Scand J Haematol(l977) 19, 449-452
Acute Myeloid Leukaemia with the Philadelphia Chromosome ANITAGUSTAVSSON, FELIX MITELMAN & INGEOLSSON Department of Internal Medicine and Department of Clinical Genetics, University of Lund, Lund, Sweden
A case report of serial chromosome studim on a 26-year-old male with acute myeloid leukaemia (AML) is presented. The classic Philadelphia chromosome (Phl) translocation, t (9; 22) was found in 77 % of the metaphases at diagnosis and in 100 % in relapse; during a 3-month remission period the cytogenetic picture was normal or the Phl was present in a minor cell population only. The clinical and morphologic features of this case indicated that it was really a case of AML and less likely chronic myeloid leukaemia (CML) presenting in blast crisis. It is suggested that the oncogen producing the 9;22-translocation and CML may also induce AML in rare instances. K e y words: acute myeloid leukaemia
- Philadelphia
chromosome
Accepted for publication June 11, 1977 Correspondence to#:Inge Olsson, M.D., Research Department 2, E-blocket, University Hospital, S-22185 Lund, Sweden
The Philadelphia chromosome (Phl) (Nowell & Hungerford 1960), recently defined by means of chromosome banding techniques as a balanced translocation, t (9; 22) (Rowley 1973), is a characteristic finding in chronic myeloid leukaemia (CML). Before the introduction of modern banding techniques, the presence of a Phl-like chromosome was described also in other myeloproliferative disorders, including acute myeloid leukaemia (AML) (Hossfeld et a1 1971), but so far the translocation of the distal part of the long arm of chromosome No. 22 to chromosome No. 9, i.e. t(9;22) as in CML, has been verified in only one case of AML, (Sonta et a1 1976). In the present paper, the Phl chromosome, idenScand J Haematol(l977) 19
tified with Giemsa banding as a t (9; 22) (q34;qll), is reported in an additional case of AML. CASE REPORT The patient was a 26-year-old male. Tonsillectomy was performed at the age of 10 yrs because of repeated episodes of tonsillitis. Otherwise he had been well and serving as a blood donor for several years; 2 months prior to diagnosis the Hb value and ESR were normal. H e was admitted with a 1-month history of fatigue and upper respiratory tract infection. T h e spleen was of normal size judged from radiography, but he had moderately enlarged submandibular lymph nodes. There was no involvement of the central nervous system. Blood examination showed Hb 80 g/l; WBC 88.3 x lWA, with neutrophils 5.5 x 109/1, 29
ANITA GUSTAVSSON, FELIX MITELMAN & INGE OLSSON
450
lymphocytes 4.0 x 1W1, monocytes 4 x 109/1, myelocytes 4.2 x 109/1, and blasts 70 x 109/l. N o basophilic granulocytes were found. Sheep erythrocyte rosette forming cells (T-lymphocytes) constituted 3 x 1Wl. Serum BIZ was 740 pmoV1. Serum lysozyme was increased, 15.5 mg/l. The bone m m o w smear showed increased cellularity and was dominated by myeloblast-like cells, 82 %, some of which had scattered azurophi1 granulation and appeared to, diffefrentiate into the neutrophil series. Myelocytes, 3.6 %, and more differentiated granulopoietic cells were also found. In addition, a population of lymphocytelike cells (or microblasts), 4 %, were seen. N o basophilic granulocytes were detected. Erythroblasts represented 7 %. A diagnosis of AML was made. Bone marrow cells or peripheral blood leucocytes grown in agar culture (Pike & Robinson 1970) gave growth of a small amount of clusters, one of the typical growth patterns in AML (Moore et a1 1974). For remission induction 5 d courses of thioguanine, cytosin arabinoside and prednisone were administered every 10-14 d with rubidomycin on the first day (TRAP) (Figure 1). Blast cells disappeared rapidly from the marrow and peripheral blood. After 3 courses of TRAP the marrow was dominated by small lymphocyte-like, periodic acid-Schiff negative cells. These disappeared too after one 5 d course of cyclophosphamide, cytosin arabinoside and prednisone with vincristine on the
first day (COAP) and a complete remission was achieved. Bone marrow grown in agar culture showed a normal growth pattern. The remission was, however, of short duration and the patient relapsed after 3 months, and agar culture now showed the growth of a very small amount of small clusters. The bone marrow morphology was identical with that at diagnosis. In spite of vigorous therapy, a second remission was not obtained, and the patient died of intracerebral haemorrhage 11 months after diagnosis. Towards the end massive splenomegaly developed. RESULTS
Bone marrow chromosomes were analysed serially during the disease (Figure 1) by a direct non-culture preparation technique (Mitelman et a1 1976); the chromosomes were stained by the trypsin-Giemsa banding technique. A total of 292 metaphases were analysed. At diagnosis, 77 % of the marrow metaphases had the karyotype 46, XY, t (9; 22) (q34; q l l ) , i.e. a deletion of the long arm of one chromosome No. 22 and a translocation of this segment to the long arm of one chromosome No. 9 (Figure 2); the remaining 23 % of the bone marrow cells had
1
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8
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b.d+-&-.d
IRAPU COAPI
0
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0
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0
'
0
1
I
I
JULV '
I
I
0
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c 2 0 0 0 0
'
' NOW '
1 . 1
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' JAN. '
Figure 1. Serial studies on the AML patient of blood blasts, neutrophils and platelets as well as marrow blasts and marromw cellularity (cells per ml aspirated marrow x 1 P ) . Results of karyotype analyses are sholwn at top. Courses of treatment given (TRAP and COAP) are indicated.
AML WITH THE Ph' CHROMOSOME
Figure 2. Partial karyotype of a bone marrow cell demonstrating the Phl-chromosome with the 9; 22 translocation (indicated by arrow).
a normal diploid karyotype, 46, XY. The Phl-positive cells disappeared upon treatment; when the marrow was dominated by lymphocyte-like cells (June 1976) all metaphases displayed a normal karyotype. In remission the Phi was detected at one occasion in 7 % of marrow metaphases and also in 5.5 % of 110 analysed metaphases of PHA stimulated cells from the peripheral blood. During relapse the Phl was present in 100 % of all marrow metaphases analysed at 4 occasions; no additional chromosomal abnormalities developed during the course of the disease. DISCUSSION
The present case is interesting since it represents one of the very few cases of AML reported, where the typical translocation (9;22) of the Phl chromosome is documented. First, however, can it be ruled out by certainty that this is a case of CML
45 1
presenting in blastic crisis? Blast crisis as an initial manifestation of CML has been reported (Peterson et a1 1976), characterized with marked leucocytosis, basophilia, and splenomegaly. Infections, lymphadenopathy, tissue infiltration and central nervous system involvement were more common in patients who presented with blastic leukaemia as compared to patients with a previous history of CML. Blood and bone marrow morphology is not uniform in CML presenting in blastic phase and the morphological appearance of the blast cells can be identical with that of AML or even ALL; basophilia and myeloid differentiation of the blast cells are morphological characteristics suggestive of CML in blastic crisis. The absence of basophilia in the present case is not consistent with CML presenting in blastic crisis, nor is the absence of splenomegaly at diagnosis, which was present in 8/9 such cases (Peterson et a1 1976). Slightly increased levels for vitamin Biz and lysozyme of serum found in our case do not represent s i m c a n t findings for the diEerential diagnosis. In vitrcr growth pattern in agar of marrow cells does not distinguish between AML and CML in blastic crisis and the growth pattern obtained in our case would be consistent with both diagnoses. But several features of the present case undoubtedly suggest that it is distinct from CML, in blastic crisis. This conclusion is furthermore supported by the change of the karyotype during remission. Reversion to a normal karyotype during remission is well documented in AML, but has, to our knowledge, so far not been reported in remission of the blastic phase of CML (Canel10s et a1 1971). That it should represent ALL, where Phl has been demonstrated in a few cases, is highly unlikely. The lymphocyte-like cells dominating the marrow
452
ANITA GUSTAVSSON, FELIX MITELMAN & INGE OLSSON
picture just prior to remission are of unknown significance: anyhow they were Phlnegative. It is concluded that our case most likely represents AML. The significance of the unusual karyotype of the present case is unclear. The breakpoints on chromosomes Nos. 9 and 22, located at bands q34 and q 11, respectively, are identical to those in classical CML and apparently also identical to the other case of AML reported by Sonta et a1 (1976). In addition, the t (9; 22) (q34; q l l ) has been verified in 3 cases of ALL (Philip et a1 1976, Secker-Walker I& Hardy 1976, Mandel et a1 1977). It seems highly unlikely that the sequence of events producing this particular aberration would occur by chance in the different malignant disorders. Experimental evidence, based on results from chromosome studies in sarcomas, carcinomas and leukaemias induced by different etiologic agents, indicate that the karyotypic pattern of malignant cells is determined by the inducing agent (Mitelman et a1 1972, Levan & Mitelman 1976). In view of these results, an attractive although unproven hypothesis would be that the oacogen producing the 9;22-translocation and CML also in rare instances may induce AML and ALL. ACKNOWLEDGEMENTS This investigation was supported by the Swedish Cancer Society, the Medical Faculty o'f Lund, and the John and Augusta Pe'rsson foundation, Lund, Sweden. REFERENCES Canellos G P, De Vita V T, Whang-Peng J & Carbone P P (1971) Hematologic and cytogenetic remission of blastic transformation in chronic granulocytic leukemia. Blood 38, 67179. Hossfeld D K, Han T, Holdsworth R N & Sand-
berg A A (1971) Chromosomes and causation of human cancer and leukemia. VII. The significance of the Ph* in conditions other than CML. Cancer 27, 186-92. Levan G & Mitelman F (1976) G-banding in Rous rat sarcomas during serial transfer: Significant chromosome aberrations and incidence of stromal mitoses. Hereditas 84, 1-14. Mandel E M, Shabtai F, Gafter U, Klein B, Halbrecht I & Djaldetti M (1977) Phl-positive acute lymphocytic leukemia with chromosome 7 abnormalities. Blood 49, 281-87. Mitelman F, Mark J, Levan G & Levan A (1972) Tumor etiology and chromosome pattern. Science 176, 1340-41. Mitelman F, Nilsson P G, Levan G & Brandt L (1976) Nonrandom chromosome changes in acute myeloid leukemia. Chromosome banding examination of 30 cases at diagnosis. Int J Cancer 18, 31-38. Moore M A S, Spitzer G, Williams N, Metcalf D & Buckley J (1974) Agar culture studies in 127 cases of untreated acute leukemia: The prognostic value of reclassification of leukemia according to in vitro growth characteristics. Blood 44, 1-18. Nowell P C & Hungerford D A (1960) A minute chromosome in human granulocytic leukaemia. Science 132, 1497. Peterson L C,Bloomfield C D & Brunning R D (1976) Blast crisis as a n initial or terminal manifestation of chronic myeloid leukemia. A m J Med 60, 209-20. Philip P, Muller-Berat N & Killman S-Aa (1976) Philadelphia chromosome in acute lymphocytic leukaemia. Hereditas 84, 231-32. Pike B & Robinson W A (1970) Human bone marrow culture in agar gel. J Cell Physiol 76, 77-84. Rowley J D (1973) A new consistent chromosomal abnormality in chronic myelogenous leukaemia identified by quinacrine fluorescence and Giemsa staining. Nature 243, 290-93. Secker-Walker L M & Hardy J D (1976) Philadelphia chromosome in acute leukemia. Cancer 38, 1619-24. Sonta S, Oshimura M & Sandberg A A (1976) Chromosomes and causation of human cancer and leukemia. XXI. Cytogenetically unusual cases of leukemia. Blood 48, 697-705.
Acute Myeloid Leukaemia with the Philadelphia Chromosome ANITAGUSTAVSSON, FELIX MITELMAN & INGEOLSSON Department of Internal Medicine and Department of Clinical Genetics, University of Lund, Lund, Sweden
A case report of serial chromosome studim on a 26-year-old male with acute myeloid leukaemia (AML) is presented. The classic Philadelphia chromosome (Phl) translocation, t (9; 22) was found in 77 % of the metaphases at diagnosis and in 100 % in relapse; during a 3-month remission period the cytogenetic picture was normal or the Phl was present in a minor cell population only. The clinical and morphologic features of this case indicated that it was really a case of AML and less likely chronic myeloid leukaemia (CML) presenting in blast crisis. It is suggested that the oncogen producing the 9;22-translocation and CML may also induce AML in rare instances. K e y words: acute myeloid leukaemia
- Philadelphia
chromosome
Accepted for publication June 11, 1977 Correspondence to#:Inge Olsson, M.D., Research Department 2, E-blocket, University Hospital, S-22185 Lund, Sweden
The Philadelphia chromosome (Phl) (Nowell & Hungerford 1960), recently defined by means of chromosome banding techniques as a balanced translocation, t (9; 22) (Rowley 1973), is a characteristic finding in chronic myeloid leukaemia (CML). Before the introduction of modern banding techniques, the presence of a Phl-like chromosome was described also in other myeloproliferative disorders, including acute myeloid leukaemia (AML) (Hossfeld et a1 1971), but so far the translocation of the distal part of the long arm of chromosome No. 22 to chromosome No. 9, i.e. t(9;22) as in CML, has been verified in only one case of AML, (Sonta et a1 1976). In the present paper, the Phl chromosome, idenScand J Haematol(l977) 19
tified with Giemsa banding as a t (9; 22) (q34;qll), is reported in an additional case of AML. CASE REPORT The patient was a 26-year-old male. Tonsillectomy was performed at the age of 10 yrs because of repeated episodes of tonsillitis. Otherwise he had been well and serving as a blood donor for several years; 2 months prior to diagnosis the Hb value and ESR were normal. H e was admitted with a 1-month history of fatigue and upper respiratory tract infection. T h e spleen was of normal size judged from radiography, but he had moderately enlarged submandibular lymph nodes. There was no involvement of the central nervous system. Blood examination showed Hb 80 g/l; WBC 88.3 x lWA, with neutrophils 5.5 x 109/1, 29
ANITA GUSTAVSSON, FELIX MITELMAN & INGE OLSSON
450
lymphocytes 4.0 x 1W1, monocytes 4 x 109/1, myelocytes 4.2 x 109/1, and blasts 70 x 109/l. N o basophilic granulocytes were found. Sheep erythrocyte rosette forming cells (T-lymphocytes) constituted 3 x 1Wl. Serum BIZ was 740 pmoV1. Serum lysozyme was increased, 15.5 mg/l. The bone m m o w smear showed increased cellularity and was dominated by myeloblast-like cells, 82 %, some of which had scattered azurophi1 granulation and appeared to, diffefrentiate into the neutrophil series. Myelocytes, 3.6 %, and more differentiated granulopoietic cells were also found. In addition, a population of lymphocytelike cells (or microblasts), 4 %, were seen. N o basophilic granulocytes were detected. Erythroblasts represented 7 %. A diagnosis of AML was made. Bone marrow cells or peripheral blood leucocytes grown in agar culture (Pike & Robinson 1970) gave growth of a small amount of clusters, one of the typical growth patterns in AML (Moore et a1 1974). For remission induction 5 d courses of thioguanine, cytosin arabinoside and prednisone were administered every 10-14 d with rubidomycin on the first day (TRAP) (Figure 1). Blast cells disappeared rapidly from the marrow and peripheral blood. After 3 courses of TRAP the marrow was dominated by small lymphocyte-like, periodic acid-Schiff negative cells. These disappeared too after one 5 d course of cyclophosphamide, cytosin arabinoside and prednisone with vincristine on the
first day (COAP) and a complete remission was achieved. Bone marrow grown in agar culture showed a normal growth pattern. The remission was, however, of short duration and the patient relapsed after 3 months, and agar culture now showed the growth of a very small amount of small clusters. The bone marrow morphology was identical with that at diagnosis. In spite of vigorous therapy, a second remission was not obtained, and the patient died of intracerebral haemorrhage 11 months after diagnosis. Towards the end massive splenomegaly developed. RESULTS
Bone marrow chromosomes were analysed serially during the disease (Figure 1) by a direct non-culture preparation technique (Mitelman et a1 1976); the chromosomes were stained by the trypsin-Giemsa banding technique. A total of 292 metaphases were analysed. At diagnosis, 77 % of the marrow metaphases had the karyotype 46, XY, t (9; 22) (q34; q l l ) , i.e. a deletion of the long arm of one chromosome No. 22 and a translocation of this segment to the long arm of one chromosome No. 9 (Figure 2); the remaining 23 % of the bone marrow cells had
1
7.0-
0
8
10-
m
0-
q < $ -7
Tip'.
b.d+-&-.d
IRAPU COAPI
0
'1976 '
0
YAY
0
'
0
1
I
I
JULV '
I
I
0
SEP.
c 2 0 0 0 0
'
' NOW '
1 . 1
m u - ,
' JAN. '
Figure 1. Serial studies on the AML patient of blood blasts, neutrophils and platelets as well as marrow blasts and marromw cellularity (cells per ml aspirated marrow x 1 P ) . Results of karyotype analyses are sholwn at top. Courses of treatment given (TRAP and COAP) are indicated.
AML WITH THE Ph' CHROMOSOME
Figure 2. Partial karyotype of a bone marrow cell demonstrating the Phl-chromosome with the 9; 22 translocation (indicated by arrow).
a normal diploid karyotype, 46, XY. The Phl-positive cells disappeared upon treatment; when the marrow was dominated by lymphocyte-like cells (June 1976) all metaphases displayed a normal karyotype. In remission the Phi was detected at one occasion in 7 % of marrow metaphases and also in 5.5 % of 110 analysed metaphases of PHA stimulated cells from the peripheral blood. During relapse the Phl was present in 100 % of all marrow metaphases analysed at 4 occasions; no additional chromosomal abnormalities developed during the course of the disease. DISCUSSION
The present case is interesting since it represents one of the very few cases of AML reported, where the typical translocation (9;22) of the Phl chromosome is documented. First, however, can it be ruled out by certainty that this is a case of CML
45 1
presenting in blastic crisis? Blast crisis as an initial manifestation of CML has been reported (Peterson et a1 1976), characterized with marked leucocytosis, basophilia, and splenomegaly. Infections, lymphadenopathy, tissue infiltration and central nervous system involvement were more common in patients who presented with blastic leukaemia as compared to patients with a previous history of CML. Blood and bone marrow morphology is not uniform in CML presenting in blastic phase and the morphological appearance of the blast cells can be identical with that of AML or even ALL; basophilia and myeloid differentiation of the blast cells are morphological characteristics suggestive of CML in blastic crisis. The absence of basophilia in the present case is not consistent with CML presenting in blastic crisis, nor is the absence of splenomegaly at diagnosis, which was present in 8/9 such cases (Peterson et a1 1976). Slightly increased levels for vitamin Biz and lysozyme of serum found in our case do not represent s i m c a n t findings for the diEerential diagnosis. In vitrcr growth pattern in agar of marrow cells does not distinguish between AML and CML in blastic crisis and the growth pattern obtained in our case would be consistent with both diagnoses. But several features of the present case undoubtedly suggest that it is distinct from CML, in blastic crisis. This conclusion is furthermore supported by the change of the karyotype during remission. Reversion to a normal karyotype during remission is well documented in AML, but has, to our knowledge, so far not been reported in remission of the blastic phase of CML (Canel10s et a1 1971). That it should represent ALL, where Phl has been demonstrated in a few cases, is highly unlikely. The lymphocyte-like cells dominating the marrow
452
ANITA GUSTAVSSON, FELIX MITELMAN & INGE OLSSON
picture just prior to remission are of unknown significance: anyhow they were Phlnegative. It is concluded that our case most likely represents AML. The significance of the unusual karyotype of the present case is unclear. The breakpoints on chromosomes Nos. 9 and 22, located at bands q34 and q 11, respectively, are identical to those in classical CML and apparently also identical to the other case of AML reported by Sonta et a1 (1976). In addition, the t (9; 22) (q34; q l l ) has been verified in 3 cases of ALL (Philip et a1 1976, Secker-Walker I& Hardy 1976, Mandel et a1 1977). It seems highly unlikely that the sequence of events producing this particular aberration would occur by chance in the different malignant disorders. Experimental evidence, based on results from chromosome studies in sarcomas, carcinomas and leukaemias induced by different etiologic agents, indicate that the karyotypic pattern of malignant cells is determined by the inducing agent (Mitelman et a1 1972, Levan & Mitelman 1976). In view of these results, an attractive although unproven hypothesis would be that the oacogen producing the 9;22-translocation and CML also in rare instances may induce AML and ALL. ACKNOWLEDGEMENTS This investigation was supported by the Swedish Cancer Society, the Medical Faculty o'f Lund, and the John and Augusta Pe'rsson foundation, Lund, Sweden. REFERENCES Canellos G P, De Vita V T, Whang-Peng J & Carbone P P (1971) Hematologic and cytogenetic remission of blastic transformation in chronic granulocytic leukemia. Blood 38, 67179. Hossfeld D K, Han T, Holdsworth R N & Sand-
berg A A (1971) Chromosomes and causation of human cancer and leukemia. VII. The significance of the Ph* in conditions other than CML. Cancer 27, 186-92. Levan G & Mitelman F (1976) G-banding in Rous rat sarcomas during serial transfer: Significant chromosome aberrations and incidence of stromal mitoses. Hereditas 84, 1-14. Mandel E M, Shabtai F, Gafter U, Klein B, Halbrecht I & Djaldetti M (1977) Phl-positive acute lymphocytic leukemia with chromosome 7 abnormalities. Blood 49, 281-87. Mitelman F, Mark J, Levan G & Levan A (1972) Tumor etiology and chromosome pattern. Science 176, 1340-41. Mitelman F, Nilsson P G, Levan G & Brandt L (1976) Nonrandom chromosome changes in acute myeloid leukemia. Chromosome banding examination of 30 cases at diagnosis. Int J Cancer 18, 31-38. Moore M A S, Spitzer G, Williams N, Metcalf D & Buckley J (1974) Agar culture studies in 127 cases of untreated acute leukemia: The prognostic value of reclassification of leukemia according to in vitro growth characteristics. Blood 44, 1-18. Nowell P C & Hungerford D A (1960) A minute chromosome in human granulocytic leukaemia. Science 132, 1497. Peterson L C,Bloomfield C D & Brunning R D (1976) Blast crisis as a n initial or terminal manifestation of chronic myeloid leukemia. A m J Med 60, 209-20. Philip P, Muller-Berat N & Killman S-Aa (1976) Philadelphia chromosome in acute lymphocytic leukaemia. Hereditas 84, 231-32. Pike B & Robinson W A (1970) Human bone marrow culture in agar gel. J Cell Physiol 76, 77-84. Rowley J D (1973) A new consistent chromosomal abnormality in chronic myelogenous leukaemia identified by quinacrine fluorescence and Giemsa staining. Nature 243, 290-93. Secker-Walker L M & Hardy J D (1976) Philadelphia chromosome in acute leukemia. Cancer 38, 1619-24. Sonta S, Oshimura M & Sandberg A A (1976) Chromosomes and causation of human cancer and leukemia. XXI. Cytogenetically unusual cases of leukemia. Blood 48, 697-705.
