 g/dl, WBC 36.1 x 109/L (94% blasts}, platelets 30 x 109/L. Following bone marrow examination a diagnosis of probable ALL was made and she commenced treatment consisting of weekly intravenous vincristine 2 mg and adriamycin 40 mg, with oral prednisolone 100 mg/day. After 3 weeks her lymphadenopathy had resolved but bone marrow examination showed persistent disease. She was referred to this hospital for further management. Repeat marrow examination showed 95% blasts with morphologic and cytochemical features of ALL-L1. Blast cell immunophenotype was 90% positive for stem-cell markers HLA-Class II, CD34, and TdT, 90% for B-lineage markers CD10, CD19, CD22,
From the Department of Haematology [M. W., ]. H. P., E W., L. M. S.-W.), The Royal Free Hospital and School of Medicine, London; and the Human Genetics Unit (19.K.), Department of Pathology, Faculty of Medicine, Ram~thibodi Hospital, Bangkok, Thailand. Address reprint requests to: Prof. L. M. Secker-Walker, Department of Haematology, Royal Free Hospital Pond Street, London NW3 2QG, U.K. Received December 8, 1992; accepted May 6, 1993.
and cigar, and 90% for the myeloid marker, CD33, together with 89% myeloperoxidase positivity by monoclonal antibody. These results indicated a biphenotypic pre-B/myeloid acute leukemia. High-dose timed sequential chemotherapy was given consisting of cytambine 3.2G/24 hours continuous infusion for 3 days, dannorubicin 72 mg i.v. bolus on days 1, 2, and 3 (starting 12 hours after commencement of cytarabine), and etoposide 640 mg/day as a 6-hour infusion on days 8, 9, and 10. Oral prednisolone was continued for 2 weeks and a further two doses of vincristine were given at weekly intervals. The subsequent phase of pancytopenia was complicated by pyrexia that failed to respond to antibacterial, antiviral, and antifungal agents. Six weeks later, as her blood counts began to recover, she developed a cavitating pulmonary lesion. A mycotic lung sequestrum, which was positive on culture for Aspergillus, was resected. Repeat marrow aspirate 10 weeks after her referral showed morphologic remission and a second course of chemotherapy was begun. However, pneumonia developed and, in spite of antibiotics, antifungals, and full ventilatory support, the patient deteriorated and died I week later, 14 weeks after diagnosis. Cytogenetic Analysis Cytogenetic preparation from a bone marrow culture at diagnosis gave a poor mitotic yield and chromosomes of poor morphology. Three weeks later, on referral to The Royal Free Hospital with refractory disease, the bone marrow was prepared for cytogenetic analysis by 24-hour culture in RPMI 1640 with 20% fetal calf serum, harvested with standard techniques, and stained with Giemsa banding. Comparison of the metaphase spreads from the two investigations suggested that the diagnostic sample showed 46,XX,t(5;6)(p13;p23}, der(7)inv(7) (p13q36)inv[7) (p13q22),del(9) (p12),inv{10) (q24q26) [16]/46,XX[4]. On referral three clonally related cell lines were 129
© 1993 Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, New York, NY 10010
Cancer Genet Cytogenet 09:129-131 (1993) 0105-4608/93/$06.00
130
M. Wood et al.
Figure 1 Karyogram of the most complex cell line seen in the bone marrow 3 weeks from diagnosis following failure to respond to treatment: ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ del(l~)(q~~),der(2O)t(l~;2O)(2Opl3~2Oqll::llql3~llqter). Loss of 18 was not cloned.
found, i.e., 46,XX,inv(lO)(q24q26)[2]/46,XX,t(5;6)(pl3;p23), der(7)inv(7)(pl3q36)imr(71(p13q22),de1(9)(p12),iw(lO)(q24q26) [31/46,xX, t(5;6),der(~)imr(~,de1(9),imr(l0),del(ll)(qll),der(20) t(11;20)(20p13~20q11::1lq13+11qter) [15]. A karyogram of the most complex cell line is shown in Figure 1. DISCUSSION Some confusion exists about nomenclature for cases of acute leukemia with lymphoid and myeloid characteristics that are of two kinds. Bilineage cases express lymphoid and myeloid antigens on different populations of blasts. In contrast, biphenotypic cases coexpress lymphoid and myeloid antigens on the same cells. Ours was a case of biphenotypic acute leukemia in which > 90% blasts coexpressed markers of early B-lineage and myeloid cells. Chromosomal rearrangements resulted from breakage at a total of 11 different chromosomal sites. The concurrence of breakpoints commonly found in ALL, as well as in AML, was a notable feature of this case. One of the breakpoints, 74136,band location of the beta chain of the T-cell receptor gene TCRB, has been previously described in a bilineage acute leukemia with t(7;8)(q35-q36; q22); however, that case differed from ours in having blasts of M4 morphology coexpressing CM9 and CD13 but nega-
tive for CD10 and CD33 [l]. De1(9)(p12) and breakage at 7pl3 occur in both common and T ALL. Two of the remaining breakpoints, 5~13 and lOq24 have each been found as a primary change in adult T-cell leukemia/lymphoma or TALL. Involvement of sites commonly involved in T-cell malignancies was an unusual feature of this case. Breakpoints 6~23 occur and breakpoints ip22 are frequent in AML [6]. It is now recommended that immunophenotyping with monoclonal antibodies should be considered along with cytogenetics in the identification of biphenotypic leukemia [il. None of the abnormalities commonly associated with biphenotypic leukemia, t(4;11)(q21;q23) [2], translocations involving tllq23 [l, 3-51, or t(9;22)(q34;qll) [2-41 were found in the present case. Of potential interest in this case was the involvement of four chromosomal bands in which fragile sites are known to be located, including both the rare heritable sites at lOq24 and the common fragile sites at 7p13, Q22, and iQ36, which are induced by aphidicolin [8]. The patient was not investigated for fragile lOq24 and the role of heritable fragile sites in the acquisition of chromosomal abnormalities in malignancies is far from clear. Neither was there any evidence of exposure to toxic agents in this case. Nevertheless, complexity and location of the chromosomal changes raises the pos-
Biphenotypic Leukemia
sibility that environmental or therapeutic agents acting on genetically sensitive sites may have been involved i n the etiology of this chromosomally unique biphenotypic leukemia. Our patient achieved remission with intensive chemotherapy but unfortunately died of infection following consolidation chemotherapy. However, cases of acute leukemia associated with multiple karyotypic abnormalities such as this have generally had particularly poor prognoses [9], suggesting that there was a high probability that this patient would suffer an early relapse.
131 3. Guyotat D, Campos L, Shi ZH, Charrin C, Treille D, Magaud JE Fiere D (1990): Myeloid surface antigen expression in adult acute lymphoblastic leukemia. Leukemia 4:664-666. 4. Sulak LE, Clare CN, Morale BA, Hansen KL, Montiel MM (1990): Biphenotypic acute leukemia in adults. Am J Clin Pathol 94:54-58. 5. Cuneo A, Michaux J-L, Ferrant A, Van Hove L, Bosley A, Stul M, Dal Cin P, Vandenberghe E, Cassiman J-J, Negrini M, Piva N, Castoldi G, Van den Berghe H (1992):Correlation of cytogenetic patterns and clinicobiological features in adult acute myeloid leukemia expressing lymphoid markers. Blood 79:720-727.
We are grateful to the Kay Kendall Leukaemia Fund for their support.
6. Mitelman F, Kaneko Y, Trent J (1991): Report of the committee on chromosome changes in neoplasia, Human Gene Mapping 11 (1991). Cytogenet Cell Genet 58:1053-1079.
REFERENCES
7. Catovsky D, Matutes E (1992): The classification of acute leukaemia. Leukemia 6 (Suppl 2):1-6.
1. Hayashi Y, Sugita K, Nakazawa S, Abe T, Kojima S, Inaba T, Hanada R, YanmmotoK (1990): Karyotypic patterns in acute mixed lineage leukemia. Leukemia 4:121-126. 2. Altman AJ (1990): Clinical features and biological implications of acute mixed lineage (hybrid) leukemias. Am J Ped Hemat-Oncol 12:123-133.
8. Sutherland GR, Hecht F (1985): Fragile sites on human chromosomes. Oxford University Press, New York. 9. Yunis JJ, Brnnning RD (1986): Prognostic significance of chromosomal abnormalities in acute leukaemias and myelodysplastic syndromes. Clin Haematol 15:597-619.