Leukemia Research,Vol. 3, No. 5, pp. 271-275. PergamonPress, Ltd., 1979.Printedin Great Britain.
0145-2126/79/1001-0271 $02.00/0
A CASE OF CHRONIC MYELOGENOUS LEUKEMIA WITH UNUSUAL CHROMOSOMAL ABNORMALITY M. SESSAREGO, S. GRAMMENU,* G. BIANCH1 SCARRA a n d F. AJMAR Cattedra di Ematologia--I.S.M.I., Viale Benedetto XV 6, 16132 Genova, Italy (Received 28 February 1979. Revised 17 April 1979. Accepted 23 April 1979) INTRODUCTION CHROMOSOMAL a b n o r m a l i t i e s in c h r o n i c m y e l o g e n o u s l e u k e m i a ( C M L ) were recently reviewed [6]. A subject of special interest is the k a r y o t y p e changes that take place d u r i n g the e v o l u t i o n of the disease. This case r e p o r t describes a n u n u s u a l c h r o m o s o m a l a b n o r m a l i t y a p p e a r i n g with the blastic phase in a p a t i e n t with typical Ph 1 positive C M L . CASE REPORT L.D.P., a 78 yr old woman, was first admitted to the hospital in June 1977 because of weight loss, weakness, anemia and splenomegaly. Blood examination revealed: hematocrit 46~, hemoglobin 14 g/dl, W.B.C. 34,000/ram a with 20 ~ immature cells. Alkaline phosphatase of neutrophils (NAP) was significantly lowered (score 4, normal values 20-100). Chromosomal analysis from bone marrow indicated the presence of a Ph 1 chromosome. Treatment first with hydroxyurea and later with busulfan resulted in a satisfactory clinical and hematological response. In August 1978 the patient was again admitted with the following blood picture: hematocrit 37 ~o, hemoglobin 10.7 g/dl, platelets 50,000/mm a, W.B.C. 80,000/ram a with only 10~o segmented neutrophils, 5 ~ granuloblast and 85 ~o blast cells. Bone marrow examination indicated a large number of blast cells (about 90~) one third of which were Sudan Black and peroxidase positive. Treatment with vincristine (2 mg i.v. each week) and prednisone (60 mg/m 2 i.v. each day for the first 5 days) did not result in any significant response, and cytosine arabinoside and 6 thioguanine (100 mg/m 2 i.v. and 80 mg/m 2 orally for 5 days) were added, with an initial decrease of W.B.C. to 12,000/ram a, without effect on the number of blast cells (35 ~). The patient died 5 months after the detection of the blastic transformation. Chromosomal analysis Chromosome analysis was performed before treatment on peripheral blood with phytohemagglutinin (PHA) stimulation at 72 h and without PHA at 24 and 48 h, and on bone marrow immediatelyafter collection and after short term culture [7]. At least 100 metaplmses from bone marrow were observed and 60 were photographed and karyotyped. For chromosome identification conventional Giemsa stain, banding technique as described by Seabright [8] and quinacrine mustard technique according to Caspersson et al. [2] were used. In a number of cases both the Giemsa and quinacrine technique were applied to the same preparation. In a few cases the same metaphase was photographed before and after treatment with trypsin (see Fig. 1). RESULTS AND DISCUSSION While the k a r y o t y p e o f the p a t i e n t at the time o f first a d m i s s i o n revealed only a P h x c h r o m o s o m e , further a b n o r m a l i t i e s were observed d u r i n g the blastic crisis. They can be s u m m a r i z e d as follows: in all m e t a p h a s e cells a n a b n o r m a l l y large m a r k e r c h r o m o s o m e , tentatively identified as c h r o m o s o m e 14, was detected in all mitosis examined. This was the most consistent a b n o r m a l i t y f o u n d . A n o t h e r c o n s t a n t a b n o r m a l i t y was revealed o n c h r o m o some 2, which was either deleted o n the long a r m or missing. These two m a i n a b n o r m a l i t i e s i n c h r o m o s o m e s 14 a n d 2 are tentatively interpreted as t(2;14) (q21 ?;q32); in cases where the deleted 2 is lost (cells with 45 c h r o m o s o m e ) then * Dr. S. Grammenu is a visiting fellow from the Department of Pathologic Physiology, University of Athens. 271
272
M. SESSAREGO, S. GRAMMENU,G. BIANCHISCARR~.and F. AJMAR
--2, - 1 4 , +dert(2;14) (q21 ?;q327). The long form would be (14pter~14q32?::2q21 ? ~ 2qter). Further abnormalities were detected in a few mitoses: one consisted of the known t(9,22), which however was detected only in a very limited number of cells. Finally, in some cells chromosome 12 revealed an unusual morphology. Karyotypes from short term cultures of bone marrow gave similar results while the karyotype from PHA-stimulated peripheral blood at 72 h was normal. A number o f abnormalities, from the typical Ph 1 chromosome to the extremely bizarre karyotypes were described in the course of C M L [4]. The significance of such abnormalities in terms of prognosis or in relation to treatment has been analyzed. In some cases the change in the karyotype preceded the blastic crisis by 2-4 months and it is considered of poor prognosis [6]. The median survival from the appearance of the chromosomal abnormalities until death was found to be 2-6 months [1]. I n our case the survival after the discovery of the karyotype change was about 5 months. The relationship between abnormal karyotype and treatment was also evaluated. CaneUos et aL [1] reported better hematologic and cytogenetic remission in six cases treated with combined vincristine-prednisone treatment; these cases were characterized by aneuploidy, especially hypodiploidy, as in our patient. Her survival however did not differ significantly from the mean survival. The most unusual consistent abnormality in our case was on chromosome 14. Few abnormalities involving chromosome 14 were described and the translocation was between 8 and 14 [3]. A similar abnormality on chromosome 13 in a case of myelophybrosis was described by Whang Peng et aL [10]. In any case, chromosomes of groups A and D are seldom involved in karyotype changes during blastic phase of C M L [5]. Finally, in a number of cases of Ph 1 positive C M L no evidence was found of a translocation between chromosome 22 and chromosome 9. In such cases further abnormalities on other chromosomes were present with higher frequency. This may also be the case in our patient, where evidence of the t(9,22) (q34; q l l or 12) was scanty. However, due to the relatively small number of such described cases, the significance of this finding is uncertain [91. Acknowledgment--The authors wish to thank the members of the Division of Hematology who contributed to the care of this patient, and Dr. Janet Rowley for critically reviewing the manuscript. This research was supported by C.N.R. grants riDS. 48•77.01552.65 and 78/02866.96.
REFERENCES I. CANELLOSG. P., DE VrrA V. T., W~IANG-PENGJ., Ct-~BNER B. A., SCHEIN P. S. & YOUNG R. C. (1976) Chemotherapy of the blastic phase of chronic granulocytic leukemia: hypodiploidy and response to the therapy. Blood 47, 1003. 2. CASP~RSSONT., ZECH L., JOHANSSONC. & MODEST E. J. (1970) Identification of human chromosome by D N A binding fluorescing agents. Chromosoma 30, 215. 3. HAYATAI., SAKURAIM., KAKATI S. & DANDBERGA. A. (1975) Chromosomes and causation of human cancer and leukemia. XV. Banding studies of chronic myelocytic leukemia including five unusual Ph ~ translocations. Cancer 36, 1177. 4. LILLEVMANJ. S., POTTER A. M., WATMO~ A. E., COOKE P., SOKOL R. J., WOOD J. K. & Tile TRENT REGION AND ASSOCIATED HOSPrrALS WORKING PARTY ON ADULT LEUKEMIA (1978) Myeloid karyotype and the malignant phase of chronic granulocytic leukaemia. Br. d. Haemat. 39, 317. 5. LYALL J. M. 8¢, GARSON O. i . (1978) Non-random chromosome changes in the blastic transformation stage of pht-positive chronic granulocytic leukaemia. Leukemia Res. 2, 213. 6. ROWLEY J. D. (1978) Chromosome in leukemia and lymphome. In Seminars in Hematology Vol. XV, p. 301. 7. ROWLEY J. D. & POT'rER D. (1976) Chromosomal banding patterns in acute non-lymphocytic leukemia. Blood 47, 705. 8. SEAImlGHTM. (1971) A rapid banding technique for human chromosomes. Lancet ii, 971. 9. SoN'rA S.-I., OSHIMARAM. & SANDBERGA. A. (1976) Chromosomes and causation of human cancer and leukemia. XXI. Cytogenetically unusual cases of leukemia. Blood 48, 697. 10. WHANG PENG J., LEE E., KUNTSENT., CHANG P. & NIENHUISA. (1978) Cytogenetic studies in patients with myelofibrosis and myeloid metaplasia. Leukemia Res. 2, 41.
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0145-2126/79/1001-0271 $02.00/0
A CASE OF CHRONIC MYELOGENOUS LEUKEMIA WITH UNUSUAL CHROMOSOMAL ABNORMALITY M. SESSAREGO, S. GRAMMENU,* G. BIANCH1 SCARRA a n d F. AJMAR Cattedra di Ematologia--I.S.M.I., Viale Benedetto XV 6, 16132 Genova, Italy (Received 28 February 1979. Revised 17 April 1979. Accepted 23 April 1979) INTRODUCTION CHROMOSOMAL a b n o r m a l i t i e s in c h r o n i c m y e l o g e n o u s l e u k e m i a ( C M L ) were recently reviewed [6]. A subject of special interest is the k a r y o t y p e changes that take place d u r i n g the e v o l u t i o n of the disease. This case r e p o r t describes a n u n u s u a l c h r o m o s o m a l a b n o r m a l i t y a p p e a r i n g with the blastic phase in a p a t i e n t with typical Ph 1 positive C M L . CASE REPORT L.D.P., a 78 yr old woman, was first admitted to the hospital in June 1977 because of weight loss, weakness, anemia and splenomegaly. Blood examination revealed: hematocrit 46~, hemoglobin 14 g/dl, W.B.C. 34,000/ram a with 20 ~ immature cells. Alkaline phosphatase of neutrophils (NAP) was significantly lowered (score 4, normal values 20-100). Chromosomal analysis from bone marrow indicated the presence of a Ph 1 chromosome. Treatment first with hydroxyurea and later with busulfan resulted in a satisfactory clinical and hematological response. In August 1978 the patient was again admitted with the following blood picture: hematocrit 37 ~o, hemoglobin 10.7 g/dl, platelets 50,000/mm a, W.B.C. 80,000/ram a with only 10~o segmented neutrophils, 5 ~ granuloblast and 85 ~o blast cells. Bone marrow examination indicated a large number of blast cells (about 90~) one third of which were Sudan Black and peroxidase positive. Treatment with vincristine (2 mg i.v. each week) and prednisone (60 mg/m 2 i.v. each day for the first 5 days) did not result in any significant response, and cytosine arabinoside and 6 thioguanine (100 mg/m 2 i.v. and 80 mg/m 2 orally for 5 days) were added, with an initial decrease of W.B.C. to 12,000/ram a, without effect on the number of blast cells (35 ~). The patient died 5 months after the detection of the blastic transformation. Chromosomal analysis Chromosome analysis was performed before treatment on peripheral blood with phytohemagglutinin (PHA) stimulation at 72 h and without PHA at 24 and 48 h, and on bone marrow immediatelyafter collection and after short term culture [7]. At least 100 metaplmses from bone marrow were observed and 60 were photographed and karyotyped. For chromosome identification conventional Giemsa stain, banding technique as described by Seabright [8] and quinacrine mustard technique according to Caspersson et al. [2] were used. In a number of cases both the Giemsa and quinacrine technique were applied to the same preparation. In a few cases the same metaphase was photographed before and after treatment with trypsin (see Fig. 1). RESULTS AND DISCUSSION While the k a r y o t y p e o f the p a t i e n t at the time o f first a d m i s s i o n revealed only a P h x c h r o m o s o m e , further a b n o r m a l i t i e s were observed d u r i n g the blastic crisis. They can be s u m m a r i z e d as follows: in all m e t a p h a s e cells a n a b n o r m a l l y large m a r k e r c h r o m o s o m e , tentatively identified as c h r o m o s o m e 14, was detected in all mitosis examined. This was the most consistent a b n o r m a l i t y f o u n d . A n o t h e r c o n s t a n t a b n o r m a l i t y was revealed o n c h r o m o some 2, which was either deleted o n the long a r m or missing. These two m a i n a b n o r m a l i t i e s i n c h r o m o s o m e s 14 a n d 2 are tentatively interpreted as t(2;14) (q21 ?;q32); in cases where the deleted 2 is lost (cells with 45 c h r o m o s o m e ) then * Dr. S. Grammenu is a visiting fellow from the Department of Pathologic Physiology, University of Athens. 271
272
M. SESSAREGO, S. GRAMMENU,G. BIANCHISCARR~.and F. AJMAR
--2, - 1 4 , +dert(2;14) (q21 ?;q327). The long form would be (14pter~14q32?::2q21 ? ~ 2qter). Further abnormalities were detected in a few mitoses: one consisted of the known t(9,22), which however was detected only in a very limited number of cells. Finally, in some cells chromosome 12 revealed an unusual morphology. Karyotypes from short term cultures of bone marrow gave similar results while the karyotype from PHA-stimulated peripheral blood at 72 h was normal. A number o f abnormalities, from the typical Ph 1 chromosome to the extremely bizarre karyotypes were described in the course of C M L [4]. The significance of such abnormalities in terms of prognosis or in relation to treatment has been analyzed. In some cases the change in the karyotype preceded the blastic crisis by 2-4 months and it is considered of poor prognosis [6]. The median survival from the appearance of the chromosomal abnormalities until death was found to be 2-6 months [1]. I n our case the survival after the discovery of the karyotype change was about 5 months. The relationship between abnormal karyotype and treatment was also evaluated. CaneUos et aL [1] reported better hematologic and cytogenetic remission in six cases treated with combined vincristine-prednisone treatment; these cases were characterized by aneuploidy, especially hypodiploidy, as in our patient. Her survival however did not differ significantly from the mean survival. The most unusual consistent abnormality in our case was on chromosome 14. Few abnormalities involving chromosome 14 were described and the translocation was between 8 and 14 [3]. A similar abnormality on chromosome 13 in a case of myelophybrosis was described by Whang Peng et aL [10]. In any case, chromosomes of groups A and D are seldom involved in karyotype changes during blastic phase of C M L [5]. Finally, in a number of cases of Ph 1 positive C M L no evidence was found of a translocation between chromosome 22 and chromosome 9. In such cases further abnormalities on other chromosomes were present with higher frequency. This may also be the case in our patient, where evidence of the t(9,22) (q34; q l l or 12) was scanty. However, due to the relatively small number of such described cases, the significance of this finding is uncertain [91. Acknowledgment--The authors wish to thank the members of the Division of Hematology who contributed to the care of this patient, and Dr. Janet Rowley for critically reviewing the manuscript. This research was supported by C.N.R. grants riDS. 48•77.01552.65 and 78/02866.96.
REFERENCES I. CANELLOSG. P., DE VrrA V. T., W~IANG-PENGJ., Ct-~BNER B. A., SCHEIN P. S. & YOUNG R. C. (1976) Chemotherapy of the blastic phase of chronic granulocytic leukemia: hypodiploidy and response to the therapy. Blood 47, 1003. 2. CASP~RSSONT., ZECH L., JOHANSSONC. & MODEST E. J. (1970) Identification of human chromosome by D N A binding fluorescing agents. Chromosoma 30, 215. 3. HAYATAI., SAKURAIM., KAKATI S. & DANDBERGA. A. (1975) Chromosomes and causation of human cancer and leukemia. XV. Banding studies of chronic myelocytic leukemia including five unusual Ph ~ translocations. Cancer 36, 1177. 4. LILLEVMANJ. S., POTTER A. M., WATMO~ A. E., COOKE P., SOKOL R. J., WOOD J. K. & Tile TRENT REGION AND ASSOCIATED HOSPrrALS WORKING PARTY ON ADULT LEUKEMIA (1978) Myeloid karyotype and the malignant phase of chronic granulocytic leukaemia. Br. d. Haemat. 39, 317. 5. LYALL J. M. 8¢, GARSON O. i . (1978) Non-random chromosome changes in the blastic transformation stage of pht-positive chronic granulocytic leukaemia. Leukemia Res. 2, 213. 6. ROWLEY J. D. (1978) Chromosome in leukemia and lymphome. In Seminars in Hematology Vol. XV, p. 301. 7. ROWLEY J. D. & POT'rER D. (1976) Chromosomal banding patterns in acute non-lymphocytic leukemia. Blood 47, 705. 8. SEAImlGHTM. (1971) A rapid banding technique for human chromosomes. Lancet ii, 971. 9. SoN'rA S.-I., OSHIMARAM. & SANDBERGA. A. (1976) Chromosomes and causation of human cancer and leukemia. XXI. Cytogenetically unusual cases of leukemia. Blood 48, 697. 10. WHANG PENG J., LEE E., KUNTSENT., CHANG P. & NIENHUISA. (1978) Cytogenetic studies in patients with myelofibrosis and myeloid metaplasia. Leukemia Res. 2, 41.
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