The importance of cytogenetic studies in adult acute lymphocytic leukemia

The Importance of Cytogenetic Studies in Adult Acute Lymphocytic Leukemia RONALDWALTERS,M.D., HAGOPM. KANTARJIAN,M.D., MICHAELJ. KEATING,M.B., B.S., ELIHUH. ESTEY,M.D., JOSETRUJILLO,M.D., ANN CORK, M.A., KENNETHB. McCREDIE,M.B., Ch.B., EMILJ FREIREICH,M.D., Houston, Texas

PURPOSE: The prognostic importance of pretreatment bone rnerrow cytogenetic studies in adults with acute lymphocytic leukerni~ treated at a single institution, with an identical treatment program, is described. PATIENTSAND METHODS:A total of 105 patients with a documented morphologic diagnosis of acute lymphocytic leukemia were reviewed for the purpose of this analysis. All patients had an extensive workup at presentation, and cytogenetic nnalysis was performed in 103 patients, using the Giemsa banding technique with trypsin pretreatment on 24-hour cultured cells. RESULTS:The specific cytogenetic classification in the 103 patients who had the karyotypic analysis was as follows: diploid 27%; Philadelphia chromosome-positive 13%; hyperdiploid 12%; B-cell karyotype 6%; 6q- and 14q+ abnormalities 4 %; pseudediploid 8 %; hypodiploid 2 %; and insufficient metaphases 28 %. B-cell, 6q- or 14q+, and Philndelphia chromosome-positive karyotypes tended to correlate with other known negative prognostic factors. Patients with diploid, hyperdiploid, pseudodiploid, and hypodiploid karyotypes or with insufficient metaphases could be combined into one group with a favorable prognosis. In this group, the remission rate with induction chemotherapy was 89%, the median complete remi~ion duration was 26 months, and the median survival was 25 months, with a 3-year survival rate of 45 %. Patients with Phil~delphie chromosome-positive, B-cell, and 6 q - or 14q+ abnormRiities collectively had an unfavorable prognosis. Their response rate to induction chemotherapy was 65 %, the median response duration was 7 months, and the medien survival was 8 months, with a 3-year survival rate of less than 10%. From the Departments of Hematology (RW,HGK,MJK,EHE,KB McC,EJF) and Laboratory Medicine (JT,AC), M.D. Anderson Cancer Center, Houston, Texas. Dr. Kantarjian is a Scholar of the Leukemia Society of America. Requests for reprints should be addressed to Hagop M. Kantarjian, M.D., M.D. Anderson Cancer Center, Department of Hematology, Box 61, 1515 HoIcombe Boulevard, Houston, Texas 77030. Manuscript submitted April 16, 1990, and accepted in revised form July 23, 1990.

CONCLUSION:We conclude that the pretreatment bone marrow karyotype is an important part of the evaluation of adults with acute lymphocytic leukemia and provides significant prognostic information.

C

Ytogenetic studies have been instrumental in understanding disease heterogeneity and determining prognosis in various cancers. The association of karyotypic analysis with complete remission, remission duration, and survival has been documented in many entities, including chronic myelogenous [1,2] and lymphocytic leukemia [3,4], lymphoma [5,6], multiple myeloma [7], acute myelogenous leukemia [8-10], and childhood acute lymphocytic leukemia (ALL) [11-15]. Recently, Bloomfield et al [16,17] reported on the collective experience of the International Workshop on Chromosomes in Leukemia pertinent to cytogenetic studies in ALL. In adult ALL, specific karyotypic abnormalities showed strong correlations with complete remission rates and overall prognosis. This analysis included patient populations from different institutions who received variable antileukemic treatment regimens. In the current report, we describe the prognostic importance of cytogenetic studies in a large population of adults with ALL treated with a uniform approach at a single institution.

PATIENTS AND METHODS A total of 105 adult patients with a documented morphologic diagnosis of ALL, referred to the Leukemia Service between December 1983 and February 1987 without prior therapy, were reviewed for the purpose of this analysis. All patients had an extensive workup at presentation including history and physical examination; documentation of measurable disease; complete blood cell, differential, and platelet counts; SMA12 with liver and renal function studies; bone marrow aspiration and biopsy; morphology; and histochemical and enzymatic stains including myeloperoxidase, chloroacetate, nonspecific esterase, periodic-acid Schiff (PAS), and terminal nu-

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The American Journal of Medicine Volume 89

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CYTOGENETIC STUDIES IN ADULT ACUTE LYMPHOCYTIC LEUKEMIA / WALTERS ET AL

TABLE I Patient Characteristics (105 Patients) Characteristic FAB classification L1 L2 L3 Not classified WBC (X 103/,uL) <5,000 5,000-20,000 >20,000 CNS leukemia at diagnosis "Bulky disease"* Immunophenotype classification T cell B cell CALLA-positive Null cell or pre-B cell Not done or inevaluable LDH (U/L) <225 225-450 >450

Number of Patients(%) 16(15) 74 (70) 8 (8) 7 (7) 43 (41) 28 (27) 34 (32) 4 (4) 23 (22) 18 (17) 3 (3) 49 (47) 19 (18) 16 (15) 7 (7) 33 (31) 64 (61)

FAB = French-American-British;WBC = white blood cell count; CNS = central nervous system;CALLA= commonacute lymphocyticleukemiaantigen;LDH = lactate dehydrogenase. * Defined as hepatomegalyor splenomegaly>-5 cm below costal margin or major ad-

enopathy.

cleotidyl transferase (Tdt); immunophenotype, and electron microscopic analysis. Cytogenetic analysis was performed in 103 patients, using the Giemsa banding technique with trypsin pretreatment on 24-hour cultured cells as previously described [18]. Twenty-five metaphases from the bone marrow were analyzed when possible. Karyotypes were identified according to the International System for Human Cytogenetic Nomenclature. A hyperdiploid or structural clonal abnormality required its presence in at least two metaphases, while a hypodiploid clonal abnormality required its presence in at least three metaphases as previously recommended [19]. For a diploid karyotype to be called, more than five metaphases had to be analyzed. If five metaphases or less were analyzed and were diploid, this was considered to be insufficient metaphases for analysis. A diagnosis of ALL required (1) confirmation by morphology, cytochemical, and enzymatic stain analysis (negative myeloid and monocytic stains, Tdt, and PAS block positivity), and (2) the presence of 30% or more blasts in the bone marrow. I m m u n o p h e n o t y p i n g and electron microscopic studies were confirmatory, and utilized in the diagnostic evaluation of difficult cases. The induction and maintenance program (VAD) protocol consisted of the following: (1) Induction: vincristine 0.4 mg by continuous infusion daily for 4 days; Adriamycin 12 mg/m 2 by continuous infusion daily for 4 days; and decadron

580

November 1990 The American Journal of Medicine

40 mg daily for 4 days on Days 1 to 4, 9 to 12, and 17 to 20. A second cycle of the same chemotherapy plus cyclophosphamide 1 g/m 2 intravenously on Day 1 (C-VAD) was started on Day 24 of Cycle 1. (2) Consolidation: methotrexate 60 mg/m 2 intravenously on Day 1 weekly for 4 weeks, the dose being escalated to 90, 120, and 150 mg/m 2 each week if no toxicity developed; and L-asparaginase 20,000 units intravenously on Day 2 weekly for 4 weeks. (3) Early intensification: Adriamycin 60 mg/m 2 intravenously on Day 1; cytosine arabinoside 3 g/m 2 intravenously over 2 hours every 12 hours for six doses; vincristine 2 mg intravenously on Day 1; and prednisone 100 mg daily for 5 days. (4) Maintenance with M-DOMP: three cycles at 4- to 6-week intervals given as follows: methotrexate 200 mg/m 2 intravenously on Day 1; daunorubicin 60 mg/m 2 intravenously on Day 15; 6-mercaptopurine 75 mg/m 2 orally daily for 5 days starting on Day 15; and prednisone 200 mg daily for 5 days starting on Day 15. The dose of methotrexate was escalated to 400, 600, and 800 mg/m 2 in subsequent courses according to tolerance, toxicity, and methotrexate levels at 24 and 48 hours. Hydration and alkalinization with sodium bicarbonate were given with methotrexate. Citrovorum rescue was not given unless the methotrexate levels at 24 and 48 hours were higher than 10 -5 and 10 -6 molar, respectively. An autologous bone marrow pull was performed under general anesthesia after recovery from one of the 3 M-DOMP cycles to be reinfused during late intensification. (5) Late intensification with CBV: cyclophosphamide 1.5 g/m 2 intravenously daily for 4 days; carmustine (1,3-bis-(2-chloroethyl)-l-nitrosourea) 300 mg/m 2 intravenously on Day 1; and etoposide (VP16) 250 mg/m 2 intravenously daily for 3 days. The autologous bone marrow was reinfused on Day 6 or 7. (6) Second maintenance: 3 cycles of M-DOMP: The total cycle of chemotherapy was repeated one more time, but late intensification was replaced by a maintenance cycle of M-DOMP. The total duration of therapy was 24 to 30 months. Remission and Survival A complete remission required the presence of a normocellular marrow with less than 5% blasts in addition to a hemoglobin greater than 11 g/dL, a granulocyte count greater than 1.5 × 103/#L, and a platelet count greater than 100 × 103/#L. Remission duration was calculated from the time of achievement of a complete remission until documented leukemia relapse. Survival was calculated from the time of start of therapy.

Volume 89

CYTOGENETICSTUDIESIN ADULT ACUTE LYMPHOCYTICLEUKEMIA / WALTERS ET AL

Cytogenetic Categories Patients were grouped based on chromosomal findings. Patients were first classified according to the presence or absence of a clonal chromosome abnormality. Patients with chromosomal abnormalities were categorized as having the following: (1) Philadelphia chromosome (Ph) abnormality, usually resulting from a 9;22 translocation; (2) Bcell karyotypes involving translocations between chromosomes 8 and 14, 2, or 22 [t(8;14), t(8;2), or t(8;22)]; (3) abnormal karyotypes involving additions to the long arm of chromosome 14 (14q+); or deletion in the long arm of chromosome 6 (6q-). The remaining chromosomal abnormalities were coded according to the chromosome modal number as: (4) hypodiploid (less than 46 chromosomes); (5) pseudodiploid (46 chromosomes); or (6) hyperdiploid (more than 46 chromosomes). Statistical Considerations Comparison of differences in patient populations were made using the chi-square or Wilcoxon test. Survival and remission duration curves were estimated by the method of Kaplan and Meier [20]. Differences between curves were based on a generalized Wilcoxon for censored observations [21]. RESULTS The characteristics of the population study are detailed in Table I. The patients' median age was 30 years (range: 15 to 75 years), and 64 (61%) were males. The distribution of the cytogenetic karyotypes is detailed in Table II. A high incidence of patients with diploid karyotype (27%) or insufficient metaphases (28%) was observed. Thirteen patients (13%) had Ph-positive ALL, and six patients (6%) exhibited karyotypic abnormalities associated with Bcell disease. Unlike the situation in childhood ALL

TABLE II Cytogenetic Profiles (103 Patients) CytogeneticCategory Diploid(46,XX, or 46,XY) Philadelphiachromosome-positive B-cell karyotype Abnormalitiesinvolving6q- or 14q+ Hyperdiploidkaryotype 47 to 50 chromosomes Morethan 50 chromosomes Pseudodiploidkaryotype Hypodiploidkaryotype Insufficientmetaphases

Number of Patients(%) 28 (27) 13 (13) 6 (6) 4 (4) 12 (12) 8 (8) 4 (4) 8 (8) 2 (2) 30 (28)

where the incidence of hyperdiploid karyotypes with more than 50 chromosomes is frequent, only four of the 103 patients (4%) had such abnormalities. Similarly, the incidence of other common childhood ALL karyotypes was rare among adults. D e l e t i o n of t h e s h o r t a r m of c h r o m o s o m e 9 [del(9q-)] was noted in one patient with hyperdiploid karyotype and, in this study, no abnormalities involving t(1;19) or t(4;ll) were observed. The specific cytogenetic profiles of 45 patients with chromosomal abnormalities are indicated in Table III. The association of specific cytogenetic abnormalities with the patients' characteristics are shown in Table IV. Because of the small numbers, patients with hyperdiploid karyotypes with chromosome numbers 47 to 50 or greater than 50 are included in one group, as well as those with B-cell, 6 q - , or 14q+. Features known to be related to poor prognosis tended to occur more frequently in patients with Ph-positive, B-cell, and 6 q - or 14q+ abnormalities; while they were less common in those with insufficient metaphases, diploid, or hyperdiploid karyotypes. These factors included older age, L3 morp h o l o g y by t h e F r e n c h - A m e r i c a n - B r i t i s h classification, elevated lactic dehydrogenase, low-

TABLE III

CytogeneticProfiles of the 45 Patientswith AneuploidKaryotypes

Patient Number 1 2 3

Category Philadelphiachromosome(n = 13) 13 ceils: 46,XY,t(9;22)(q34,q11) 12 cells: 46,XY 17 cells: 46,XY,t(9;22)(q34,q11) 8 cells:46,XY 21 cells: 46,XX,t(9;22)(q34;q11) 4 cells: 46,XX

Numberof Abnormal Metaphases/ Number of Metaphases Analyzed

Percent Abnormal Metaphases

13/25

52

17/25

68

21/25

84

Continued on next page

November 1990 The American Journal of Medicine Volume 89

581

CYTOGENETIC STUDIES IN ADULT ACUTE LYMPHOCYTIC LEUKEMIA / WALTERS ET AL TABLE ill (Cont'd) Cytogenetic Profiles of the 45 Patients with Aneuploid Karyotypes

Patient Number 4 5 6

7

8

9 10 11 12 13

14 15 16 17 18 19 2O 21 22 23 24 25

Category Insufficient yield (5 cells: Ph+) 9 cells: 46,XX 3 cells: 46,XX,t(9;22)(q34;q11) 14 celts: 49,XY,+6,- 19,-t-22,t(9;22)(q34;q11), t(9;22)(q34;q11),del(12)(p13),+del (22)(q11),+mar 8 cells: 47,XX,-10,-19,+22,t(9,22)(q34;q11) t(9;22)(q34;q 11),del(11)(p13),+del (22)(ql 1),+mar 3 cells: 48,XY,-19,+22,t(9;22)(q34;q11),t (9;22)(q34;q11),del(12)(p13),+del (22)(q11),+mar 7 cells: 46,XX 6 cells: Metaphaseswith 47-49 chromosomes [similar changes: +5,+6,t(9[delp22];22) (q34;q11)] 17 cells: 46,XY,t(9;22)(q34;q11) 6 cells: 45,XY,-13,3q+,t(9[delp22];22) (q34;q11),17q+ 2 cells: 45,XY,-13,t(9[delp22];22)(q34;ql 1) 25 cells: 46,XY,t(9;22)(q34;q11) "Philadelphia-like" 9 cells: 46,XY 3 cells: 47 chromosomes [similar changes:+X, t(9;22)(q34:q11)] 6 ceils: 45-46 chromosomes [similar changes: - 11,-13,+ 19,del(1)(q32),del(22)(q11),+mar] 4 cells: 46,XX 12 cells: 46,XY 5 cells: 45-47 chromosomes [similar changes: -7, 7q+,9q+,del(20)(q 13),del(22)(q11)] 8 cells: 46,XY 1 cell; 46,XY,+X,-22,9q+,del(11)(q23),del(15)(q15) Hyperdiplotd(n = 12) 24 cells: 46,XX 1 cell: 62,XX,+X,+4,+5,+6,+7,+8,+9,+II,+15 •1.1.17,,1.1.19,,1.21,+21 ,,1.2mar, dir dup(1)(q32--,-ter) 22 cells: 55,XY,+X,+4,-l-8,+9,+14,+17?,+21,-l-22,+mar 3 cells: 46,XY 16 cells: 48,XY,+21,+22,del(9)(p13),del(13)(q14) 24 cells: 46,XY i cell: 48,XY,-l-X,-21,+6q-l-,+mar 15 cells: 54,XY,+X,+4,+8,-I-14,-I-17,+18,+21,-I-21 10 cells: 46,XY 18 ceils: 46,XX 7 cells: 47,XX,21p+,+mar 15 cells: 46,XY 10 cells: 49,XY,+8,-1+I0,+14 17 cells: 48,XX,+19,+21 7 cells: 46,XX i cell: 47,XX,+mar 24 cells: 47,t(X;9)(q24),Y,+12 2 cells: Metaphaseswith 49 and 56 chromosomesand similarchanges 13 cells: Metaphaseswith 45-47 chromosomes

[similar changes: 12p+;18p+;+mar] 6 cells: 46,XY 25 cells: Metaphaseswith 50-59 chromosomes [similar changes: -I-X,+6,+18,+21,+mar] 22 cells: 46,XX 3 cells: 48 chromosomes (similar changes:+X, -9,3q+,+mar Continued on nextpage

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November 1990 The American Journal of Medicine Volume 89

Numberof Abnormal Metaphases/ Numberof Metaphases Analyzed

Percent Abnormal Metaphases

5/5

100

3/12

25

25/25

100

6/13

46

25/25 25/25

IO0 IO0

3/12

25

6/10

60

5/17

29

1/9

52

1/25

22•25 16/16

88 100

1/25

4

15/25

60

7/25

28

10/25

40

18/25

72

26•26

100

13/19

68

25/25

I00

3/25

12

CYTOGENETIC STUDIES IN ADULT ACUTE LYMPHOCYTIC LEUKEMIA / WALTERSET AL TABLE III (Cont'd) Cytogenetic Profiles of the 45 Patients with Aneuploid Karyotypes

Patient Number

26

27

28 29 30 31 32

33 34 35

36 37 38 39

40 41 42

43

Category

B cell or lymphoma (n = 10) 22 cells: 47,XX,-6,3q+,4q+,t(8;14)(q24;q32), 9p+,del(9)(p13),del(11)(q13),del(13) (q22), 16q+,+del(18)(q21),+mar 1 cells; 46,XX 7 cells: 46,XX,det(6)(q23),t(8;22)(q24;q11),del (13)(q22) 4 cells; 46,dir dup(1)(q31-,-ter),del(6)(q23), 6q+,t(8;22)(q24;q11) 3 cells: 46,XX,dir dup(1)(q31-*ter),del(6)(q23), t(8;22)(q24;q11),del(13)(q22) 3 cells: 46,XX, dir dup(1)(q31--*ter),del(6)(q23), t(8;22)(q24;11) 2 cells: 46,XX,dir dup(1)(q31-*ter),t(8;22) (q24;q11) 2 cells: 46,XX,t(8;22)(q24;q11) 1 cell: 47,XX+12,dir dup(1)(q31--~ter),del(6) (q23),t(8;22)(q24;q11) 1 cell: 46,XX 24 cells: 46,XY,ins dup(1)(q21;q42),t(8;14)(q24;q32) 1 cell: 46,XY 20 cells: 46,XY,t(8; 14)(q24;q32),del(13)(q14) 5 cells: 46,XY,t(8;14)(q24;q32) 16 cells: 46,XY 3 cells: 46,XY,dir dup(1)(cen-~125),t(8;14)(q24;q32) 24 cells; 46,XX 1 cell: 46,XX,t(8;22)(q24;q11) 22 cells; 48,XY,+16,del(6)(q15)+del(6)(q15) 8p+,t(14:18)(q32;q21) 2 cells: 47,XY,+16,del(6)(q15),gp+,t(14;18)(q32;q21) 1 cell: 49,XY,+Y,+16,del(6)(q15),+del(6)(q15), 8p+,t(14;18)(q32;q21) 14 cells: 46,XY,del(6)(q21),del(10)(q24) 9 cells: 46,XY 2 cells: 46,XY,del(6)(q21) 8 cells: 46,XX 1 cell: 46,XX,?del(6)(q25) 8 cells; 46,XX 7 cells; Pseudodiploidcells [del(6)(q23) with other nonspecificchanges] Pseudodlploid(n = 8) 5 cells: 46,XY 4 celts: 46,XY,del(11)(q32) 27 cells: 46,XY,del(20)(p11) 13 cells: 46,XY 2 cells: 46,XY,20q+ 16 celrs: 46,XY,19q-'F 6 cerls: 46,XY 19 cells: 47,XXY,-20,del(7)(q22),19p+,+mar 3 cells; 46 or 47 chromosomes with changessimilar to above 2 cells; 47,XXY [Klinefelter syndrome] 22 ceils; 46,XY,t(9;18)(q24;q12) 3 cells: 46,XY 25 cells: 46,XY,det(20)(q11) 11 cells: 46,XX,t(10;11)(q15;q21) 6 cells: 46,XX 6 cells: 45,XX,-5,-g,+9,-19,4p+,t(10;11) (p15;q21),del(17)(p11),+mar 6 cells; 43-45 chromosomes with changes similar to above 5 cells: Abnormal polyploid metaphases 22 cells; 46,XX,dir dup(1)(cen~ter) 3 cells: 46,XX

Number of Abnormal Metaphases/ Number of Metaphases Analyzed

Percent Abnormal Metaphases

23/23

96

22/23

96

24/25

96

25/25

100

3/19

16

1/25

4

25/25

100

23/25

92

1/9

11

7/15

47

4/9

44

29/42

69

16/22

73

22/24

92

22/25 25/25

88 100

34/34

100

22/25

88

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CYTOGENETIC STUDIES IN ADULT ACUTE LYMPHOCYTIC LEUKEMIA / WALTERS ET AL

TABLE III (Cont'd) Cytogenetic Profiles of the 45 Patients with Aneuploid Karyotypes

Patient Number 44 45

Category

Number of Abnormal Metaphases/ Number of Metaphases Analyzed

Percent Abnormal Metaphases

4/4

100

12/26

48

Hypodiploid(n = 2) 4 cells: Metaphaseswith 44-46 chromosomes [similar changes:-5,+mar] 14 cells: 46,XX 9 cells: 45,XX,-17,del(2)(q31),t(6;17)(q21;q11), del(10)(q22) 3 cells: Metaphaseswith 45-47 chromosomes and similar changes

TABLE IV Association of Cytogenetic Karyotypes with Other Pretreatment Characteristics

Total (n = 103)

Diploid (n = 28)

Number of Patients in Cyto~eneticGroup (%) Philadelphia Insufficient Chromosome Hyperdiploid Metaphases Positive (n = 12) (n = 30) (n = 13)

Age _>50years 24(23) 3(11) 2(17) 10(33) FABclassification L2 73 (71) 21 (75) 10 (83) 19 (63) L3 8 (8) 1 (4) 0 (0) 0 (0) WBC > 10 X 103/#L 46 (45) 14 (50) 5 (42) 10 (33) LDH >__450U/L 63 (61) 19 (68) 6 (50) 13 (43) Albumin <3.5 g/dL 22 (21) 5 (18) 1 (8) 5 (17) Creatinine >_1,3 mg/dL 15(15) 2(7) 2(17) 4(13) "Bulky disease" 23 (22) 8 (29) 2 (17) 4 (13) CNS leukemia 5 (5) 0 (0) 0 (0) 0 (0) Immunophenotype Tcell 17(17) ~ 0(0) 2(7) Null or pre-B cell 18 (17) 6(21) 2(17) 6 (20) CALLA-positive 50 (49) 11 (39) (L9_(Z~ 9 14 (47) NS= not significant;significantlydifferentvaluesare in boxes.Otherabbreviationsasin TableI.

4(31) ~ ~

6 (46) 10 (77) 4 (31) 3(23) 0 (0) 0 (0)

0(0) 0(0~ 112(92) 1

BCell;6q14q+ (n = 10)

Pseudodiploid or Hypodiploid (n = 10)

p Value

4(40)

1(10)

NS

7 (70) 0 (0) 6 (60) 6 (60) 1 (10) ~ [ ~

<0.01 <0.01 NS 0.07 0.03 NS 0.01 <0.01

~ ~ 2 (20)

<0.01 NS <0.01

~ ~/~ ~ ~ 2(20) ~ { ~ 1(10) 1 (10) 2 (20)

TABLE V Association of Karyotypos with Responses, Remission Duration, and Survival

584

Cytogenetic Category

Number of Patients

Number of Complete Remissions (%)

Diploid Insufficient metaphases Hyperdiploid Hypodiploid;pseudodiploid Total "favorable"

28 30 12 10 80

27 (96) 26 (81) 11 (92) 7 (70) 71 (89)

14 51 27+ 24+ 26

17 27 34 34 25

40 38 39 50 45

Philadelphia B cell;6q-; 14q+ Total "unfavorable"

13 10 23

9 (69) 6 (60) 15 (65)

7 6 7

12 4 8

0 10 6

November 1990 The American Journal of Medicine Volume 89

Median Remission Duration (months)

Median Survival (months)

ThreeYear Survival Rate (%)

CYTOGENETIC STUDIES IN ADULT ACUTE LYMPHOCYTIC LEUKEMIA / WALTERSET AL 100

~

KaevotvDe

Oiploid

90

~. 70

20 13 10 12 10

Philadelphtachromosome posllive " 0 - " Bcell;6q- ; 14q* .-~.. Hy~erdiploid "11" H yOOdl#Old; psegd Odiploi° ""~*" ' Insufficient metaphases --ik- 30

80 i'~ T':~

100 -

Tolal RelapSe

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19 12 9 7 179

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4q+

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18 24 30 36 42 48 Remission Duration (Months)

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Figure 2. Duration by cytogenetic group.

Figure 1. Survival by cytogenetic group.

oo

ered serum albumin, and central nervous system disease at presentation. Association of Cytogenetic Studies with Complete Remission, Remission Duration, and Survival Overall, 88 of the 105 patients (84%) achieved complete remission and 14 (13%) were resistant to induction therapy. The induction-related mortality was low (three patients; 3%). The median follow-up of these patients is 36 months. At the time of analysis, 40 of 105 patients (40%) are alive. The 3-year survival rate is 34%. The median complete remission duration was 22 months, with a 3-year rate of 40%. A strong correlation was observed between complete remission rate and karyotype. Despite the small numbers in each cytogenetic category, complete remission rates ranged from 60% to 70% in patients with "unfavorable" karyotypes such as Phpositive, B-cell, and 6 q - or 14q+ abnormalities, and from 80% to 96% for those with insufficient metaphases, diploid, or hyperdiploid karyotypes (p <0.01). Similar patterns were observed for remission duration and survival (Table V, Figures I and 2). The 3-year survival rates ranged from less than 10% for patients with Ph-positive, B-cell, and 6 q or 14q+ karyotypes, to more than 35% for those with diploid or hyperdiploid karyotypes, or those who had insufficient metaphases (Table V, Figure 3). By separating the 23 patients with Ph-positive, B-cell, or 6 q - and 14q+ abnormalities, patients could be classified as having "favorable" karyotypes with a complete response rate of 89%, a medi-

9o 80

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24 30 36 42 Duration (Months)

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Figure 3. Survival and complete remission duration among favorable and unfavorable risk groups, as defined by k a r y o type.

an remission duration of 26 months, a median survival of 25 months, and a 3-year survival rate of 45%; and those having "unfavorable" karyotypes with a complete response rate of 65%, a median remission duration of only 7 months, a median survival of 8 months, and a 3-year survival rate of less than 10% (Table V). Cytogenetic Studies at Relapse Seventeen relapses have occurred among the 33 patients with karyotypic abnormalities who achieved a complete remission. Nine of these 17

November 1990 The American Journal of Medicine Volume 89

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patients have had subsequent cytogenetic analysis done at relapse. Three of the 9 patients experienced relapse with a different cytogenetic clone than that present at diagnosis. The first patient (Patient 24) analyzed at relapse had 27 metaphases that were normal and one metaphase that showed 53, XX, +X, +6, +11, +18, +21, +21, +21, del(1)(q31), del(1)(q31), t(3;15)(q21;q26), +mar. The second patient (Patient 33) showed at relapse eight normal metaphases and one metaphase with 46, XY, del(6)(q21), 16 p+, 18p+. The third patient (Patient 34) showed at relapse 24 normal metaphases and one metaphase with 46, XX, t(13;17). Thus, one of the three patients had a cytogenetic clonal abnormality different from the one present at diagnosis. The other two had the same clonal abnormalities present at diagnosis with additional chromosomal changes. The phenotype of the three patients at relapse remained lymphoid. The four patients with Ph-positive ALL who were studied at relapse all experienced recurrence with the Ph abnormality.

COMMENTS Karyotypic studies have emerged as major prognostic determinants in several tumors including leukemias, lymphomas, multiple myeloma, and solid tumors [1-15]. This is not surprising, since chromosomal abnormalities reflect grossly observed genetic changes associated with abnormal molecular events. This is exemplified by the molecular studies in Ph-positive ALL, acute myelogenous leukemia associated with abnormalities in chromosomes 5 or 16, Burkitt's lymphoma, and others [22-26]. ALL is recognized as a very heterogeneous disease [27]. While treatment remains the major prognostic determinant in ALL, extreme outcome heterogeneity is observed even with uniform intensive chemotherapy [28-30]. Patients with childhood and adult ALL can be categorized into low- or high-risk categories with long-term survival rates of 60% to 70% and 20% to 30%, respectively. Prognostication is based on age, white blood cell count, performance status, organ dysfunction, parameters of tumor burden such as lactic dehydrogenase levels, and leukemic cell characteristics such as morphology and immunophenotype [28-31]. The leukemia karyotype has emerged as one of the most important factors in both childhood and adult ALL. Cytogenetic studies in childhood ALL have associated a better prognosis with hyperdiploid karyotypes and a worse prognosis with balanced chromosomal translocations [12-15]. More recently, Bloomfield et al [17] improved significantly our understanding of the value of cytogenetic studies in ALL by correlating specific cytogenetic abnormalities with patient outcome in both 586

childhood and adult ALL. Among 172 adults analyzed, the most common cytogenetic patterns included diploid karyotype (31%), hyperdiploid karyotype (13%), the presence of the Ph chromosome (17%), and B-cell-associated abnormalities (13%). Complete remission rates varied from 44% to 87%, and median survivals from 5 to 24 months depending on the specific cytogenetic abnormality. Poorer complete remission rates, complete remission durations, and survivals were seen in patients with B-cell karyotypes, Ph-positive disease, abnormalities involving t(4;ll), 14q+, and hypodiploid karyotypes. The best prognoses were demonstrated in patients with diploid and hyperdiploid karyotypes (chromosome number more than 50) where the complete remission rates were 87% and 78%, respectively, and the median survivals 24 and 21 months, respectively. Despite the large number of patients analyzed, certain cytogenetic categories (hyperdiploid more than 50 chromosomes, hypodiploid, t(4;ll), B-cell karyotype, and 6q-) included 10 patients or less, thus precluding any definite conclusions regarding the prognostic associations with the cytogenetic subset. Our analysis of 105 adults with ALL receiving a uniform protocol, the VAD regimen, treated in one institution, confirms the observation of Bloomfield et al [17]. Patients with "unfavorable" karyotypes included those with Ph-positive, B-cell, and 6 q - or 14q+ abnormalities. Such patients had the poorest prognosis, with complete remission rates of 60% to 70% and 3-year survival rates of less than 10%. On the other hand, those with "favorable" karyotypes or with insufficient metaphases had a favorable prognosis, with complete remission rates of 80% to 95%, and 3-year survival rates of 35% to 50%. As with the study of Bloomfield et al [17], several cytogenetic subcategories [hypodiploid; chromosome 6 abnormalities; t(4;ll); t(ll;14); t(1;19)] had too few patients to draw meaningful conclusions. These studies need to be expanded in order to accumulate enough knowledge concerning each of these entities. Sizable populations will also allow the objective definition of cytogenetic subsets in adult ALL in terms of their biologic, clinical, and laboratory features, as well as prognosis. The high incidence of insufficient metaphases in our study may be related to different methodologies, sample handling, or population referral. The issue is important since this defined category is associated with a favorable prognosis. Insufficient metaphases may reflect the "fragility" of the leukemia cells to survive the procedure, or their exquisite and correlated sensitivity to spindle poisons in vitro (colchicine used in the preparation of metaphases) or in vivo (vincristine used in ALL therapy). The

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incidence of insufficient metaphases is higher than that of some published reports, but similar to more recently published data in adult ALL. Gaynor et al [29] reported that, in the Memorial Sloan Kettering experience, 24 of 111 (22%) patients had no analyzable metaphases. Similar to our experience, this subgroup had a very high complete remission rate of 92%. A similarly high incidence of insufficient metaphases of 20% was reported by Fenaux et al [32] in their analysis of 73 adults with ALL. Therefore, it appears that, unlike childhood ALL, cytogenetic studies in adult ALL demonstrated (1) a high incidence of insufficient metaphases, Ph-positive, and B-cell karyotypes; and (2) a low incidence of hyperdiploid karyotypes with more than 50 chromosomes, t(1;19), and t(4;ll). In summary, the cytogenetic studies have shown major prognostic correlations in adults with ALL and should be part of the initial work-up of every patient. Larger-scale studies will help refine our understanding of the less common categories, and conduct multivariate analysis to define the relative prognostic value of karyotypic results.

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