ABO Blood Groups in Hematologic Malignancies Vijayalakshmi Janardhana, David N. Propert, and Ralph E. Green
ABSTRACT: This article examines the genetic predisposition of individuals to lymphoma and leukemia with regard to the ABO blood groups. Blood samples from 558 patients suffering from various forms of lymphmna and leukemia were collected and typed for ABO blood groups. The ABO blood group phenotype frequencies of lymphoma patients were similar to those in control samples. Among leukemia patients, a significant increase in the frequency of the A 2 phenotype was found in chronic lymphocytic leukemia. Possible mechanisms underlying the predisposition of individuals with the A 2 blood group to chronic lymphocytic leukemia suggested by these preliminary results are discussed. INTRODUCTION The specificities of the ABO blood group system, like most other polymorphic genetic markers, occur with frequencies that are more or less stable w i t h i n populations but differ from one population to another [1]. These variations may be due to random genetic drift and/or natural selection. This leads to the speculation that i n d i v i d u a l s of some ABO phenotype(s) are more susceptible than others to certain diseases. The first positive correlation between ABO blood groups and disease was published by Aird and coworkers [2], who surveyed patients with stomach cancer for ABO blood groups and found an increased frequency of group A. This report triggered an enormous a m o u n t of investigation of the ABO system in a variety of h u m a n diseases. The reports prior to 1977 have been reviewed [3], and this review encompasses a u t o i m m u n e diseases, infectious diseases, and malignancies of different systems. A brief review of ABO blood groups in hematologic malignancies is of particular relevance to this report. A n early investigation [4} of leukemia and reticulosis sufferers from London failed to show any association, but a subsequent study [5] showed an increased frequency of groups B and AB in leukemia patients. The same study also revealed that blacks were less susceptible to leukemias than whites, and Jewish whites were more susceptible than other whites. Analysis of 352 U.S. whites suffering from leukemia for age, sex, and blood groups [6] did not provide any conclusive result. However, certain trends were observed among the patients with regard to the above criteria, i n c l u d i n g an increased frequency of group O in 44 patients with monocytic leukemia. Analysis of data published between 1941 and 1961 [7] showed an increased frequency of group Fromthe Departmentof AppliedBiology.RoyalMelbourneInstituteof Technology,Melbourne,Australia. Address reprint requests to: Dr. D. N. Propert, Department of Applied Biology, Royal Melbourne Institute of Technology, 124 Latrobe Street, Melbourne, Victoria, 3000, Australia. Received March 20, 1990; accepted May 14, 1990.
113 © 1991 ElsevierSciencePublishingCo., Inc. 655 Avenue of the Americas,New York, NY 10010
Cancer Genet Cytogenet51:113-120 (1991) 0165-4608/91/$93.50
v. ]anardhana et al.
114 Table 1
Differential diagnosis of patients
Clinical diagnosis Hodgkin disease Diffuse, large-cell lymphoma Diffuse, poorly-differentiated lymphocytic lymphoma Nodular, poorly-differentiated lymphocytic lymphoma Nodular mixed-cell lymphoma Well-differentiated lymphocytic lymphoma Nodular, large-cell lymphoma Diffuse, mixed-cell lymphoma Miscellaneous lymphomas Myeloma Acute myeloid leukemia Acute lymphocytic leukemia Chronic myeloid leukemia Chronic lymphocytic leukemia Hairy cell leukemia Total
Abbreviation
Number
HD DLCL DPDLL NPDLL NMCL WDLL NLCL DMCL
148 72 29 82 19
AML ALL CML CLL HCL
23 27 27 52 22 31 31 3 558
A in leukemia sufferers. A study [8] of 1,063 patients with various malignancies in Egypt found an increased frequency of group O among patients suffering from l y m p h o r e t i c u l a r diseases such as leukemia and l y m p h o m a . An increased incidence of group A in 117 patients with leukemia from Orissa (India) has also been reported [9]. Analysis of the ABO groups of 175 Polish patients suffering from leukemia found no association [10]. No correlation was found in a survey of 114 Thai patients, including children and adults, suffering from leukemia or l y m p h o m a [11]. A n investigation of 533 patients with different types of leukemia in Poland [12] showed no significant divergence from controls. However, a study of 144 leukemic blacks and whites from Louisiana (U.S.A.) found an increased frequency of group A among black males and white females [13]. Investigations of the association of ABO groups with various types of l y m p h o m a are also inconclusive. Analysis of a large sample of 500 U.S. whites suffering from Hodgkin disease (HD) found an increased frequency of group B and a decreased frequency of group A [14]. Analysis of 51 patients with HD from Manchester (U.K.) showed no ABO associations [15]. Investigation of children in the Nigerian Yoruba tribe suffering from Burkitt l y m p h o m a failed to show any marked divergence from the control population [16]. In this article we report the frequencies of ABO blood groups in 558 Caucasian patients suffering from various hematologic malignancies and compare these frequencies to those of healthy subjects of the same ethnographic background. MATERIALS A N D METHODS
Blood samples collected by venepunture from 558 Caucasian patients of European descent suffering from either leukemia or l y m p h o m a (Table 1) were stored at 4 ° prior to testing. All samples were processed and t y p e d within 48 hours of collection. Information provided by each patient concerning his or her family background indicated that 72% had families originating from the United Kingdom, 6% from southern and eastern Europe, 4% from northwestern Europe, and 16% were of mixed European origin. The remaining 2% were Caucasians of Asian origin. This closely reflects the k n o w n composition of the Melbourne gene pool.
115
ABO Blood Groups in Hematologic Malignancies
Table 2
ABO blood group phenotype and allele frequencies in l y m p h o m a and leukemia patients and healthy controls Lymphoma
Phenotype
Leukemia °
Controls
n
%
n
%
n
%
A2 B A1B A2B O
116 42 40 5 11 213
27.2 9.8 9.4 1.2 2.6 49.8
30 25 12 3 1 60
22.9 19.1 9.1 2.3 0.8 45.8
338 101 120 27 15 514
30.3 9.1 10.8 2.4 1.3 46.1
Total
427
100.0
131
100.0
1115
100.0
Allele
Frequency -+ SE
A1
Aa A2
B O
0.1539 0.0768 0.0677 0.7016
0.0129 0.0101 0.0087 0.0167
Frequency -+ SE 0.1348 0.1235 0.0631 0.6786
0.0219 0.0227 0.0153 0.0311
Frequency -+ SE 0.1800 0.0661 0.0755 0.6784
0.0086 0.0059 0.0057 0.0106
a Leukemiapatients vs. controls: X2, 5 df = 14.44, p < 0.025.
Forward and reverse ABO grouping was carried out using reagents and methods obtained from the Commonwealth Serum Laboratories, Parkville, Victoria, Australia. Forward typing of patient red cells was done using anti-A, anti-B and anti-A,B antisera. Dolichos biflorus lectin was used for A subgrouping [17]. A sample was considered to be group A 2 if it reacted strongly with anti-A and anti-A,B antisera but was negative w h e n tested with the lectin. Reverse grouping of patient sera was done using "Revercells" of group A 1, Az and B and group O "Abtectcells." Frequencies of ABO phenotypes and genotypes in healthy Caucasian Melbourne residents were obtained from a survey of a large, random sample of the Melbourne population [18]. The distributions of the phenotypes in control and patient populations were compared by contingency chi-square testing. The frequencies of the ABO alleles were estimated by m a x i m u m likelihood analysis [19] using the maximation program MAXLIK [20]. The allele frequencies of the patients and controls were compared by the likelihood ratio criterion [21]. The detailed application of this method has been described previously [22]. RESULTS
The distributions of the ABO phenotypes and alleles in lymphoma, leukemia, and controls are presented in Table 2. The phenotypic frequencies in lymphoma patients do not differ significantly from those of controls (X2, 5 df = 7.86, p > 0.05}. The distribution of phenotypes in leukemia patients is significantly different to that of controls (X 2, 5 df = 14.44, p < 0.025). The difference is essentially due to the increased frequency of the A 2 phenotype and decreased frequency of the A 2 phenotype and remains statistically significant w h e n the probability value is multiplied by two to correct for the n u m b e r of patient groups involved. The distributions of the phenotypes in major clinical subgroups of lymphoma and leukemia are shown in Table 3. Contingency analysis of the leukemia subgroups versus controls revealed significant variation only in chronic lymphocytic leukemia (CLL) (X2, 5 df = 16.66, p < 0.01). This difference results essentially from an increased frequency of CLL patients with the A 2 phenotype and a decreased frequency with
148
69
100.0
46.7
2.7
1.3
10.8
8.1
30.4
%
72
39
1
1
6
5
20
n
100.0
54.2
1.4
1.4
8.3
6.9
27.8
%
DLCL
29
19
0
1
3
1
5
n
100.0
65.5
0.0
3.4
10.4
3.4
17.3
%
DPDLL
3.8 0.0 2.4
3 0 2 82
100.0
54.9
10.9
45
28.0
%
9
n
NPDLL
subgroups
27
13
0
0
4
6
4
n
100.0
52
24
48.2 100.0
46.2
1.9 0.0
1 0
0.0
0.0
14.8 11.5
17.3
9 6
23.1
12
22.2
14.8
%
n
AML
22
11
0
1
1
100.0
50.1
0.0
4.5
4.5
4.5
36.4
8 1
%
n
23
8
1
0
2
6
6
n
leukemia,
ALL
of lymphoma,
%
Myeloma
in different
23
frequencies
Abbreviations: See Table 1. I’ CLL patients vs. controls: xx 5 df = 16.66. p > 0.01
Total
0
2
16
B
4
12
A,
A,B
45
A,
A,B
n
HD
ABO blood group phenotype
Phenotype
Table
100.0
34.8
4.3
0.0
8.7
26.1
26.1
Y0
CML
31
15
0
100.0
48.4
0.0
3.2
6.5
2 1
29.0
12.9
%
9
4
n
CLL”
and controls
1115
514
15
27
120
101
338
n
1.3
2.4
10.8
9.1
30.3
%
100.0
46.1
Controls
ABO Blood Groups in Hematologic Malignancies
117
A1 and remains significant when corrected for the number of leukemia subgroups involved. The allelic frequencies in major subgroups of lymphoma and leukemia are presented in Table 4. Log likelihood comparisons of allele frequencies in subgroups of leukemia versus control frequencies show a significant increase in the frequency of the A 2 gene in CLL (X2, 1 df = 6.87, p < 0.01). It is of interest that the chronic myeloid leukemia (CML) patients also have an increased frequency of the A 2 allele but, because of the smaller size of this sample, the difference does not reach statistical significance. DISCUSSION Comparison of the distribution of ABO phenotypic frequencies in lymphoma as a group with those of the control subjects did not reveal any significant variation. However, comparison of the subgroups of lymphoma was also carried out to see whether the distributions are consistent with previous reports. The frequencies of ABO phenotypes in 148 HD patients are similar to those of controls. This finding is in agreement with that of a survey of 51 patients from Manchester suffering from Hodgkin disease [15], but does not support the increased frequency of group B and decreased frequency of group A found in U.S. white HD patients [14]. The distribution of phenotypes in sufferers of leukemia is different to that of the control subjects. The frequency of A 1 is decreased while that of A 2 is increased. However, the cumulative frequency of the phenotypes A 1 and A 2 of leukemic patients, considered as group A, is closely in agreement with that in controls. This finding superficially confirms previous reports [10, 12, 13]. However, these investigations did not include typing for subgroups of A. On division of the leukemic patients into subgroups, alterations in the frequencies of ABO phenotypes is noticed only in CLL. At the gene level, the frequency of the A 2 allele is significantly increased compared to that in the control subjects. When corrected for the altered frequency of A 2, the difference in the frequency of each other allele is not significant. This association is not likely to have arisen as a result of a type 1 statistical error because the corrected p value of 0.04 is still significant when the initial p value is multiplied by the number of leukemia subgroups involved. Nor is the association likely to have resulted from ethnic differences between the patients and controls. The patients were representative of the Melbourne population in terms of geographic origins (see earlier), and, while the controls were not specifically questioned concerning their countries of origin, they are also thought to be representative of the Melbourne population [18]. Subsequent analysis of immunoglobulin allotypes in the same control series [23] supported this assumption. Although the findings of this investigation are of a preliminary nature and will need to be confirmed in an independent population of patients, it is of interest to speculate on reasons for an association between ABO blood groups and CLL. The increased frequency of the A 2 allele in CLL may be due to one or a combination of reasons. First, people with the A 2 allele may be more susceptible to CLL than those lacking this allele. Second, selective forces acting upon CLL patients might be favorable to the survival of patients posessing the A 2 allele. Third, considering the biochemical synthesis of the ABO antigens, it may be speculated that the increase in the frequency of the A 2 phenotype and corresponding decrease in the frequency of the A1 phenotype might be the result of a conversion of A~ to A 2 at the phenotypic level as a result of malignancy. The loss of blood group A was recently reported [24] in a patient with acute myelomonocytic leukemia. It was shown that the loss of A antigen in this patient was not due to an abnormality of the enzyme required to convert H substance to A substance, but instead was associated with alteration to red cell morphology. Last, the increase in the frequency of the A 2 phenotype might have arisen
118
dd
+I
A B O B l o o d G r o u p s in H e m a t o l o g i c M a l i g n a n c i e s
119
as a result of i n c o m p l e t e or i n h i b i t e d s y n t h e s i s of A 1 antigen. H o w e v e r , based on the p r e s e n t study, it is not p o s s i b l e to d e t e r m i n e w h e t h e r the i n c r e a s e d f r e q u e n c y of the A 2 allele is the c a u s e or effect of m a l i g n a n c y . A l o n g - t e r m p r o s p e c t i v e s t u d y of the A B O b l o o d groups in patients w i t h h e m a t o l o g i c m a l i g n a n c i e s m i g h t t h r o w s o m e light on the a b o v e s p e c u l a t i o n s . A l t h o u g h CLL is the m o s t c o m m o n l e u k e m i a in p o p u l a t i o n s of E u r o p e a n descent, it is e x t r e m e l y rare in the O r i e n t [25]. It is r e l e v a n t to our p r e s e n t finding that O r i e n t a l p o p u l a t i o n s h a v e a l o w f r e q u e n c y of the A 2 gene [1]. We wish to thank Dr. Ian Cooper and Dr. Max Wolf, Haematology Research Unit, Peter MacCallum Cancer Institute, Melbourne, and Dr. O. Margaret Garson, Department of Cytogenetics, St Vincent's Hospital, Fitzroy, for providing the blood samples. We also wish to thank Dr. John Hopper and Mr. Barry Dickson, Epidemiology Unit, University of Melbourne, Parkville, for their help with statistical analyses and Mrs. Margaret Dorbolo and Ms. Penny Alberts, who prepared the manuscript. V. J. was a John Storey Junior Memorial Scholar at the time of this investigation, and this support is also gratefully acknowledged.
REFERENCES 1. Mourant AE, Kopec AC, Domaniewski-Sobczak K (1976): The Distribution of the Human Blood Groups and Other Polymorphisms. Oxford University Press, London. 2. Aird I, Bentall HH, Roberts JAF (1953): A relationship between cancer of stomach and the ABO blood groups. Br Med J 1:799-801. 3. Mourant AE, Kopec AC, Domaniewski-Sobczak K (1978): Blood Groups and Diseases. Oxford University Press, Oxford. 4. Kay HEM, Shorter RG (1956): Blood groups in leukaemia and the reticuloses. Vox Sang 1:255-258. 5. MacMahon B, Folusiak JC (1958): Leukemia and ABO blood group. Am J Hum Genet 10:287-293. 6. Lucia SP, Hunt ML, Petrakis NL (1958): The leukemias in relation to age, sex, and blood group. Vox Sang 3:354-362. 7. Shirley R, Desai RG (1965): Association of leukaemia and blood groups. J Med Genet 2:189-191. 8. Hammouda F, Soliman HA, Hussein MH (1972): ABO blood group distribution in relation to malignancies in Egypt. Royal Egyptian Med Assn J 55:655-660. 9. Nayak SK (1971): ABO blood groups in different diseases. J Indian Med Assn 57:449452. 10. Gurda M, Turowska B (1970): Distribution of the ABO and Rh D blood groups in patients with leukemia. Pol Med Sc Hist Bull 13:89-91. 11. Saichua S, Chiewsilp P (1978): Red cell ABH antigens in leukaemias and lymphomas. Vox Sang 35:154-159. 12. Moszczynski P, Lisiewicz J (1973): ABO and RhD blood groups in leukaemic patients. Folia Haematol (Leipz) 100:395400. 13. Newell GR, Gordon JE, Monlezun AP, Horwitz JS (1974): ABO blood groups and cancer. J Nat Cancer lnst 52:1425-1430. 14. Levitan R, Razis DV, Diamond HD, Craver LF (1959): ABO blood groups in Hodgkin's disease. Acta Haematol 22:12-19. 15. Harris R, Wentzel J, Carroll CA, Garrett JV, Jackson SM, Dodge OG (1972): A study of HLA in patients with Hodgkin's disease. In: Histocompatibility Testing, J. Dausset, J. Colombani, eds. Munksgaard, Copenhagen, pp. 603-609. 16. Williams AO (1966): Haemoglobin genotypes, ABO blood groups, and Burkitt's tumour. J Med Genet 3:177-179. 17. American Association of Blood Banks (1985): Technical Manual, 9th Ed., FK Widmann, ed. American Association of Blood Banks, Arlington, pp. 113-121. 18. Brackenridge CJ, Case J, Sheehy AJ (1975): Distributions, sex and age effects, and joint associations between phenotypes of 14 genetic systems in an Australian population sample. Hum Hered 25:520-529.
120
v . J a n a r d h a n a et al.
19. CavalliiSforza LL, Bodmer WF (1971): The Genetics of Human Populations. Freeman and Co., San Francisco, pp. 885-888. 20. Kaplan EB, Elston RC (1972): A subroutine package of maximum likelihood estimation (MAXLIK). University of North Carolina, Institute of Statistics, Mimeo series No. 823. 21. Kendall MG, Stuart A (1973): The Advanced Theory of Statistics, Vol. 2. Griffin, London, pp. 234-272. 22. Janardhana V, Propert DN, Cooper I, Wolf M, Garson OM, Hopper JL, Dickson BJ (1988): Immunoglobulin allotypes Gm and Km in hematologic malignancies. Cancer Genet Cytogenet 31:179-186. 23. Propert DN (1978): PhD thesis, University of Melbourne, Melbourne, Australia. 24. Atkinson JB, Tanley PC, Wallas CH (1987): Loss of blood group A in acute leukemia: Morphologic and biochemical studies of red cells. Transfusion 27:45-48. 25. Heim S, Mitelman F (1987): Cancer Cytogenetics. Alan R. Liss, Inc., New York, p. 177.
ABSTRACT: This article examines the genetic predisposition of individuals to lymphoma and leukemia with regard to the ABO blood groups. Blood samples from 558 patients suffering from various forms of lymphmna and leukemia were collected and typed for ABO blood groups. The ABO blood group phenotype frequencies of lymphoma patients were similar to those in control samples. Among leukemia patients, a significant increase in the frequency of the A 2 phenotype was found in chronic lymphocytic leukemia. Possible mechanisms underlying the predisposition of individuals with the A 2 blood group to chronic lymphocytic leukemia suggested by these preliminary results are discussed. INTRODUCTION The specificities of the ABO blood group system, like most other polymorphic genetic markers, occur with frequencies that are more or less stable w i t h i n populations but differ from one population to another [1]. These variations may be due to random genetic drift and/or natural selection. This leads to the speculation that i n d i v i d u a l s of some ABO phenotype(s) are more susceptible than others to certain diseases. The first positive correlation between ABO blood groups and disease was published by Aird and coworkers [2], who surveyed patients with stomach cancer for ABO blood groups and found an increased frequency of group A. This report triggered an enormous a m o u n t of investigation of the ABO system in a variety of h u m a n diseases. The reports prior to 1977 have been reviewed [3], and this review encompasses a u t o i m m u n e diseases, infectious diseases, and malignancies of different systems. A brief review of ABO blood groups in hematologic malignancies is of particular relevance to this report. A n early investigation [4} of leukemia and reticulosis sufferers from London failed to show any association, but a subsequent study [5] showed an increased frequency of groups B and AB in leukemia patients. The same study also revealed that blacks were less susceptible to leukemias than whites, and Jewish whites were more susceptible than other whites. Analysis of 352 U.S. whites suffering from leukemia for age, sex, and blood groups [6] did not provide any conclusive result. However, certain trends were observed among the patients with regard to the above criteria, i n c l u d i n g an increased frequency of group O in 44 patients with monocytic leukemia. Analysis of data published between 1941 and 1961 [7] showed an increased frequency of group Fromthe Departmentof AppliedBiology.RoyalMelbourneInstituteof Technology,Melbourne,Australia. Address reprint requests to: Dr. D. N. Propert, Department of Applied Biology, Royal Melbourne Institute of Technology, 124 Latrobe Street, Melbourne, Victoria, 3000, Australia. Received March 20, 1990; accepted May 14, 1990.
113 © 1991 ElsevierSciencePublishingCo., Inc. 655 Avenue of the Americas,New York, NY 10010
Cancer Genet Cytogenet51:113-120 (1991) 0165-4608/91/$93.50
v. ]anardhana et al.
114 Table 1
Differential diagnosis of patients
Clinical diagnosis Hodgkin disease Diffuse, large-cell lymphoma Diffuse, poorly-differentiated lymphocytic lymphoma Nodular, poorly-differentiated lymphocytic lymphoma Nodular mixed-cell lymphoma Well-differentiated lymphocytic lymphoma Nodular, large-cell lymphoma Diffuse, mixed-cell lymphoma Miscellaneous lymphomas Myeloma Acute myeloid leukemia Acute lymphocytic leukemia Chronic myeloid leukemia Chronic lymphocytic leukemia Hairy cell leukemia Total
Abbreviation
Number
HD DLCL DPDLL NPDLL NMCL WDLL NLCL DMCL
148 72 29 82 19
AML ALL CML CLL HCL
23 27 27 52 22 31 31 3 558
A in leukemia sufferers. A study [8] of 1,063 patients with various malignancies in Egypt found an increased frequency of group O among patients suffering from l y m p h o r e t i c u l a r diseases such as leukemia and l y m p h o m a . An increased incidence of group A in 117 patients with leukemia from Orissa (India) has also been reported [9]. Analysis of the ABO groups of 175 Polish patients suffering from leukemia found no association [10]. No correlation was found in a survey of 114 Thai patients, including children and adults, suffering from leukemia or l y m p h o m a [11]. A n investigation of 533 patients with different types of leukemia in Poland [12] showed no significant divergence from controls. However, a study of 144 leukemic blacks and whites from Louisiana (U.S.A.) found an increased frequency of group A among black males and white females [13]. Investigations of the association of ABO groups with various types of l y m p h o m a are also inconclusive. Analysis of a large sample of 500 U.S. whites suffering from Hodgkin disease (HD) found an increased frequency of group B and a decreased frequency of group A [14]. Analysis of 51 patients with HD from Manchester (U.K.) showed no ABO associations [15]. Investigation of children in the Nigerian Yoruba tribe suffering from Burkitt l y m p h o m a failed to show any marked divergence from the control population [16]. In this article we report the frequencies of ABO blood groups in 558 Caucasian patients suffering from various hematologic malignancies and compare these frequencies to those of healthy subjects of the same ethnographic background. MATERIALS A N D METHODS
Blood samples collected by venepunture from 558 Caucasian patients of European descent suffering from either leukemia or l y m p h o m a (Table 1) were stored at 4 ° prior to testing. All samples were processed and t y p e d within 48 hours of collection. Information provided by each patient concerning his or her family background indicated that 72% had families originating from the United Kingdom, 6% from southern and eastern Europe, 4% from northwestern Europe, and 16% were of mixed European origin. The remaining 2% were Caucasians of Asian origin. This closely reflects the k n o w n composition of the Melbourne gene pool.
115
ABO Blood Groups in Hematologic Malignancies
Table 2
ABO blood group phenotype and allele frequencies in l y m p h o m a and leukemia patients and healthy controls Lymphoma
Phenotype
Leukemia °
Controls
n
%
n
%
n
%
A2 B A1B A2B O
116 42 40 5 11 213
27.2 9.8 9.4 1.2 2.6 49.8
30 25 12 3 1 60
22.9 19.1 9.1 2.3 0.8 45.8
338 101 120 27 15 514
30.3 9.1 10.8 2.4 1.3 46.1
Total
427
100.0
131
100.0
1115
100.0
Allele
Frequency -+ SE
A1
Aa A2
B O
0.1539 0.0768 0.0677 0.7016
0.0129 0.0101 0.0087 0.0167
Frequency -+ SE 0.1348 0.1235 0.0631 0.6786
0.0219 0.0227 0.0153 0.0311
Frequency -+ SE 0.1800 0.0661 0.0755 0.6784
0.0086 0.0059 0.0057 0.0106
a Leukemiapatients vs. controls: X2, 5 df = 14.44, p < 0.025.
Forward and reverse ABO grouping was carried out using reagents and methods obtained from the Commonwealth Serum Laboratories, Parkville, Victoria, Australia. Forward typing of patient red cells was done using anti-A, anti-B and anti-A,B antisera. Dolichos biflorus lectin was used for A subgrouping [17]. A sample was considered to be group A 2 if it reacted strongly with anti-A and anti-A,B antisera but was negative w h e n tested with the lectin. Reverse grouping of patient sera was done using "Revercells" of group A 1, Az and B and group O "Abtectcells." Frequencies of ABO phenotypes and genotypes in healthy Caucasian Melbourne residents were obtained from a survey of a large, random sample of the Melbourne population [18]. The distributions of the phenotypes in control and patient populations were compared by contingency chi-square testing. The frequencies of the ABO alleles were estimated by m a x i m u m likelihood analysis [19] using the maximation program MAXLIK [20]. The allele frequencies of the patients and controls were compared by the likelihood ratio criterion [21]. The detailed application of this method has been described previously [22]. RESULTS
The distributions of the ABO phenotypes and alleles in lymphoma, leukemia, and controls are presented in Table 2. The phenotypic frequencies in lymphoma patients do not differ significantly from those of controls (X2, 5 df = 7.86, p > 0.05}. The distribution of phenotypes in leukemia patients is significantly different to that of controls (X 2, 5 df = 14.44, p < 0.025). The difference is essentially due to the increased frequency of the A 2 phenotype and decreased frequency of the A 2 phenotype and remains statistically significant w h e n the probability value is multiplied by two to correct for the n u m b e r of patient groups involved. The distributions of the phenotypes in major clinical subgroups of lymphoma and leukemia are shown in Table 3. Contingency analysis of the leukemia subgroups versus controls revealed significant variation only in chronic lymphocytic leukemia (CLL) (X2, 5 df = 16.66, p < 0.01). This difference results essentially from an increased frequency of CLL patients with the A 2 phenotype and a decreased frequency with
148
69
100.0
46.7
2.7
1.3
10.8
8.1
30.4
%
72
39
1
1
6
5
20
n
100.0
54.2
1.4
1.4
8.3
6.9
27.8
%
DLCL
29
19
0
1
3
1
5
n
100.0
65.5
0.0
3.4
10.4
3.4
17.3
%
DPDLL
3.8 0.0 2.4
3 0 2 82
100.0
54.9
10.9
45
28.0
%
9
n
NPDLL
subgroups
27
13
0
0
4
6
4
n
100.0
52
24
48.2 100.0
46.2
1.9 0.0
1 0
0.0
0.0
14.8 11.5
17.3
9 6
23.1
12
22.2
14.8
%
n
AML
22
11
0
1
1
100.0
50.1
0.0
4.5
4.5
4.5
36.4
8 1
%
n
23
8
1
0
2
6
6
n
leukemia,
ALL
of lymphoma,
%
Myeloma
in different
23
frequencies
Abbreviations: See Table 1. I’ CLL patients vs. controls: xx 5 df = 16.66. p > 0.01
Total
0
2
16
B
4
12
A,
A,B
45
A,
A,B
n
HD
ABO blood group phenotype
Phenotype
Table
100.0
34.8
4.3
0.0
8.7
26.1
26.1
Y0
CML
31
15
0
100.0
48.4
0.0
3.2
6.5
2 1
29.0
12.9
%
9
4
n
CLL”
and controls
1115
514
15
27
120
101
338
n
1.3
2.4
10.8
9.1
30.3
%
100.0
46.1
Controls
ABO Blood Groups in Hematologic Malignancies
117
A1 and remains significant when corrected for the number of leukemia subgroups involved. The allelic frequencies in major subgroups of lymphoma and leukemia are presented in Table 4. Log likelihood comparisons of allele frequencies in subgroups of leukemia versus control frequencies show a significant increase in the frequency of the A 2 gene in CLL (X2, 1 df = 6.87, p < 0.01). It is of interest that the chronic myeloid leukemia (CML) patients also have an increased frequency of the A 2 allele but, because of the smaller size of this sample, the difference does not reach statistical significance. DISCUSSION Comparison of the distribution of ABO phenotypic frequencies in lymphoma as a group with those of the control subjects did not reveal any significant variation. However, comparison of the subgroups of lymphoma was also carried out to see whether the distributions are consistent with previous reports. The frequencies of ABO phenotypes in 148 HD patients are similar to those of controls. This finding is in agreement with that of a survey of 51 patients from Manchester suffering from Hodgkin disease [15], but does not support the increased frequency of group B and decreased frequency of group A found in U.S. white HD patients [14]. The distribution of phenotypes in sufferers of leukemia is different to that of the control subjects. The frequency of A 1 is decreased while that of A 2 is increased. However, the cumulative frequency of the phenotypes A 1 and A 2 of leukemic patients, considered as group A, is closely in agreement with that in controls. This finding superficially confirms previous reports [10, 12, 13]. However, these investigations did not include typing for subgroups of A. On division of the leukemic patients into subgroups, alterations in the frequencies of ABO phenotypes is noticed only in CLL. At the gene level, the frequency of the A 2 allele is significantly increased compared to that in the control subjects. When corrected for the altered frequency of A 2, the difference in the frequency of each other allele is not significant. This association is not likely to have arisen as a result of a type 1 statistical error because the corrected p value of 0.04 is still significant when the initial p value is multiplied by the number of leukemia subgroups involved. Nor is the association likely to have resulted from ethnic differences between the patients and controls. The patients were representative of the Melbourne population in terms of geographic origins (see earlier), and, while the controls were not specifically questioned concerning their countries of origin, they are also thought to be representative of the Melbourne population [18]. Subsequent analysis of immunoglobulin allotypes in the same control series [23] supported this assumption. Although the findings of this investigation are of a preliminary nature and will need to be confirmed in an independent population of patients, it is of interest to speculate on reasons for an association between ABO blood groups and CLL. The increased frequency of the A 2 allele in CLL may be due to one or a combination of reasons. First, people with the A 2 allele may be more susceptible to CLL than those lacking this allele. Second, selective forces acting upon CLL patients might be favorable to the survival of patients posessing the A 2 allele. Third, considering the biochemical synthesis of the ABO antigens, it may be speculated that the increase in the frequency of the A 2 phenotype and corresponding decrease in the frequency of the A1 phenotype might be the result of a conversion of A~ to A 2 at the phenotypic level as a result of malignancy. The loss of blood group A was recently reported [24] in a patient with acute myelomonocytic leukemia. It was shown that the loss of A antigen in this patient was not due to an abnormality of the enzyme required to convert H substance to A substance, but instead was associated with alteration to red cell morphology. Last, the increase in the frequency of the A 2 phenotype might have arisen
118
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A B O B l o o d G r o u p s in H e m a t o l o g i c M a l i g n a n c i e s
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as a result of i n c o m p l e t e or i n h i b i t e d s y n t h e s i s of A 1 antigen. H o w e v e r , based on the p r e s e n t study, it is not p o s s i b l e to d e t e r m i n e w h e t h e r the i n c r e a s e d f r e q u e n c y of the A 2 allele is the c a u s e or effect of m a l i g n a n c y . A l o n g - t e r m p r o s p e c t i v e s t u d y of the A B O b l o o d groups in patients w i t h h e m a t o l o g i c m a l i g n a n c i e s m i g h t t h r o w s o m e light on the a b o v e s p e c u l a t i o n s . A l t h o u g h CLL is the m o s t c o m m o n l e u k e m i a in p o p u l a t i o n s of E u r o p e a n descent, it is e x t r e m e l y rare in the O r i e n t [25]. It is r e l e v a n t to our p r e s e n t finding that O r i e n t a l p o p u l a t i o n s h a v e a l o w f r e q u e n c y of the A 2 gene [1]. We wish to thank Dr. Ian Cooper and Dr. Max Wolf, Haematology Research Unit, Peter MacCallum Cancer Institute, Melbourne, and Dr. O. Margaret Garson, Department of Cytogenetics, St Vincent's Hospital, Fitzroy, for providing the blood samples. We also wish to thank Dr. John Hopper and Mr. Barry Dickson, Epidemiology Unit, University of Melbourne, Parkville, for their help with statistical analyses and Mrs. Margaret Dorbolo and Ms. Penny Alberts, who prepared the manuscript. V. J. was a John Storey Junior Memorial Scholar at the time of this investigation, and this support is also gratefully acknowledged.
REFERENCES 1. Mourant AE, Kopec AC, Domaniewski-Sobczak K (1976): The Distribution of the Human Blood Groups and Other Polymorphisms. Oxford University Press, London. 2. Aird I, Bentall HH, Roberts JAF (1953): A relationship between cancer of stomach and the ABO blood groups. Br Med J 1:799-801. 3. Mourant AE, Kopec AC, Domaniewski-Sobczak K (1978): Blood Groups and Diseases. Oxford University Press, Oxford. 4. Kay HEM, Shorter RG (1956): Blood groups in leukaemia and the reticuloses. Vox Sang 1:255-258. 5. MacMahon B, Folusiak JC (1958): Leukemia and ABO blood group. Am J Hum Genet 10:287-293. 6. Lucia SP, Hunt ML, Petrakis NL (1958): The leukemias in relation to age, sex, and blood group. Vox Sang 3:354-362. 7. Shirley R, Desai RG (1965): Association of leukaemia and blood groups. J Med Genet 2:189-191. 8. Hammouda F, Soliman HA, Hussein MH (1972): ABO blood group distribution in relation to malignancies in Egypt. Royal Egyptian Med Assn J 55:655-660. 9. Nayak SK (1971): ABO blood groups in different diseases. J Indian Med Assn 57:449452. 10. Gurda M, Turowska B (1970): Distribution of the ABO and Rh D blood groups in patients with leukemia. Pol Med Sc Hist Bull 13:89-91. 11. Saichua S, Chiewsilp P (1978): Red cell ABH antigens in leukaemias and lymphomas. Vox Sang 35:154-159. 12. Moszczynski P, Lisiewicz J (1973): ABO and RhD blood groups in leukaemic patients. Folia Haematol (Leipz) 100:395400. 13. Newell GR, Gordon JE, Monlezun AP, Horwitz JS (1974): ABO blood groups and cancer. J Nat Cancer lnst 52:1425-1430. 14. Levitan R, Razis DV, Diamond HD, Craver LF (1959): ABO blood groups in Hodgkin's disease. Acta Haematol 22:12-19. 15. Harris R, Wentzel J, Carroll CA, Garrett JV, Jackson SM, Dodge OG (1972): A study of HLA in patients with Hodgkin's disease. In: Histocompatibility Testing, J. Dausset, J. Colombani, eds. Munksgaard, Copenhagen, pp. 603-609. 16. Williams AO (1966): Haemoglobin genotypes, ABO blood groups, and Burkitt's tumour. J Med Genet 3:177-179. 17. American Association of Blood Banks (1985): Technical Manual, 9th Ed., FK Widmann, ed. American Association of Blood Banks, Arlington, pp. 113-121. 18. Brackenridge CJ, Case J, Sheehy AJ (1975): Distributions, sex and age effects, and joint associations between phenotypes of 14 genetic systems in an Australian population sample. Hum Hered 25:520-529.
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19. CavalliiSforza LL, Bodmer WF (1971): The Genetics of Human Populations. Freeman and Co., San Francisco, pp. 885-888. 20. Kaplan EB, Elston RC (1972): A subroutine package of maximum likelihood estimation (MAXLIK). University of North Carolina, Institute of Statistics, Mimeo series No. 823. 21. Kendall MG, Stuart A (1973): The Advanced Theory of Statistics, Vol. 2. Griffin, London, pp. 234-272. 22. Janardhana V, Propert DN, Cooper I, Wolf M, Garson OM, Hopper JL, Dickson BJ (1988): Immunoglobulin allotypes Gm and Km in hematologic malignancies. Cancer Genet Cytogenet 31:179-186. 23. Propert DN (1978): PhD thesis, University of Melbourne, Melbourne, Australia. 24. Atkinson JB, Tanley PC, Wallas CH (1987): Loss of blood group A in acute leukemia: Morphologic and biochemical studies of red cells. Transfusion 27:45-48. 25. Heim S, Mitelman F (1987): Cancer Cytogenetics. Alan R. Liss, Inc., New York, p. 177.
