Four cases of acute leukemia with trisomy 4

Four Cases of Acute Leukemia with Trisomy 4 P. W. Thompson, E. N. Thompson, and J. A. Whittaker

ABSTRACT: We report further on four cases of trisomy 4 in acute leukemia. Two cases were FAB type M4, one was type M1, and one was an undifferentiated leukemia. Two of our patients were children, aged 13 months and 11 years, respectively. In one case there was evidence of trisomy 4 occurring as a secondary change.

INTRODUCTION

Trisomy 4 has recently been reported as a specific cytogenetic change associated with acute n o n l y m p h o c y t i c leukemia (ANLL), usually FAB type M4 [1-9]. We report on a further four cases. Two of our patients are children, aged 13 months and 11 years, respectively. In one of the patients there is possible evidence of the trisomy 4 being a secondary change.

CASE REPORT A N D CYTOGENETICS Patient 1

A 52-year-old male was referred in January 1987 with recent weight loss, painful and swollen gums, and a history of previous recurrent chest and ear infections. He was employed at a motorcycle manufacturer and had worked previously with copper and brass tubing and as a cement packer. On examination, there was marked gum hypertrophy and oral thrush; his spleen was enlarged 5 cm below the left ribs. The blood showed hemoglobin 6.4 g/dl, white blood cell count (WBC) was 79 x 109/L, with neutrophils 2%, lymphocytes 13%, monocytes 4%, monocytoid blasts 78%, and nucleated red blood cells (RBC) 3%. Platelets were 34 x 109/L. Bone marrow aspirate showed 95% blasts of FAB M4 type, some of which contained single Auer rods and were Sudan Black and myeloperoxidase positive and periodic acid-Schiff (PAS) negative. Chloroacetate and nonspecific esterase stains were positive in the blast cells. The acid phosphatase stain was negative. I m m u n o p h e n o t y p i n g of bone marrow m o n o n u c l e a r cells showed the following percentage positivity: OKM1 30%; Ia 22%; 86H1 26%; H6 17%; OKT3 1%; O K T l l 1%~ CALLA 0%; My7 6%; and My9 6%. The patient was treated with two cycles of cytosine arabinoside, doxorubicin, and 6-thioguanine, following which the marrow contained 60% blast cells. He then From the Department of Haematology,Universityof WalesCollegeof Medicine,Cardiff, UnitedKingdom (P. W. T., J. A. W.) and the Department of Child Health, LlandoughHospital, Llandough, Penarth, United Kingdom (E. N. T.}. Address reprint requests to: Dr. P. W. Thompson, Leukaemia Cytogenetics Laboratory, Department of Haematology, University of Wales College of Medicine, Heath Park, Cardiff, United Kingdom. Received April 4, 1989; accepted May 24, 1989.

211 © 1989 ElsevierScience PublishingCo., Inc. 655 Avenue of the Americas, New York~NY 10010

Cancer Genet Cytogenet43:211 217 (1989) 0165-4608/89/$03.50

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Figure 1

4

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I0

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X

Y

Karyotype of case 1: 46,X,-Y,+4.

received two courses of Bisanterene, but died with an Escherichia coli septicemia during a p e r i o d of m a r r o w suppression. Cytogenetic analysis of the bone marrow at diagnosis showed 52 out of 60 cells to have a normal male karyotype. The remaining eight cells were missing the Y c h r o m o s o m e and h a d an extra c h r o m o s o m e 4 (46,X,-Y, ÷4) (Fig. 1). During treatment only n o r m a l cells were seen. Patient

A n 11-year-old p r e v i o u s l y healthy boy was referred in August 1985 with a 6-week history of vague ill health c u l m i n a t i n g in severe tonsillitis and a leg abscess. He was the first-born child in the family, conceived 12 months after discontinuing contraception. No drugs or x-rays were taken during the pregnancy. Both parents were e m p l o y e d full-time, the mother as a secretary and the father in m i d d l e grade m a n a g e m e n t in a plastics and silicone factory. Neither had been involved directly with c h e m i c a l s or solvents. The mother's subsequent obstetric history was complicated by two s p o n t a n e o u s miscarriages (16 and 19 weeks, respectively) between the patient's birth and the births of two subsequent live children. Sibs and parents are well and there is no family history of cancer. On a d m i s s i o n there was exudative tonsillitis and abscess of the right leg. There was significant generalized l y m p h a d e n o p a t h y , with enlargement of the liver (4 cm) and spleen (5 cm) b e l o w the costal margin. The blood showed hemoglobin 12 g/dl, WBC 94 × 109/L, n e u t r o p h i l s 1%, l y m p h o c y t e s 27%, blasts 69%, and platelets 95 × 109/L.

Trisomy 4 in Acute Leukemia

213

Bone marrow aspirate s h o w e d almost complete replacement with myeloblasts (FAB M1), some of w h i c h contained Auer rods, were Sudan Black positive, and PAS negative. I m m u n o p h e n o t y p e was TdT and CALLA negative, Ia 55%, T l l 58%, and 86H1 87%. Remission was achieved following two courses of DAT 3 x 10 (duanorubicin days 1, 3, and 5, cytosine arabinoside twice daily for 10 days, and thioguanine daily for 10 days). Consolidation consisted of a course of MAZE (mAMSA, Azacytidine, etopiside) and a further course of DAT 2 x 10. He r e m a i n e d well, in complete remission for 9 months with serial examinations of the blood and bone marrow normal. In December 1986 he was referred back with a 5-day history of feeling u n w e l l with tonsillitis and was found to be in florid relapse. Bone marrow aspirate was identical to the original marrow. The leukemia was resistant to further intensive c h e m o t h e r a p y and resulted in his death 4 months later, 15 months after diagnosis. Cytogenetic analysis at diagnosis showed an extra chromosome 4 to be present in all nine cells e x a m i n e d (47,XY,+4). During remission, a normal karyotype was seen. At relapses additional copies of both chromosomes 4 and 11 were found (48,XY,+4,+11). Patient 3

A 13-month-old male infant was referred in January 1988 with a 5-day history of vague ill health and a 2-day history of a b d o m i n a l distention and easy bruising. He was born following a normal pregnancy and had remained well until this illness. An earlier pregnancy at the age of 16 with a different partner terminated s p o n t a n e o u s l y at 4 months as a hydatidiform mole. The mother was u n d e r regular surveillance thereafter and r e m a i n e d well with no evidence of any malignant change. She subsequently married and conceived normally. There was no history of any drug ingestion or radiation during either pregnancy. The father was a policeman, and neither had been actively involved with drugs, chemicals, or solvents. On examination, he was a w e l l - n o u r i s h e d child with a hemorrhagic rash and a large bruise on the forehead. There was generalized l y m p h a d e n o p a t h y with enlargement of the liver (7 cm) and spleen (9 cm) below the costal margin. A mild degree of gingival h y p e r t r o p h y was present. The blood s h o w e d hemoglobin 10.8 g/dl, WBC 92.1 x 109/L, neutrophils 6%, l y m p h o c y t e s 27%, blasts 65%, and platelets 53 x 109/L. Bone marrow aspirate showed almost total replacement with primitive hemopoetic cells. There was marked p l e o m o r p h i s m with some indented nuclei. No Auer rods were present, nucleoli were seen in some cells, and large numbers showed vacuolated cytoplasm. The blasts were PAS positive, esterase and Sudan Black negative. The morphologic appearance was that of acute undifferentiated leukemia. I m m u n o p h e n o t y p i n g was not possible because of the unsuitability of the sample. A c o m p l e t e remission was achieved within 4 weeks with vincristine, daunorubicin, asparaginase, and prednisolone. Consolidation consisted of a 5-day block of cytosine arabinoside and VP16 with a single dose of vincristine on day 1 and d a n n o r u b i c i n on days 1 and 2. Cranial prophylaxis has been intrathecal methotrexate to date. He remains in clinical remission 15 months from diagnosis. Maintenance therapy consists of 6-mercaptopurine, methotrexate, vincristine, and prednisolone. Cytogenetic analysis of the initial marrow sample showed the presence of three cell lines. In three out of 17 cells a normal male karyotype was present. In a further three cells there was a three-way translocation involving chromosomes 1, 10, and 11: 46,XY,t(1;10;11)(p32;q24;q23). In the m a i n cell line (11 of 17 cells), in a d d i t i o n to the translocation there was an extra chromosome 4 homolog: 47,XY,+4,t(1;10;11) (p32;q24;q23) (Fig. 2). A normal karyotype is present in remission.

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1

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Figure 2 Karyotype of case 3: 47,XY,+4,t(1;10;11)(p32;q24;q23). cation products.

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Patient 4

A 67-year-old retired farmer presented in January 1989 with a short history of sore throat, fever, and bruising of his skin and gums. His blood showed hemoglobin 12.1 g/dl, WBC 154 x 109/L, neutrophils 25%, lymphocytes 8%, atypical monocytes 50%, monoblasts 12%, monocytes 5%, and platelets 29 x 10"/L. Bone marrow aspirate was c o m p l e t e l y replaced with primitive m o n o c y t o i d blasts of FAB M4 type, many of w h i c h were myeloperoxidase positive. I m m u n o p h e n o t y p ing showed 57% of cells CD11 positive; CD33 and HLA DR were also strongly positive, while all l y m p h o i d markers were negative. F o l l o w i n g the insertion of a mitral valve prosthesis in March 1985, the patient had received Warfarin, and at presentation his INR was 8. In addition, he had clinical signs of vertebrobasilar insufficiency and mild renal failure (blood urea 17.3 m m o l / L serum creatinine 220/xmol/L). Warfarin was s t o p p e d and, following three units of fresh frozen plasma, he received an initial 5-day treatment with cytosine arabinoside and thioguanine that c o n s i d e r a b l y r e d u c e d the n u m b e r of blast cells in his blood. He is currently awaiting further i n d u c t i o n chemotherapy. Cytogenetic analysis of the bone marrow aspirate at diagnosis showed the presence of an extra c h r o m o s o m e 4 homolog in 36 out of 40 cells examined (47,XY,+4). The remaining four cells had a normal male karyotype.

Trisomy 4 in Acute Leukemia

Table 1 No.

2 15

R e p o r t e d c a s e s of t r i s o m y 4 in ANLL Sex

Age

FAB

1 2 3

F F F

17 64 56

M2 M4 M4

4 5 6 7 8 9 10 11 12 13 14 15 16

M F F F F M M F M F F F F

15 58 25 53 74 54 25 52 64 54 75 34 71

M4 RAEB-t M4 M4 M4 M2 or M4 M1 M2 M2 M2 or M4 M1 M2 M4

17 18 19 20 21

M F M M M

72 51 52 11 1

M4 M4 M4 M1 M0

22

M

67

M4

WBC (xlOg/L)

Survival (mo)

Remission

Karyotype

Percent of cells

33.7 18.7 248

7 12+ 1.5

Yes Yes No

4.7 15.8 ~' 25.2 1.4 3.8 449 41.2 Normal 84.0 35.2 206.0 110 124

6 22+ 1.5 18+ 4+ Uncertain 25+ 11 6 10 17 48 4

Yes No No -No b No Yes No Yes Yes Yes Yes No t

1.1 2.6 79.0 94 92.1

16 24 4 15 12+

No Yes No Yes Yes

+4 +4 +4 +4,+7 +4 +4 +4 +4 +4,dmin +4 +4 +4,dmin +4 +4,+13 +4 +4 +4 +4,dmin +4,+del(3) +4 relapse +4,-Y +4 t(1;10;11) t(1;10;11),+4 +4

67 93 92 8 62 100 96 87 100 50 100 43 78 100 100 68 36 64 84 70 13 100 17 65 90

154

1+

--

Reference

[1]

[2] [3] [4] [5] [6] [7]

[8] Present cases

WBC 3.6 x 10~ L at presentation. ~'No treatment given. ': Hydroxyurea treatment only.

DISCUSSION I n c l u d i n g t h e f o u r p a t i e n t s d e s c r i b e d h e r e , t h e r e are n o w 22 p u b l i s h e d c a s e s of t h e a s s o c i a t i o n b e t w e e n t r i s o m y 4 a n d a c u t e l e u k e m i a (Table 1). M e c u c c i ' s o r i g i n a l r e p o r t [1] of five p a t i e n t s w i t h t r i s o m y 4 s u g g e s t e d a p l e u r i p o t e n t s t e m cell d e f e c t or an a b n o r m a l i t y i n a n e a r l y m y e l o i d s t e m cell w i t h t h e c a p a b i l i t y of d i f f e r e n t i a t i n g a l o n g a m o n o c y t i c or g r a n u l o c y t i c lineage. D y s e r y t h r o p o i e t i c c h a n g e s , w h i c h inc l u d e d m e g a l o b l a s t o s i s in e r y t h r o i d cells, P e l g e r - H u e t a n o m a l i e s , h y p o g r a n u l a t i o n of g r a n u l o c y t e s , a n d a b n o r m a l m e g a k a r y o c y t e s w e r e n o t e d in e a c h of t h e five p a t i e n t s . T h e r e w a s n o e v i d e n c e of d y s e r y t h r o p o i e s i s in our p a t i e n t s , a n d s i n c e M e c u c c i ' s r e p o r t [1], o n l y o n e o t h e r r e p o r t e d p a t i e n t h a s s h o w n t h i s c h a n g e [8]. A b o u t h a l f (13 of 22) of t h e p a t i e n t s n o w d e s c r i b e d h a v e h a d a c u t e l e u k e m i a of FAB M4 s u b t y p e , b u t f o u r p a t i e n t s h a v e s h o w n a less w e l l - d i f f e r e n t i a t e d m o r p h o l o g y of M0 or M1 t y p e . P r i o r to t h i s s t u d y , t h e large m a j o r i t y of p a t i e n t s w i t h t r i s o m y 4 h a v e b e e n f e m a l e (13 of 18), a l t h o u g h a n u n e q u a l sex d i s t r i b u t i o n s e e m s less likely in v i e w of o u r O b s e r v a t i o n s in f o u r m a l e p a t i e n t s . A h i g h WBC, a l t h o u g h o c c a s i o n a l l y s e e n in M4 l e u k e m i a , m a y h a v e a p a r t i c u l a r a s s o c i a t i o n w i t h t r i s o m y 4. As s h o w n i n Table 1, t e n of t h e 22 p a t i e n t s h a d a WBC at p r e s e n t a t i o n t h a t w a s g r e a t e r t h a n 75 x 109/L. T h e s e h i g h WBC w e r e s e e n w i t h t h e M4 s u b t y p e in five p a t i e n t s a n d w i t h o t h e r FAB s u b t y p e s in t h e r e m a i n d e r . It is of

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interest that the only other specific abnormality of chromosome 4 in acute leukemia, the t(4:11), is also associated with a high WBC [10]. The association of trisomy 4 and acute leukemia is distributed throughout life, with several examples in the elderly (Table 1). The two cases of childhood leukemia presented here are the youngest patients so far reported with the anomaly, being 13 months and 11 years, respectively, at diagnosis. Response to treatment was unrelnarkable and c e r t a i n h m3t significantl~ different from ANLL in general. Eighteen of the 22 patients received adequate induction treatment, with 11 remissions (61%). When one considers that 16 of the 22 patients were over 50 years, and that treatment was with a variety of regimens, this seems satisfactory. Based on tim data from initial publications 11, 2], Sandberg suggested that trisomy 4 may result from exposure to environmental or carcinogenic agents [91. There was no evidence of such exposure in any of our patients, nor of repeated or prolonged antibiotic exposure [51. In 14 of the 22 cases now reported, trisomy 4 was present as the sole cytogenetic change, half of these having M4-type ANNL, and the remainder with other FAB subtypes. Of the eight cases with additional abnormalities, only double minute chromosomes were featured more than once. Their presence ill three patients seems a high n u m b e r compared to their occurrence in acute leukemia in general, and more cases need to be reported to see if this figure is representative. Two of our patients presented with trisomy 4 as the only cytogenetic change [patients 2 and 4). In case 1, trisomy 4 was found together with loss of the Y chromosome. Y chromosome loss is a common finding in haematologic disorders and has been reported with many other specific chromosomal findings [11]. The most interesting case, cytogenetically, is case 3, which shows evidence of trisomy 4 being a secondary change. The main cell line contained the three-way translocation t(1:10;11) and an extra chromosome 4 homolog: however, there was a minor clone that showed only the translocation. Tbe probable explanation for this is that the cell line with the translocation developed first and then acquired the extra chromosome 4 as a secondary change. This suggests that trisomy 4, like trisomy 8, may confer some kind of proliferative advantage to myeloid cells, rather than being one of the primary leukemic changes [12]. Conversely, it is also possible that clonal evolution has occurred with loss of the chromosome 4, and random loss of the 4 homolog cannot be totally excluded as a further explanation for these three cells. The increased n u m b e r of reported cases of trisomy 4 is helpful in our understanding of the clinical and cytogenetic picture in patients with this anomaly, yet recent data has failed to support the suggestion of Sandberg [91 that environmental agents may be involved. We are still no closer, therefore, to explaining the lack of detection of this chromosomal abnorlnality in the past, or for its recent discovery.

REFERENCES

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5. Hoyle CF, Boughton BJ, Hayhoe FG (19881: Two further cases of acute myeloid leukemia with trisomy 4. Cancer Genet Cytogenet 34:29-32. 6. Fujishita M, Miyagi T, Takeuchi T, Kubonishi I, Niiya K, Taguchi H. Ohtsuki Y, Miyoshi I (1988): Trisomy 4 in a case of acute nonlymphocytic leukemia {M2). Cancer Cenet Cytogenet 34:281 284. 7. Juneja S, Brown J, Chong Ding ], Carson OM (19881: Trisomy 4 in acute nonlymphocytic leukemia. An Australian case. Cancer Genet Cytogenet 34:25-28. 8. Suciu S, Weh H-J, Kuse R, Meier CB, Hossfeld DK (1988): Trismny 4 in two cases of dCtlle myelomonocytic leukemia. Cancer Genet Cytogenet 33:19 23. 9. Sandberg AA, Van Den Berghe H, Hecht F {1987): Trisomy 4 in hematologic disorders. Cancer Genet Cytogenet 26:175. 10. De Braekeleer M (1986): t(4;11) Translocation-associated acute leukemia: an update. Cancer Genet Cytogenet 23:333-335. 11. Mitehnan F (1987): Catalog of Chromosome Aberrations in Cancer, 3rd ed. Alan R. Liss, New York. 12. Cassano WF, Hintz MS (1988): Clonal trisomy 8 is associated with myeloid phenotype rather than the neoplastic transformation in acute leukemia. Am I Hematol 27:184 189.