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t(8;21) prior to acute leukemia
t(8;21) Prior to Acute Leukemia Roland Berger, Josette Hillion, Daniel Janvier, Zhu Chen, and Annette Bussel
ABSTRACT: A t(8;21)(q22;q22) without blood and bone marrow invasion by immature myeloid precursor cells occurred in a patient previously treated for polycythemia vera. The presence of a molecular rearrangement confirmed that the chromosomal abnormality was identical to that observed in acute leukemia with t(8;21). This case shows that the translocation, t(8;21), may occur in myelodysplasia and suggests that it can precede the appearance of overt leukemia.
The translocation t(8;21)(q22 ;q22) is usually associated with a particular subtype of acute myeloblastic leukemia (AML) classified as M2 in the FAB nomenclature ([1] for review). The breakpoints on chromosomes 8 and 21 have been recently cloned and it is now possible to recognize the chromosome abnormality using molecular techniques. We report a new case of t(8;21) without the usual clinical and hematologic characteristics associated with this chromosomal abnormality.
Case Report M. B., CGl109, a 51-year-old woman of Algerian origin was followed for obesity, diabetes, and hypertension. In April 1979, her spleen was found to be enlarged and hematologic data showed: hemoglobin 148 g/L, hematocrit 45%, leukocytes 22.1 x 109/L with 81% polymorphonuclear cells, and 650 × 109/L platelets in the peripheral blood. Bone marrow was hypercellular with 82 % granulocytic cells without excess of precursor cells; myelofibrosis was present on trephine biopsy examination. The diagnosis was agnogenic myeloid metaplasia and the patient was treated with hydroxyurea (15-20 mg/kg). One year later, the hematocrit was 60%, hemoglobin 207 g/L, leukocytes 19 × 109/L with 84% granulocytes, 13% lymphocytes, and 3% monocytes, and 340 × 109/L platelets. The diagnosis of polycythemia vera (PV) became obvious. The same treatment was given over the following years, but in January 1990, a phlebitis occurred at the same time that the number of erythrocytes and granulocytes increased. Phlebotomies were insufficient and the patient received 32p (8 mCi) twice in February and September 1990. In May 1991, the leukocyte count was 45 × 109/L with 90% From INSERM U 301 and CNRS SDI No. 15954 I (R. B., J. H.), IGM, Paris; Secteur d~I~mobiologie-Transfusion Paris-Est (13.J.), H6pital Lariboisi~re, Paris; Laboratory of Molecular Biology (7,. C.), Shanghai Second Medical University, Shanghai, China; and Centre d' H~mobiologie et Transfusion (A. B.), H6pital Saint Louis, Paris France. Address reprint requests to: Dr. Roland Berger, U301, IGM, 27 rue Juliette Dodu, 75010, Paris, France. Received February 19, 1993; accepted May 26, 1993.
polymorphonuclear neutrophils, hemoglobin 130 g/L and platelets 329 x 109/L. In September 1991, the liver and the spleen were found enlarged, and parasthesia of the trigeminal nerve appeared. In the peripheral blood, the leukocyte count was 120 × 109/L with 84% neutrophils, 3% myeloblasts, 5% basophilic cells, hemoglobin 96 g/L, and 100 × 109/L platelets. Bone marrow was hypercellular, with 2% blast cells, 51% granulocytic cells without excess of granulocyte precursors, 4% monocytes, 41% erythroblastic cells, 2 % lymphocytes, and decrease of megakaryocytic cell number. Blood typing revealed a loss of A antigen in this untransfused patient, previously known as group A. A mixed-field pattern of agglutination was observed with anti-A reagents; 20% of the red cells were apparently O. Exposure to a cryptic antigen was ruled out by testing the red cells with a panel of appropriate lectins. The red cells were also found to give a positive acid hemolysis test, suggesting a loss of phosphatidylinositol-linked membrane proteins, which protect the cells against complement lysis. Spinal fluid contained 36/mL cells (polymorphonuclear and myeloblasts). Nuclear magnetic resonance (NMR) studies showed the presence of sub- and supra-tentorial diffuse lesions and right parietal and left temporo-parietal subdural hematomas. Chemotherapy (cytosine arabinoside and 6-mercaptopurine) was started, together with intrathecal injections of methotrexate and cytosine arabinoside. Blast cells appeared in the peripheral blood on the first days of December (8% on the 6th of December, and then 24% on the 12th). A cerebral hemorrhage occurred and the patient died on December 15, 1991.
Cytogenetics The first bone marrow study, performed in March 1979 with a direct method, showed a normal female karyotype (14 cells). The second cytogenetic study was performed on bone marrow (24-hr in vitro culture) in October 1991. The karyotype was as follows: 46,XX [11]/46,XX,t(8;21)(q22;q22) [9]/48,XX,t(8;21), + 18, 125
© 1993 Elsevier Science P u b l i s h i n g Co., Inc. 655 A v e n u e of the Americas, N e w York, NY 10010
Cancer Genet Cytogenet 70:125-126 (1993) 0165-4608/93/$06.00
126
R. Berger et al.
+ der(21)t(a;21)(q22;q22)[13]/48,XX,del(7)(q22),t(8;21), + 18, + der(21) [2].
Molecular Studies High m o l e c u l a r weight DNA was p r e p a r e d from peripheral blood cells in October 1991, and Southern blot studies performed. The probes used were genomic fragments isolated from a DNA library by using polymerase chain reaction (PCR). The products of reverse transcriptase/polymerase chain reaction (RT/PCR) were obtained with primers deduced from the AML-1 gene cDNA [2]. These probes detect the breakpoint in 24/29 AML patients with t(8;21) studied in our laboratory (in preparation). A s u p e r n u m e r a r y fragment was present in the DNA of the patient digested by BamHI and EcoRV (Fig. 1).
We thank Mrs J. Derr~, M. Le Coniat, and M. A. Flexor for their expert technical assistance.
DISCUSSION A t(8;21)(q22;q22) and a m o l e c u l a r rearrangement similar to the translocation associated with a subset of AML, M2 were found in a patient previously treated for PV. There was no signs of bone marrow invasion by leukemic cells at that time, and the small percentage of blast cells (3%) present in peripheral blood cells a c c o m p a n y i n g hyperleukocytosis w i t h 84% mature n e u t r o p h i l i c granulocytes d i d not allow the diagnosis of leukemia. The p r e s e n c e of macroplatelets and of a double ABO p o p u l a t i o n in p e r i p h e r a l b l o o d suggested a s e c o n d a r y myelodysplasia, as seen in the outcome of some patients with PV, rather t h a n an evolution of the myeloproliferative disorder. Translocation (8;21) is u s u a l l y associated w i t h AML-M2, but has also b e e n reported in other types of AML such as M1, M4, or eosinophflic leukemia. It has occasionally been observed associated w i t h the Ph c h r o m o s o m e [3, 4] or w i t h the Ph negative chronic myeloid leukemia p h e n o t y p e [5, 6]. The same translocation has also been found in rare patients Figur~ 1 DNA digests of patient (B) and control (C) hybridized with the probe specific to AML-1. Rearrangements are detected in BamHI and EcoRV digests (arrow) but not in BglII digest.
C
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with myelodysplastic syndromes [7, 8] and in "secondary" leukemia, after treatment for osteosarcoma [9] and for Hodgkin's disease [10], P h i l a d e l p h i a positive acute l y m p h o b l a s tic leukemia [11], a n d after essential thrombocythemia [12]. The case reported by Sadamori et al. [13] concerns a patient with a normal karyotype referred because of a slight leukocytosis w i t h o u t any signs of leukemia who, 15 months later, developed a t(8;21) AML-M2. It thus appears that t(8;21) may be present in some patients with myelodysplasia without any overt leukemia. Furthermore, the case reported here suggests that t(8;21) may occur prior to the invasion of the bone marrow by myeloblasts, favoring the causal role of the chromosomal rearrangement in the development of the AML, M2 subset with this translocation.
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REFERENCES 1. Sandberg AA (1990): The Chromosomes in Human Cancer and Leukemia. 2nd Ed. Elsevier, New York. 2. Miyoshi H, Shimizhu K, Kozu T, Maseki N, Kaneko Y, Ohki M (1991): t(8;21) breakpoims on chromosome 21 in acute myeloid leukemia are clustered within a limited region of a single gene, AML1. Proc Natl Acad Sci USA 88:10431-10434. 3. Francesconi D, Pasquali F (1978): 8/21 translocation, loss of the Y chromosome and Philadelphia chromosome. Br J Haematol 38:149-150. 4. Ferro MT, Steegman JL, Escribano L, Heiurichs B, Parada L, Garcia-Sagredo JM, Resino M, Cabello P, San Roman C (1992): Ph-positive chronic myeloid leukemia with t(8;21 )(q22 ;q22) in blastic crisis. Cancer Genet Cytogenet 58:96-99. 5. Raskind WH, Papayannopoulou T, Hammond WP (1988):' T(8;21) with a phenotype of chronic myeloid leukemia. Am J Hematol 28:266-269. 6. Cheng G, Ha SY, Liu HW, Kwong YL, Li CK, Chan LC (1992): A patient with marked leucocytosis, t(8; 2 I), absent Philadelphia chromosome, but rearranged BCR gene. Br J Haematol 82:171-172. 7. Czepulkowski B, Gibbons B, Tucker J, Amess J, Lister A (1987): Duplication of one of the products of the t(8;21) translocation in a patient with refractory anemia with excess blasts in transformation. Cancer Genet Cytogenet 25:175-177. 8. Estey E, Trujillo JM, Cork A, O'Brien S, Beran M, Kantarjian H, Keating M, Freireich EJ, Stass S (1992): AML-associated cytogenetic abnormalities (inv(16), del(16),t(8;21)) in patients with myelodysplastic syndromes. Hematol Pathol 6:43-48. 9. Davies SV, Murray JA, Bowser-Riley SM (1988): Secondary leukemia with a translocation (8; 21 )? Cancer Genet Cyto genet 31:271-274. 10. Dallorso S, Sessagero M, Garr6 ML, Haupt R, Pasino M, Sansone R (1990): Secondary acute promyelocytic leukemia with t(8;21) and t(9;22) at onset and loss of the Philadelphia chromosome at relapse. Cancer Genet Cytogenet 47:41-46. 11. De Cuia MR, Alimena G, Gastaldi R, Aloe Spiritti MA, Giona F, Mancini M, Mandelli F (1989): Acute myeloblastic leukemia with t(8;21) following Philadelphia positive acute lymphoblastic leukemia. Leukemia 3:310-313. 12. Knottenbelt E, Hallett J, Jacobs P (1989): 8;21 translocation in myelodysplasia secondary to essential thrombocythemia. Am J Hematol 30:233-235. 13. Sadamori N, Amagasaki T, Nakamura H, Sasagawa I, Itoyama T, Tokunaga S, Ichimaru M (1990): Appearance time of leukemic cells with t(8;21) in bone marrow. Cancer Genet Cytogenet 50:149-152.
ABSTRACT: A t(8;21)(q22;q22) without blood and bone marrow invasion by immature myeloid precursor cells occurred in a patient previously treated for polycythemia vera. The presence of a molecular rearrangement confirmed that the chromosomal abnormality was identical to that observed in acute leukemia with t(8;21). This case shows that the translocation, t(8;21), may occur in myelodysplasia and suggests that it can precede the appearance of overt leukemia.
The translocation t(8;21)(q22 ;q22) is usually associated with a particular subtype of acute myeloblastic leukemia (AML) classified as M2 in the FAB nomenclature ([1] for review). The breakpoints on chromosomes 8 and 21 have been recently cloned and it is now possible to recognize the chromosome abnormality using molecular techniques. We report a new case of t(8;21) without the usual clinical and hematologic characteristics associated with this chromosomal abnormality.
Case Report M. B., CGl109, a 51-year-old woman of Algerian origin was followed for obesity, diabetes, and hypertension. In April 1979, her spleen was found to be enlarged and hematologic data showed: hemoglobin 148 g/L, hematocrit 45%, leukocytes 22.1 x 109/L with 81% polymorphonuclear cells, and 650 × 109/L platelets in the peripheral blood. Bone marrow was hypercellular with 82 % granulocytic cells without excess of precursor cells; myelofibrosis was present on trephine biopsy examination. The diagnosis was agnogenic myeloid metaplasia and the patient was treated with hydroxyurea (15-20 mg/kg). One year later, the hematocrit was 60%, hemoglobin 207 g/L, leukocytes 19 × 109/L with 84% granulocytes, 13% lymphocytes, and 3% monocytes, and 340 × 109/L platelets. The diagnosis of polycythemia vera (PV) became obvious. The same treatment was given over the following years, but in January 1990, a phlebitis occurred at the same time that the number of erythrocytes and granulocytes increased. Phlebotomies were insufficient and the patient received 32p (8 mCi) twice in February and September 1990. In May 1991, the leukocyte count was 45 × 109/L with 90% From INSERM U 301 and CNRS SDI No. 15954 I (R. B., J. H.), IGM, Paris; Secteur d~I~mobiologie-Transfusion Paris-Est (13.J.), H6pital Lariboisi~re, Paris; Laboratory of Molecular Biology (7,. C.), Shanghai Second Medical University, Shanghai, China; and Centre d' H~mobiologie et Transfusion (A. B.), H6pital Saint Louis, Paris France. Address reprint requests to: Dr. Roland Berger, U301, IGM, 27 rue Juliette Dodu, 75010, Paris, France. Received February 19, 1993; accepted May 26, 1993.
polymorphonuclear neutrophils, hemoglobin 130 g/L and platelets 329 x 109/L. In September 1991, the liver and the spleen were found enlarged, and parasthesia of the trigeminal nerve appeared. In the peripheral blood, the leukocyte count was 120 × 109/L with 84% neutrophils, 3% myeloblasts, 5% basophilic cells, hemoglobin 96 g/L, and 100 × 109/L platelets. Bone marrow was hypercellular, with 2% blast cells, 51% granulocytic cells without excess of granulocyte precursors, 4% monocytes, 41% erythroblastic cells, 2 % lymphocytes, and decrease of megakaryocytic cell number. Blood typing revealed a loss of A antigen in this untransfused patient, previously known as group A. A mixed-field pattern of agglutination was observed with anti-A reagents; 20% of the red cells were apparently O. Exposure to a cryptic antigen was ruled out by testing the red cells with a panel of appropriate lectins. The red cells were also found to give a positive acid hemolysis test, suggesting a loss of phosphatidylinositol-linked membrane proteins, which protect the cells against complement lysis. Spinal fluid contained 36/mL cells (polymorphonuclear and myeloblasts). Nuclear magnetic resonance (NMR) studies showed the presence of sub- and supra-tentorial diffuse lesions and right parietal and left temporo-parietal subdural hematomas. Chemotherapy (cytosine arabinoside and 6-mercaptopurine) was started, together with intrathecal injections of methotrexate and cytosine arabinoside. Blast cells appeared in the peripheral blood on the first days of December (8% on the 6th of December, and then 24% on the 12th). A cerebral hemorrhage occurred and the patient died on December 15, 1991.
Cytogenetics The first bone marrow study, performed in March 1979 with a direct method, showed a normal female karyotype (14 cells). The second cytogenetic study was performed on bone marrow (24-hr in vitro culture) in October 1991. The karyotype was as follows: 46,XX [11]/46,XX,t(8;21)(q22;q22) [9]/48,XX,t(8;21), + 18, 125
© 1993 Elsevier Science P u b l i s h i n g Co., Inc. 655 A v e n u e of the Americas, N e w York, NY 10010
Cancer Genet Cytogenet 70:125-126 (1993) 0165-4608/93/$06.00
126
R. Berger et al.
+ der(21)t(a;21)(q22;q22)[13]/48,XX,del(7)(q22),t(8;21), + 18, + der(21) [2].
Molecular Studies High m o l e c u l a r weight DNA was p r e p a r e d from peripheral blood cells in October 1991, and Southern blot studies performed. The probes used were genomic fragments isolated from a DNA library by using polymerase chain reaction (PCR). The products of reverse transcriptase/polymerase chain reaction (RT/PCR) were obtained with primers deduced from the AML-1 gene cDNA [2]. These probes detect the breakpoint in 24/29 AML patients with t(8;21) studied in our laboratory (in preparation). A s u p e r n u m e r a r y fragment was present in the DNA of the patient digested by BamHI and EcoRV (Fig. 1).
We thank Mrs J. Derr~, M. Le Coniat, and M. A. Flexor for their expert technical assistance.
DISCUSSION A t(8;21)(q22;q22) and a m o l e c u l a r rearrangement similar to the translocation associated with a subset of AML, M2 were found in a patient previously treated for PV. There was no signs of bone marrow invasion by leukemic cells at that time, and the small percentage of blast cells (3%) present in peripheral blood cells a c c o m p a n y i n g hyperleukocytosis w i t h 84% mature n e u t r o p h i l i c granulocytes d i d not allow the diagnosis of leukemia. The p r e s e n c e of macroplatelets and of a double ABO p o p u l a t i o n in p e r i p h e r a l b l o o d suggested a s e c o n d a r y myelodysplasia, as seen in the outcome of some patients with PV, rather t h a n an evolution of the myeloproliferative disorder. Translocation (8;21) is u s u a l l y associated w i t h AML-M2, but has also b e e n reported in other types of AML such as M1, M4, or eosinophflic leukemia. It has occasionally been observed associated w i t h the Ph c h r o m o s o m e [3, 4] or w i t h the Ph negative chronic myeloid leukemia p h e n o t y p e [5, 6]. The same translocation has also been found in rare patients Figur~ 1 DNA digests of patient (B) and control (C) hybridized with the probe specific to AML-1. Rearrangements are detected in BamHI and EcoRV digests (arrow) but not in BglII digest.
C
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B
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with myelodysplastic syndromes [7, 8] and in "secondary" leukemia, after treatment for osteosarcoma [9] and for Hodgkin's disease [10], P h i l a d e l p h i a positive acute l y m p h o b l a s tic leukemia [11], a n d after essential thrombocythemia [12]. The case reported by Sadamori et al. [13] concerns a patient with a normal karyotype referred because of a slight leukocytosis w i t h o u t any signs of leukemia who, 15 months later, developed a t(8;21) AML-M2. It thus appears that t(8;21) may be present in some patients with myelodysplasia without any overt leukemia. Furthermore, the case reported here suggests that t(8;21) may occur prior to the invasion of the bone marrow by myeloblasts, favoring the causal role of the chromosomal rearrangement in the development of the AML, M2 subset with this translocation.
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REFERENCES 1. Sandberg AA (1990): The Chromosomes in Human Cancer and Leukemia. 2nd Ed. Elsevier, New York. 2. Miyoshi H, Shimizhu K, Kozu T, Maseki N, Kaneko Y, Ohki M (1991): t(8;21) breakpoims on chromosome 21 in acute myeloid leukemia are clustered within a limited region of a single gene, AML1. Proc Natl Acad Sci USA 88:10431-10434. 3. Francesconi D, Pasquali F (1978): 8/21 translocation, loss of the Y chromosome and Philadelphia chromosome. Br J Haematol 38:149-150. 4. Ferro MT, Steegman JL, Escribano L, Heiurichs B, Parada L, Garcia-Sagredo JM, Resino M, Cabello P, San Roman C (1992): Ph-positive chronic myeloid leukemia with t(8;21 )(q22 ;q22) in blastic crisis. Cancer Genet Cytogenet 58:96-99. 5. Raskind WH, Papayannopoulou T, Hammond WP (1988):' T(8;21) with a phenotype of chronic myeloid leukemia. Am J Hematol 28:266-269. 6. Cheng G, Ha SY, Liu HW, Kwong YL, Li CK, Chan LC (1992): A patient with marked leucocytosis, t(8; 2 I), absent Philadelphia chromosome, but rearranged BCR gene. Br J Haematol 82:171-172. 7. Czepulkowski B, Gibbons B, Tucker J, Amess J, Lister A (1987): Duplication of one of the products of the t(8;21) translocation in a patient with refractory anemia with excess blasts in transformation. Cancer Genet Cytogenet 25:175-177. 8. Estey E, Trujillo JM, Cork A, O'Brien S, Beran M, Kantarjian H, Keating M, Freireich EJ, Stass S (1992): AML-associated cytogenetic abnormalities (inv(16), del(16),t(8;21)) in patients with myelodysplastic syndromes. Hematol Pathol 6:43-48. 9. Davies SV, Murray JA, Bowser-Riley SM (1988): Secondary leukemia with a translocation (8; 21 )? Cancer Genet Cyto genet 31:271-274. 10. Dallorso S, Sessagero M, Garr6 ML, Haupt R, Pasino M, Sansone R (1990): Secondary acute promyelocytic leukemia with t(8;21) and t(9;22) at onset and loss of the Philadelphia chromosome at relapse. Cancer Genet Cytogenet 47:41-46. 11. De Cuia MR, Alimena G, Gastaldi R, Aloe Spiritti MA, Giona F, Mancini M, Mandelli F (1989): Acute myeloblastic leukemia with t(8;21) following Philadelphia positive acute lymphoblastic leukemia. Leukemia 3:310-313. 12. Knottenbelt E, Hallett J, Jacobs P (1989): 8;21 translocation in myelodysplasia secondary to essential thrombocythemia. Am J Hematol 30:233-235. 13. Sadamori N, Amagasaki T, Nakamura H, Sasagawa I, Itoyama T, Tokunaga S, Ichimaru M (1990): Appearance time of leukemic cells with t(8;21) in bone marrow. Cancer Genet Cytogenet 50:149-152.