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Rare tetraploidy with large 5q deletion in acute myeloid leukemia with myelodysplasia-related changes (AML-MRC)
Leukemia Research 36 (2012) e68–e70
Contents lists available at SciVerse ScienceDirect
Leukemia Research journal homepage: www.elsevier.com/locate/leukres
Letter to the Editor Rare tetraploidy with large 5q deletion in acute myeloid leukemia with myelodysplasia-related changes (AML-MRC) 1. Introduction In 2008, the World Health Organization (WHO) revised its classification of hematopoietic neoplasms and new “acute myeloid leukemia with myelodysplasia-related changes (AML-MRC)” was defined as “AML arising from a previous MDS or MDS/MPN, AML with an MDS-related cytogenetic abnormality, and/or AML-MLD changes, mainly with a complex karyotype” [1]. Myelodysplastic syndrome (MDS)-related chromosomal changes involve mainly aberrations of chromosomes 5, 7, and a complex karyotype. The change from ploidy to tetraploidy (4n) is a rare chromosomal abnormality in AML, and only a few cases have been described in the literature [2,3]. Despite its rarity in AML, tetraploidization can initiate chromosomal instability (CIN) and promote cell transformation [4,5]. Presented here is a case of a 52-year-old male with an initial diagnosis of AML-MRC with tetraploid clones detected in his bone marrow. FISH analysis revealed a large deleted derivative chromosome 5 within a complex karyotype. To the best of our knowledge, such findings in AML-MRC have not yet been reported in the literature. 2. Case report A 52-year-old male, whose original occupation was a coal miner, was examined by a local hematologist after a year of weakness and fatigue. Myelodysplastic syndrome was suspected based on the observation of leucopenia with neutropenia and macrocytic anemia (white blood cells 1.4 × 109 /L, hemoglobin 116 g/L, thrombocytes 211 × 109 /L). The patient was referred to the Department of Hemato-Oncology, University Hospital Olomouc. Laboratory tests performed 10 days later at the department confirmed anemia and leukopenia (white blood cells 1.07 × 109 /L, red blood cells 3.35 × 1012 /L, hemoglobin 114 g/L, thrombocytes 173 × 109 /L). Examination of bone marrow cells showed hypocellular smears with pronounced (57.2%) dysplastic erythropoiesis (polynucleated cells, nuclear budding, internuclear bridges, cytoplasmic vacuolization and megaloblastic changes), marked reduction of normal granulopoiesis and a total of 22% of myeloblasts. Immunophenotypic analysis of bone marrow cells also revealed 22% of myeloblasts expressing CD34: 22%, CD33: 50%, CD13: 47%, CD15: 23%, CD65: 50%, and HLA-DR: 28%. Intracellular markers were also analyzed (MPO: 12%, TdT: 33%, Ki-67: 0.3%, CD79a: 7%, cyCD22: 0.60%, cyCD3: 22%). A diagnosis of AML-MRC was assigned. Chromosomal analysis on bone marrow cells using Gbanding revealed three clones: 92,XXYY [2]/92,XXYY,?del(5q31) [3]/46,XY[12] (Fig. 1a). FISH with a commercially available probe (LSI ERG1/D5S23, D5S721 Dual Color Probe, Abbott Molecular, Des Plains, IL, USA) was performed according to the manufacturer’s 0145-2126/$ – see front matter © 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.leukres.2011.12.014
instructions. Two green and two red signals (2G2R), indicative of normal diploid cells, were observed in the majority of cells (64.5%). Four green and four red signals (4G4R), indicative of tetraploidy, were observed in 7.8% of cells. A total of 27.7% of cells (86 out of 310 interphase cells) had 4G3R signals confirming 5q deletion in tetraploid metaphases (Fig. 1b). For precise mapping of the deleted region, FISH with LSI CSF1R and TelVysion 5q and mBAND FISH for chromosome 5 (MetaSystems, Altlussheim, Germany) (Fig. 1c) followed by whole chromosome paint probes (WCP) for chromosomes 1, 2, 3, 5, 13 and 14, was performed. The deleted chromosome 5 was shown to be a derivative chromosome 5 as the result of translocation der(5)t(5;14)(q23.1;q?). Additional chromosomal changes were also revealed: der(2)t(1;2)(q?;?) and der(3)t(3;13)(?;q?) (Fig. 1 d,e). BAC probes (BlueGnome, Cambridge, UK and Chambon Inc Laboratory, Prague, Czech Republic) were used for precise mapping of the deleted 5q region. The deletion was determined as 5q23.1qter with breakpoint mapped to band 5q23.1 between clones RP11-1160A17 and CTD-2334D19 comprising a total of ∼60.8 Mb in length. Furthermore, analysis of molecular markers including the JAK2V617F , MPLW515 , MPLS505 , NPM1 exon 12, FLT3 internal tandem duplication (ITD) and FLT3D835 mutations were performed on genomic DNA or RNA (NPM1 mutation only) extracted from diagnostic peripheral blood cells. No mutation was detected in any of the genes analyzed. The patient was started on induction therapy “3 + 7” (AraC 100 mg/m 7 days; KIN + Mitoxantrone 7 mg/m 3 days, OD) followed by Novia (consolidation: 3x Novia AraC 0.5 g/m BID 4 days, +Mitoxantrone 7 mg/m 3 days, OD) and achieved hematological remission by day 59, which was maintained for 13 months after diagnosis. Hematological remission was not followed by cytogenetic remission, as we confirmed the presence of 10% of cells with a 5q deletion by interphase FISH 9 months after chemotherapy. At the time of this report, the patient received maintenance chemotherapy and hematological remission persisted in his bone marrow for 14 months from diagnosis.
3. Discussion We report a case of a patient with primary AML-MRC and a complex karyotype in a tetraploid clone involving a large 5q deletion. The 5q deletion in AML is most often found as part of a complex karyotype. The precise role of this aberration within a complex karyotype and the underlying basis of the heterogeneity of the deleted region in AML remain to be characterized [2]. Notably, in AML-MRC, 5q deletion is usually associated with a complex karyotype and poorer outcomes following treatment [2,3]. A prognostic analysis of a large cohort of patients with AML-MRC was published recently [6]. This analysis of 55 cases with AML-MRC confirmed that the presence of MDS-related cytogenetic changes is associated with shorter median EFS and OS. Multilineage dysplasia alone showed
Letter to the Editor / Leukemia Research 36 (2012) e68–e70
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Fig. 1. Cytogenetic and FISH findings. (A) G-banded karyotype: 92,XXYY,?del(5q).(B) FISH with LSI ERG1/D5S23, D5S721 Dual Color Probe (Abbott Molecular) with a 3R4G signal pattern on metaphase chromosomes. (C) mBAND FISH of chromosome 5 (MetaSystems) confirming deletion 5q23.1. (D) WCP 5 (orange) and WCP14 (green) confirmed der(5)t(5;14) in the tetraploid metaphase. (E)WCP 5 (orange) and WCP 2 (green) showed the presence of derivative chromosomes.
no independent clinical effect, whereas cytogenetics and MDS history were prognostically relevant. Our patient had no history of MDS. In our case, a tetraploid clone without 5q deletion was found, confirming that 5q- could be a later event in the pathogenesis of AML-MRC. The deletion was mapped precisely and involved loss of the 5q telomere. We believe that instability of the deleted chromosome 5 due to telomere loss caused an unbalanced translocation. Potential relationship between aneuploidy and tumor development has been confirmed in numerous current studies because tetraploid cells are frequently found in early stages of tumor development [7]. In many tumors, changes in ploidy are associated with the presence of chromosomal gains and losses, with so-called chromosomal instability (CIN) resulting in karyotypic changes [5]. This feature was also observed in the reported patient. Because tetraploidy may be normally present in all tissues with a frequency of 0.5–20% [7], tetraploidy in a tumor population of cells as in this case could be overlooked as well as the changes in this clone.
In conclusion, our case report represents an interesting description of cytogenetic and clinical findings in an AML-MRC patient with rare tetraploidy with 5q deletion and a complex karyotype. Tetraploidy is rare but could be an important step in the pathogenesis of AML-MRC and together with additional cytogenetic changes could be considered a prognostic marker of poor outcome. Conflict of interest The authors declare no conflict of interest. Acknowledgements This work was supported by grants from the Czech Ministry of Education, Youth and Sports (MSM 6198959205) and Palacky University student project LF-2011-006.
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Letter to the Editor / Leukemia Research 36 (2012) e68–e70
Contributions. MJ and KI wrote the paper and suggested experiments; RN, MH, and PM performed cytogenetic and molecular cytogenetic analyses; BK performed molecular genetic analyses; JH and TP were responsible for clinical management of patients; ZP performed immunophenotyping. References [1] Vardiman JW, Thiele J, Arber DA, et al. The 2008 revision of the WHO classification of myeloid neoplasms and acute leukemia: rationale and important changes. Blood 2009;114:937–51. [2] Clarke MR, Lynch FE, Contys LC, et al. Near-tetraploidy in adult acute myelogenous leukemia. Cancer Genet Cytogenet 1996;86:107–15. [3] Watanabe A, Inokuchi K, Yamaguxhi H, et al. Near-triploidy and near-tetraploidy in hematological malignancies and mutation of the p53 gene. Clin Lab Haematol 2004;26:25–30. [4] Boveri T. Zur frage der Entstehung maligner. Jena: G.Fischer; 1914. [5] Lengauer C, Kinzler KW, Vogelstein B. Genetic instability in colorectal cancers. Nature 1997;386:623–7. [6] Miesner M, Haferlach C, Bacher U, et al. Multilineage dysplasia (MLD) in acute myeloid leukemia (AML) correlates with MDS-related cytogenetic abnormalities and a prior history of MDS or MDS/MPN but has no independent prognostic relevance: a comparison of 408 cases classified as “AML not otherwise specified” (AML-NOS) or “AML with myelodysplasia-related changes” (AML-MRC). Blood 2010;116:2742–51. [7] Storchova Z, Kuffer Ch. The consequences of tetraploidy and aneuploidy. J Cell Sci 2008;121:3859–66.
Marie Jarosova ∗ Radka Nedomova Jaromir Hubacek Milena Holzerova Pavla Mickova Beata Katrincsakova Zuzana Pikalova Tomas Papajik Karel Indrak Department of Hemato-oncology, Medicine and Dentistry, Palacky University Olomouc, Olomouc, Czech Republic ∗ Corresponding
author at: Department of Hemato-oncology, Medicine and Dentistry, Palacky University Olmouc, I.P. Pavlova 6, 77520 Olomouc, Czech Republic. Tel.: +420 588 443 290; fax: +420 588 442 517. E-mail address: [email protected] (M. Jarosova) 22 October 2011 Available online 28 January 2012
Contents lists available at SciVerse ScienceDirect
Leukemia Research journal homepage: www.elsevier.com/locate/leukres
Letter to the Editor Rare tetraploidy with large 5q deletion in acute myeloid leukemia with myelodysplasia-related changes (AML-MRC) 1. Introduction In 2008, the World Health Organization (WHO) revised its classification of hematopoietic neoplasms and new “acute myeloid leukemia with myelodysplasia-related changes (AML-MRC)” was defined as “AML arising from a previous MDS or MDS/MPN, AML with an MDS-related cytogenetic abnormality, and/or AML-MLD changes, mainly with a complex karyotype” [1]. Myelodysplastic syndrome (MDS)-related chromosomal changes involve mainly aberrations of chromosomes 5, 7, and a complex karyotype. The change from ploidy to tetraploidy (4n) is a rare chromosomal abnormality in AML, and only a few cases have been described in the literature [2,3]. Despite its rarity in AML, tetraploidization can initiate chromosomal instability (CIN) and promote cell transformation [4,5]. Presented here is a case of a 52-year-old male with an initial diagnosis of AML-MRC with tetraploid clones detected in his bone marrow. FISH analysis revealed a large deleted derivative chromosome 5 within a complex karyotype. To the best of our knowledge, such findings in AML-MRC have not yet been reported in the literature. 2. Case report A 52-year-old male, whose original occupation was a coal miner, was examined by a local hematologist after a year of weakness and fatigue. Myelodysplastic syndrome was suspected based on the observation of leucopenia with neutropenia and macrocytic anemia (white blood cells 1.4 × 109 /L, hemoglobin 116 g/L, thrombocytes 211 × 109 /L). The patient was referred to the Department of Hemato-Oncology, University Hospital Olomouc. Laboratory tests performed 10 days later at the department confirmed anemia and leukopenia (white blood cells 1.07 × 109 /L, red blood cells 3.35 × 1012 /L, hemoglobin 114 g/L, thrombocytes 173 × 109 /L). Examination of bone marrow cells showed hypocellular smears with pronounced (57.2%) dysplastic erythropoiesis (polynucleated cells, nuclear budding, internuclear bridges, cytoplasmic vacuolization and megaloblastic changes), marked reduction of normal granulopoiesis and a total of 22% of myeloblasts. Immunophenotypic analysis of bone marrow cells also revealed 22% of myeloblasts expressing CD34: 22%, CD33: 50%, CD13: 47%, CD15: 23%, CD65: 50%, and HLA-DR: 28%. Intracellular markers were also analyzed (MPO: 12%, TdT: 33%, Ki-67: 0.3%, CD79a: 7%, cyCD22: 0.60%, cyCD3: 22%). A diagnosis of AML-MRC was assigned. Chromosomal analysis on bone marrow cells using Gbanding revealed three clones: 92,XXYY [2]/92,XXYY,?del(5q31) [3]/46,XY[12] (Fig. 1a). FISH with a commercially available probe (LSI ERG1/D5S23, D5S721 Dual Color Probe, Abbott Molecular, Des Plains, IL, USA) was performed according to the manufacturer’s 0145-2126/$ – see front matter © 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.leukres.2011.12.014
instructions. Two green and two red signals (2G2R), indicative of normal diploid cells, were observed in the majority of cells (64.5%). Four green and four red signals (4G4R), indicative of tetraploidy, were observed in 7.8% of cells. A total of 27.7% of cells (86 out of 310 interphase cells) had 4G3R signals confirming 5q deletion in tetraploid metaphases (Fig. 1b). For precise mapping of the deleted region, FISH with LSI CSF1R and TelVysion 5q and mBAND FISH for chromosome 5 (MetaSystems, Altlussheim, Germany) (Fig. 1c) followed by whole chromosome paint probes (WCP) for chromosomes 1, 2, 3, 5, 13 and 14, was performed. The deleted chromosome 5 was shown to be a derivative chromosome 5 as the result of translocation der(5)t(5;14)(q23.1;q?). Additional chromosomal changes were also revealed: der(2)t(1;2)(q?;?) and der(3)t(3;13)(?;q?) (Fig. 1 d,e). BAC probes (BlueGnome, Cambridge, UK and Chambon Inc Laboratory, Prague, Czech Republic) were used for precise mapping of the deleted 5q region. The deletion was determined as 5q23.1qter with breakpoint mapped to band 5q23.1 between clones RP11-1160A17 and CTD-2334D19 comprising a total of ∼60.8 Mb in length. Furthermore, analysis of molecular markers including the JAK2V617F , MPLW515 , MPLS505 , NPM1 exon 12, FLT3 internal tandem duplication (ITD) and FLT3D835 mutations were performed on genomic DNA or RNA (NPM1 mutation only) extracted from diagnostic peripheral blood cells. No mutation was detected in any of the genes analyzed. The patient was started on induction therapy “3 + 7” (AraC 100 mg/m 7 days; KIN + Mitoxantrone 7 mg/m 3 days, OD) followed by Novia (consolidation: 3x Novia AraC 0.5 g/m BID 4 days, +Mitoxantrone 7 mg/m 3 days, OD) and achieved hematological remission by day 59, which was maintained for 13 months after diagnosis. Hematological remission was not followed by cytogenetic remission, as we confirmed the presence of 10% of cells with a 5q deletion by interphase FISH 9 months after chemotherapy. At the time of this report, the patient received maintenance chemotherapy and hematological remission persisted in his bone marrow for 14 months from diagnosis.
3. Discussion We report a case of a patient with primary AML-MRC and a complex karyotype in a tetraploid clone involving a large 5q deletion. The 5q deletion in AML is most often found as part of a complex karyotype. The precise role of this aberration within a complex karyotype and the underlying basis of the heterogeneity of the deleted region in AML remain to be characterized [2]. Notably, in AML-MRC, 5q deletion is usually associated with a complex karyotype and poorer outcomes following treatment [2,3]. A prognostic analysis of a large cohort of patients with AML-MRC was published recently [6]. This analysis of 55 cases with AML-MRC confirmed that the presence of MDS-related cytogenetic changes is associated with shorter median EFS and OS. Multilineage dysplasia alone showed
Letter to the Editor / Leukemia Research 36 (2012) e68–e70
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Fig. 1. Cytogenetic and FISH findings. (A) G-banded karyotype: 92,XXYY,?del(5q).(B) FISH with LSI ERG1/D5S23, D5S721 Dual Color Probe (Abbott Molecular) with a 3R4G signal pattern on metaphase chromosomes. (C) mBAND FISH of chromosome 5 (MetaSystems) confirming deletion 5q23.1. (D) WCP 5 (orange) and WCP14 (green) confirmed der(5)t(5;14) in the tetraploid metaphase. (E)WCP 5 (orange) and WCP 2 (green) showed the presence of derivative chromosomes.
no independent clinical effect, whereas cytogenetics and MDS history were prognostically relevant. Our patient had no history of MDS. In our case, a tetraploid clone without 5q deletion was found, confirming that 5q- could be a later event in the pathogenesis of AML-MRC. The deletion was mapped precisely and involved loss of the 5q telomere. We believe that instability of the deleted chromosome 5 due to telomere loss caused an unbalanced translocation. Potential relationship between aneuploidy and tumor development has been confirmed in numerous current studies because tetraploid cells are frequently found in early stages of tumor development [7]. In many tumors, changes in ploidy are associated with the presence of chromosomal gains and losses, with so-called chromosomal instability (CIN) resulting in karyotypic changes [5]. This feature was also observed in the reported patient. Because tetraploidy may be normally present in all tissues with a frequency of 0.5–20% [7], tetraploidy in a tumor population of cells as in this case could be overlooked as well as the changes in this clone.
In conclusion, our case report represents an interesting description of cytogenetic and clinical findings in an AML-MRC patient with rare tetraploidy with 5q deletion and a complex karyotype. Tetraploidy is rare but could be an important step in the pathogenesis of AML-MRC and together with additional cytogenetic changes could be considered a prognostic marker of poor outcome. Conflict of interest The authors declare no conflict of interest. Acknowledgements This work was supported by grants from the Czech Ministry of Education, Youth and Sports (MSM 6198959205) and Palacky University student project LF-2011-006.
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Letter to the Editor / Leukemia Research 36 (2012) e68–e70
Contributions. MJ and KI wrote the paper and suggested experiments; RN, MH, and PM performed cytogenetic and molecular cytogenetic analyses; BK performed molecular genetic analyses; JH and TP were responsible for clinical management of patients; ZP performed immunophenotyping. References [1] Vardiman JW, Thiele J, Arber DA, et al. The 2008 revision of the WHO classification of myeloid neoplasms and acute leukemia: rationale and important changes. Blood 2009;114:937–51. [2] Clarke MR, Lynch FE, Contys LC, et al. Near-tetraploidy in adult acute myelogenous leukemia. Cancer Genet Cytogenet 1996;86:107–15. [3] Watanabe A, Inokuchi K, Yamaguxhi H, et al. Near-triploidy and near-tetraploidy in hematological malignancies and mutation of the p53 gene. Clin Lab Haematol 2004;26:25–30. [4] Boveri T. Zur frage der Entstehung maligner. Jena: G.Fischer; 1914. [5] Lengauer C, Kinzler KW, Vogelstein B. Genetic instability in colorectal cancers. Nature 1997;386:623–7. [6] Miesner M, Haferlach C, Bacher U, et al. Multilineage dysplasia (MLD) in acute myeloid leukemia (AML) correlates with MDS-related cytogenetic abnormalities and a prior history of MDS or MDS/MPN but has no independent prognostic relevance: a comparison of 408 cases classified as “AML not otherwise specified” (AML-NOS) or “AML with myelodysplasia-related changes” (AML-MRC). Blood 2010;116:2742–51. [7] Storchova Z, Kuffer Ch. The consequences of tetraploidy and aneuploidy. J Cell Sci 2008;121:3859–66.
Marie Jarosova ∗ Radka Nedomova Jaromir Hubacek Milena Holzerova Pavla Mickova Beata Katrincsakova Zuzana Pikalova Tomas Papajik Karel Indrak Department of Hemato-oncology, Medicine and Dentistry, Palacky University Olomouc, Olomouc, Czech Republic ∗ Corresponding
author at: Department of Hemato-oncology, Medicine and Dentistry, Palacky University Olmouc, I.P. Pavlova 6, 77520 Olomouc, Czech Republic. Tel.: +420 588 443 290; fax: +420 588 442 517. E-mail address: [email protected] (M. Jarosova) 22 October 2011 Available online 28 January 2012