GENES, CHROMOSOMES & CANCER 35-1
(1991)
Chromosome I6 Abnormalities Associated With Myeloid Malignancies Lynda J. Campbell, Jacqueline Challis, Thomas Fok, and 0. Margaret Carson Department of Cytogenetics, St. Vincent’s Hospital, Melbourne, Australia (L.J.C..J.C..O.M.G.) and Department of Haematology, Royal Children’s Hospital, Melbourne, Australia (T.F.)
Twenty-six patients who had cytogenetic analyses performed for myeloid malignancies at St. Vincent’s Hospital over a 6-year period were found to have an inversion abnormality of chromosome I 6 (25 patients) or t ( 16; 16) (I patient). Only I 6 patients had all the features of M4Eo, while the other 10 patients had diagnoses of M2, M4, M5, WEB, and WEB-T; six of these had abnormal eosinophils. Thus, abnormal eosinophils were present in 22 of 26 patients (85%). Thirteen patients had additional cytogenetic abnormalities at diagnosis, the commonest being +8 in 5, del(7q) in 4, and +21 in 3. Twenty-three patients received chemotherapy and 20 (87%) achieved complete remission. The median survival of the treated group was I88 weeks with a 6 I% 2-year and 45% 5-year survival. No significant difference in survival was observed between those patients with a diagnosis of M4Eo and those with other diagnoses suggesting that it is the abnormality of chromosome I 6 which confers an improved prognosis. Additional cytogenetic abnormalities present at diagnosis did not affect prognosis. CNS relapse was observed in only t w o patients (8%), thus indicating no increased incidence of this complication. This study supports the premise that a chromosome abnormality involving 16p13 and 16q22 defines a good prognosis subset of myeloid leukemia despite morphological variations.
INTRODUCTION
In 1983, a clinicopathological subset of acute nonlymphocytic leukemia (ANLL) was described by Arthur and Bloomfield (1983). In 5 cases from a series of 60 patients with ANLL, bone marrow eosinophilia was found to be associated with a deletion of chromosome 16 a t band 16q22. L e Beau et al. (1983) further defined this entity when they identified 18 patients among 308 cases of newly diagnosed ANLL. These patients all had the features of acute myelomonocytic leukemia (AMMLM4) together with the presence of abnormal eosinophils in the bone marrow which has come to be designated M4Eo in the morphological FAB classification (Bennett et al., 1985). On cytogenetic analysis, all 18 patients were found to have a pericentric inversion of chromosome 16 with breaks on both the short arm a t band p13 and the long arm at band q22 with subsequent rejoining of the inverted segment. A further abnormality of chromosome 16 associated with M4Eo was described by Hogge et al. in 1984. This was a translocation between the short arm of one chromosome 16 and the long arm of the other, with breaks at p13 and q22 as in the inversion 16. Arthur and Bloomfield (1983) and subsequently Le Beau e t al. (1983) observed that this group of patients appeared to have an improved survival compared with ANLL patients as a whole. This finding has been supported by data from other groups (Holmes et al., 1985; Larson et al., 1986) 0 1991 WILEY-LISS, INC.
but an increased incidence of central nervous system (CNS) leukemia at relapse has also been described (Bernard e t al., 1989; Holmes e t al., 1985; Ohyashiki et al., 1988) indicating that modified treatment regimens may be required for this group. T o investigate the pathological and clinical features of patients with this type of myeloid leukemia, we undertook a retrospective study of patients whose cytogenetic analysis in our department had revealed one of the characteristic abnormalities of chromosome 16. PATIENTS AND METHODS
Between January 1982 and December 1987, 452 patients with ANLL and over 1,500 patients with a myelodysplastic syndrome (MDS) had bone marrow cytogenetic analyses performed in the St. Vincent’s Hospital Department of Cytogenetics. Twenty-six patients were found to have either inv(l6) or t(16;16) and they form the basis of this study. Cytogenetic analysis was performed on Gbanded preparations of bone marrow in all cases. Routine culturing and banding techniques were used as previously described (Webber and Garson, 1983). Clinical details were obtained from a review of the medical records of each patient and followReceived January 30, 1990; accepted October 10, 1990. Address reprint requests to Associate Professor 0. Margaret Garson, Director, Department of Cytogenetics, St. Vincent’s Hospital, Victoria Parade, Fitzroy, Victoria, Australia, 3065.
56
CAMPBELL E T AL.
up was available on all but one patient (Patient No. 15). T h e diagnostic marrow aspirates were reviewed for all but one patient (Patient No. 24) by LJC and their FAB classification affirmed or revised according to Bennett et al. (1982, 1985). Actuarial patient survival analysis was done using statistical software (EPILOG PLUS, Los Angeles) and the logrank statistics (EPILOG PLUS 1988). Multivariate analysis was performed using the Cox model. Differences at the level of P < 0.05 were considered significant. RESULTS
Clinical details of the 26 patients are summarised
in Table 1 . Their ages ranged from 1 to 71 years with a median age of 33 years and the group comprised 13 males and 13 females. Sixteen patients had the hematological features of AMML M4Eo and a further two patients (Nos. 18 and 22) with a diagnosis of refractory anemia with excess blasts in transformation (RAEB-T) on the basis of less than 30% blast cells in the bone marrow, had the other features of M4Eo, namely monocytoid cells, bone marrow eosinophilia, and abnormal eosinophils. Three patients had AMoL M5, all of whom had abnormal eosinophils in the bone marrow and two patients had AML MZ, one with abnormal eosinophils. One patient had AMML M4 with only 4%
TABLE I. Clinical, Hematological, and Survival Data for All Patients
Patient No.
Age (years)
Diagnosis (F.A.B.)
% BM blasts
WCC at diagnosis ( X IO’hter)
I 2
I.5 2
80
88.5 48.4
3
8
44
64.2
4
II
35
37. I
5
13
55
8.5
6
13
63
92. I
7
13
53
79.6
8 9 10
16 19 25
45 40 43
30.3 21.3 83.8
II
29
35
22.2
12 13
30 32
90 60
325.0 87.9
14 15 16 17 18 19 20 21 22 23 24 25 26
34 40 47 48 50 52 53 54 54 62 65 65 71
35 86 35 60 30 45 53 52 29 65 15 32
16.7 41.2 9. I 8.6 6. I 3.9 4. I 41.9 13.2 31.8 3.6 11.6 I.8
50
% BM eosinophils (and presence of abn. eos.)
Disease
Treatment’ Ara-C, DNR Ara-C, DNR, 6TG Auto Tx Ara-C, DNR, 6TG Allo-TX Ara-C, DNR, VP- I6 Auto-Tx Ara-C, DNR Auto-Tx Ara-C, DNR, 6TG Auto-Tx Ara-C, DNR, 6TG Auto-Tx Ara-C, DNR, VP16 Ara-C, DNR Ara-C, DNR Allo-Tx in 3rd CR Ara-C, DNR, VP I6 Allo-TX Nil Ara-C, DNR, VP I6 Allo-TX Ara-C, DNR, 6TG Ara-C, DNR Ara-C, DNR, VP16 Ara-C, DNR, VP16 Nil Ara-C, DNR, VP16 Ara-C, ADR Ara-C, AMSA, 6TG Ara-C, DNR, VP16 Ara-C, DNR, 6TG Low dose Ara-C Nil Low Dose Ara-C
free survival (weeks)
Overall survival (weeks)
161+
12 I68+
43
50
+
303+
I72+
179+
93+
Ioo+
145+
+ 87 + 274 +
295
41 260+ 22
151
237+
24
33
54
0.4 58
48 62+ 6 69
188 69 + II I18+ 3 6 21 I26 211+ 362+ 35 19 80
-
9 60 207 35 -
+
32
An-C, cfiosine arabinoside; ADR adriamycin; DNR, daunorubicin; 6TG, 6-thioguanine; Auto Tx, autologous bone marrow transplant; Allo Tx, allogeneic bone marrow transplant; CR, complete remission. Transformed to AML (M4) as terminal event. NR, not recorded.
57
CHROMOSOME 16 ABNORMALITIES IN ANLL AND MDS
bone marrow eosinophils and no evidence of abnormal eosinophils morphologically or on chloroacetate-stained slides. T h e remaining two patients had refractory anemia with excess blasts (RAEB), one of whom developed AMML M4 but without abnormal eosinophils as a terminal event. T h e ten patients who did not have M4Eo included 6 with abnormal eosinophils in their diagnostic bone marrow aspirates. Thus, abnormal eosinophils were present in 22 of 26 patients (85%). T h e cytogenetic data are presented in Table 2 . Twenty-five patients had inv( 16)(p13qZ2) and one patient had a translocation involving both 16 chromosomes, viz. t( 16; 16)(p13;q22). Thirteen patients (50%) had an additional chromosome abnormality at diagnosis. T h e most common additional numerical abnormality was trisomy 8, which oc-
curred in 5 patients, in 3 of whom it was the only additional abnormality. Trisomy 21 occurred in 3 patients, and was the sole additional abnormality in one. A partial deletion of the long arms of chromosome 7 was the most common additional structural abnormality occurring in 4 patients, with breakpoints at q22 in two patients and q32 in two others. There were two additional translocations which involved chromosome 17 but at different sites. Patients 16 and 18 presented with two apparently independent clones in addition to the inv 16. Both contained a del(7q) in one clone and trisomy 8 in the other, but in patient 18 there was an extra 9 and 21 as well. Twenty-three patients received active treatment and 20 (87%) achieved complete remission. Of the five patients who received no chemotherapy, Pa-
TABLE 2. Chromosome Abnormalities in Bone Marrow Cells Patient No.
Diagnosis
Total No. of cells analysed II 21 14 21 17 17 20 35
II 13 13 10 II 10 10 23
9 10 II 12 13 14 15 16
M4Eo WEB-T
17 18
20 23
20 19 21 20 II
19 20 21 22 23 24
WEB-M4
13
16 21
25 26 Developed +8 (80%) at relapse. Developed +8, +9, 14, +21 at relapse.
+
Karyotype at diagnosis 46,XX,inv( I6)(p I 3q22) 46,XX,de1(7)(q22),inv( I6)(p I3q22) 46,XY,inv( I6)(pl3q22) 46,XY,inv( I6)(pl3q22) 46,XX(50%)/47,XX,+21 ,inv( I6)(pl3q22) (50%) 46,XX,inv( I6)(p I3q22) 46,XY(5%)/46,XY,inv( I6)(pl3q22) (95%) 46,XY,t( 16; I6)(p I 3;q22) (44%)/ 45,XY.- 20,inv(2 I)(p I2q I I), t( I 6; I6)(p I 3;q22) (56%) 46,XX,inv( I6)(p I 3q22),t(8; I7)(q22;q I I) 46,XY,inv( I6)(pl3q22),t( 16;17)(p12;q2S) 47,XY,+8,inv( 16)(pl3q22) 46,XY,inv( I6)(pl3q22) 46,XY,inv( I6)(pl3q22) 46,XX(50%)/46,XX,inv( I6)(p I 3q22) (50%)a 47,XY,+22,deI(7)(q32),inv( I6)(p I 3q22) 46,XY,inv( I6)(p I3q22)(20%)/ 46,XY,de1(7)(q32),inv( I6)(p I 3q22)(40%)/ 47,XY,+8,inv( 16)(pl3q22) (40%) 49,XX,+8,+ I3,+21,inv(16)(pl3q22) 46.XX(2 I %)/46,XX,inv( I6)(p I 3q22)(44%)/ 46,XX,del(7)(q22),inv( I6)(p I 3q22)(22%)1 49,XX,+8,+9,+21,inv(I6)(p13q22) (13%) 46,XX,inv( I6)(p I3q22) 46,XX,inv( I6)(p I3q22) 46,XX,inv( I6)(p I3q22) 46,XY,inv( I6)(pl3q22) 46,XY,inv( Ib)(pl3q22)(50%)/ 47,XY,+8,inv( I6)(pl3q22) (50%) 46,XX,inv( I6)(p I3q22)(50%)b/ 46,XX,-2,inv( 16)(pl3q22), +der(Z)t(Z!)(p23;?) (50%) 46,XX(87%)/46,XX,inv( I6)(p I 3q22) (I 3%) 48,XX,+9,+22,inv( I6)(pl3q22)
58
CAMPBELL ET AL.
tient 9 died within 3 days of diagnosis with severe sepsis, Patient 18 had coexistent disseminated adenocarcinoma of the cervix, and Patient 25 had a myelodysplastic syndrome and died of hemorrhagic complications after symptomatic treatment only. Several different therapeutic regimens were utilised as patients were managed in different institutions. However, 21 (91%) received variations of standard induction regimens which included daunarubicin and cytosine arabinoside and 19 achieved complete remission. Two patients were treated with low dose cytosine arabinoside only (Patient No. 26 with ANLL and Patient 24 with RAEB). Patient 26 achieved complete remission on this regime. T h e median survival of the treated group was 188 weeks with a 61% 2-year and 45% 5-year survival (Fig. 1). Patients 2,4, 5, 6, and 7 were all children treated in the same institution with similar induction and consolidation therapy followed by high dose melphalan and autologous bone marrow transplantation. These patients all remain disease free, a median of 143 weeks posttransplant (range 41-274 weeks). Four patients received allogeneic bone marrow transplants. Patients 3, 11, and 13 died in remission of transplant-related complications, whereas patient 10, transplanted in third remission, remains disease free at 237 weeks postdiagnosis and 136 weeks posttransplant.
T h e survival of those patients with all the features of M4Eo was compared to the survival of patients with other diagnoses and no significant difference was observed ( P = 0.5278) (Fig. 2). Furthermore, no difference in survival was observed between patients with chromosome 16 abnormalities only and patients with additional chromosome abnormalities at diagnosis ( P = 0.9889) (Fig. 3). Leukemic involvement of the central nervous system (CNS) was not evident in any patient at diagnosis clinically nor on lumbar puncture (10 patients had cerebrospinal fluid examined at diagnosis). Of the patients who relapsed after attaining complete remission, only two (Patients 14 and 22) developed CNS as well as bone marrow disease at first and second relapse respectively. Both patients achieved further remissions but died of progressive disease a t 188 and 126 weeks after diagnosis. DISCUSSION
Since Arthur and Bloomfield’s first description (1983) of the association of a subset of ANLL with bone marrow eosinophilia and a cytogenetic abnormality involving chromosome 16, over 120 cases of M4 with abnormalities of chromosome 16 at the breakpoints p13 and q22 have been published (Mitelman, 1988). Most cases have had all the features of M4Eo although occasional cases of M2, M4
+ Disease Free Survival (N=20)
-
0
50
100
150
200
Survival (N=26)
250
3 00
350
WEEKS Figure I.
Overall survival curve for all 26 patients and disease free survival curve for those patients who achieved CR.
400
59
CHROMOSOME 16 ABNORMALITIES IN ANLL AND MDS
1.00
0.75
p = 0.5278
0.50
M4Eo N=16
0.25
I
I
I
I
1
1
Other Diagnosis N=4
I
0.00 1
0 Figure 2.
2
YEARS
3
4
5
6
Survival curves of treated patients with the diagnosis of M4Eo compared with other diagnoses.
cluded 10 patients with inv(l6) or del(l6q) with diagnoses of M1, M2 and M5. Of our 26 patients, only 16 had all the features of M4Eo. T h e remaining 10 patients had other FAB types of ANLL or
without abnormal eosinophils, and M5 have been described with inversion 16 (Bernard et al., 1989; Larson eta]., 1986; Yunis, 1984). A recent report of childhood ANLL by Raimondi et a]. (1989) in-
-
- chromosome 16 abnormality only (N=12) additional abnormalities (N=l1)
p=0.9889
I I
0.00
I
I
A
1 1
I
I
1
1
1
1
60
CAMPBELL ET AL.
myelodysplastic syndromes, although 6 of these had either a bone marrow eosinophilia or abnormal eosinophils. T h e survival of our group was significantly improved compared with the published survival data for ANLL in general (Arthur et al., 1989), and no difference in survival was observed between those patients with M4Eo and those with other diagnoses. Therefore, the presence of a specific abnormality of chromosome 16 appears to be the feature which confers a good prognosis to this group rather than the M4Eo subgroup of the FAB classification. Thirteen of our 26 patients (50%)had additional cytogenetic abnormalities present at diagnosis, the most frequent being trisomy 8 in 5 patients, deletion of the long arm of 7 in 4 patients, and trisomy 21 in 3 patients. Abnormalities additional to those involving 16 have frequently been described in the literature. Larson et al. (1986) described 6 patients with trisomy 22, 4 patients with trisomy 8, and 3 patients with del(7q) in addition to chromosome 16 abnormalities, and Holmes et al. (1985) also reported trisomy 8 and trisomy 22 as frequent additions. Two of our patients had trisomy 22 and a further 2 had trisomy 9. Comparing the survival data for those patients with chromosome 16 abnormalities alone with those patients with additional abnormalities at diagnosis revealed no significant difference, indicating that the presence of additional abnormalities at diagnosis does not adversely affect prognosis. CNS involvement is an uncommon complication of ANLL, reported in only 7-1 1% of cases (Stewart et al, 1981). However, it has been reported in the M4Eo subgroup at relapse in up to 35% of cases (Holmes et al., 1985) characteristically with mass lesions demonstrable on CT scanning (Glass et al., 1987). T h e incidence of 8% in our series is comparable with that of ANLL in general. Larson et al. (1986) also failed to observe a marked increase in the incidence of this complication. However, preparatory chemotherapy and/or radiotherapy regimens for autologous and allogeneic bone marrow transplants received by 9 of our patients may have affected the incidence of CNS relapse in these patients. Ohyashiki et al. (1988) suggested that the presence of additional chromosome abnormalities at diagnosis increased the likelihood of CNS relapse but we found no evidence to support this suggestion. In conclusion, we have found that myeloid malignancies with associated bone marrow eosinophilia, abnormal eosinophils, and inv( 16) or t( 16; 16) are a morphologically diverse group en-
compassing several FAB subtypes of ANLL and MDS. Our patients, however, share the good prognosis ascribed to M4Eo, thus emphasising the importance of a classification of leukemias based on cytogenetic data rather than strict adherence to morphological criteria. ACKNOWLEDGMENTS
This study was performed while LJC, JC, and OMG were members of the staff of the Cytogenetics Department of St. Vincent’s Hospital. We are indebted to the hospital for permission to publish. T h e authors wish to thank Miss J. Osbourne for typing the manuscript and Dr. W. Kelly for assistance with the illustrations. OMG is in receipt of grants from the Anti-Cancer Council of Victoria and LJC is the Anti-Cancer Council of Victoria Keogh Fellow in cytogenetics. REFERENCES Arthur DC, Berger R, Golomb HM, Swansbury GJ, Reeves BR, Alimena G, Van Den Berghe H , Bloomfield CD, d e la Chapelle A, Dewald GW, Garson O M , Hagemeijer A, Kaneko Y, Mitelman F, Pierre RV, Ruutu T, Sakurai M, Lawler SD, Rowley J D (1989) T h e clinical significance of karyotype in acute myelogenous leukemia. Cancer Genet Cytogenet 40203-216. Arthur DC, Bloomfield C D (1983) Partial deletion of the long arm of chromosome 16 and bone marrow eosinophilia in acute nonlymphocytic leukemia: A new association. Blood 61:994-998. Bennett JM, Catovsky D, Daniel M T , Flandrin G, Galton DAG, Gralnick HR, Sultan C (1982) Proposals for the classification of the myelodysplastic syndromes. Br J Haematol 51: 189-199. Bennett JM, Catovsky D, Daniel M T , Flandrin G, Galton DAG, Gralnick HR, Sultan C (1985) Proposed revised criteria for the classification of acute myeloid leukemia: A report of the FrenchAmerican-British Cooperative Group. Ann Intern Med 103:62& 625. Bernard P, Dachary D, Reiffers J , Marit G, Wen 2, Jonveaux P, David B, Lacombe F , Broustet A (1989) Acute nonlymphocytic leukemia with marrow eosinophilia and chromosome 16 abnormality: A report of 18 cases. Leukemia 3:740-745. Glass JP, Van Tassel P, Keating MJ, Cork A, Trujillo J. Holmes R (1987) Central nervous system complications of a newly recognised subtype of leukemia: AMML with a pericentric inversion of chromosome 16. Neurology 37:639-644. Hogge D E , Misawa S, Parsa NZ, Pollak A, Testa JR (1984) Abnormalities of chromosome 16 in association with acute myelomonocytic leukemia and dysplastic bone marrow eosinophils. J Clin Oncol 6:55&557. Holmes R, Keating MJ, Cork A, Broach Y, Trujillo J, Dalton WT, McCredie KB, Freireich EJ (1985) A unique pattern of central nervous system leukemia in acute myelomonocytic leukemia associated with inv(16)(p13q22). Blood 65:1071-1978. Larson RA, Williams SF, Le Beau MM, Bitter MA, Vardiman JW, Rowley J D (1986) Acute myelomonocytic leukemia with abnormal eosinophils and inv( 16) or t(16; 16) has a favorable prognosis. Blood 68:1242-1249. L e Beau MM, Larson RA, Bitter MA, Vardiman JW, Golomb HM, Rowley J D (1983) Association of an inversion of chromosome 16 with abnormal marrow eosinophils in acute myelomonocytic leukemia. N Engl J Med 309:63&363. Mitelman F (1988) Catalog of Chromosome Aberrations in Cancer, 3rd ed. New York: Alan R Liss, pp 675-685.
CHROMOSOME 16 ABNORMALITIES IN ANLL AND MDS
Ohyashiki K, Ohyashiki JH, Iwabuchi A, Ito H, Toyama K (1988) Central nervous system involvement in acute nonlymphocytic leukemia with inv(16)(p13q22). Leukemia 2398-399. Raimondi SC, Kalwinsky DK, Hayashi Y, Behm FG, Mirro J. Williams DL (1989) Cytogenetics of childhood acute nonlymphocytic leukemia. Cancer Genet Cytogenet 4 0 13-27. Stewart DJ. Keating MJ, McCredie KB, Smith T L , Youness E, Murphy SG, Bodey GP, Freireich EJ (1981) Natural history of
61
central nervous system acute leukemia in adults. Cancer 47: 184196. Webber LM, Garson OM (1983) Fluorodeoxyuridine synchronization of bone marrow cultures. Cancer Genet Cytogenet 8: 123132. Yunis JJ (1984) Recurrent chromosomal defects are found in most patients with acute nonlymphocytic leukemia. Cancer Genet Cytogenet 11:125-137.
(1991)
Chromosome I6 Abnormalities Associated With Myeloid Malignancies Lynda J. Campbell, Jacqueline Challis, Thomas Fok, and 0. Margaret Carson Department of Cytogenetics, St. Vincent’s Hospital, Melbourne, Australia (L.J.C..J.C..O.M.G.) and Department of Haematology, Royal Children’s Hospital, Melbourne, Australia (T.F.)
Twenty-six patients who had cytogenetic analyses performed for myeloid malignancies at St. Vincent’s Hospital over a 6-year period were found to have an inversion abnormality of chromosome I 6 (25 patients) or t ( 16; 16) (I patient). Only I 6 patients had all the features of M4Eo, while the other 10 patients had diagnoses of M2, M4, M5, WEB, and WEB-T; six of these had abnormal eosinophils. Thus, abnormal eosinophils were present in 22 of 26 patients (85%). Thirteen patients had additional cytogenetic abnormalities at diagnosis, the commonest being +8 in 5, del(7q) in 4, and +21 in 3. Twenty-three patients received chemotherapy and 20 (87%) achieved complete remission. The median survival of the treated group was I88 weeks with a 6 I% 2-year and 45% 5-year survival. No significant difference in survival was observed between those patients with a diagnosis of M4Eo and those with other diagnoses suggesting that it is the abnormality of chromosome I 6 which confers an improved prognosis. Additional cytogenetic abnormalities present at diagnosis did not affect prognosis. CNS relapse was observed in only t w o patients (8%), thus indicating no increased incidence of this complication. This study supports the premise that a chromosome abnormality involving 16p13 and 16q22 defines a good prognosis subset of myeloid leukemia despite morphological variations.
INTRODUCTION
In 1983, a clinicopathological subset of acute nonlymphocytic leukemia (ANLL) was described by Arthur and Bloomfield (1983). In 5 cases from a series of 60 patients with ANLL, bone marrow eosinophilia was found to be associated with a deletion of chromosome 16 a t band 16q22. L e Beau et al. (1983) further defined this entity when they identified 18 patients among 308 cases of newly diagnosed ANLL. These patients all had the features of acute myelomonocytic leukemia (AMMLM4) together with the presence of abnormal eosinophils in the bone marrow which has come to be designated M4Eo in the morphological FAB classification (Bennett et al., 1985). On cytogenetic analysis, all 18 patients were found to have a pericentric inversion of chromosome 16 with breaks on both the short arm a t band p13 and the long arm at band q22 with subsequent rejoining of the inverted segment. A further abnormality of chromosome 16 associated with M4Eo was described by Hogge et al. in 1984. This was a translocation between the short arm of one chromosome 16 and the long arm of the other, with breaks at p13 and q22 as in the inversion 16. Arthur and Bloomfield (1983) and subsequently Le Beau e t al. (1983) observed that this group of patients appeared to have an improved survival compared with ANLL patients as a whole. This finding has been supported by data from other groups (Holmes et al., 1985; Larson et al., 1986) 0 1991 WILEY-LISS, INC.
but an increased incidence of central nervous system (CNS) leukemia at relapse has also been described (Bernard e t al., 1989; Holmes e t al., 1985; Ohyashiki et al., 1988) indicating that modified treatment regimens may be required for this group. T o investigate the pathological and clinical features of patients with this type of myeloid leukemia, we undertook a retrospective study of patients whose cytogenetic analysis in our department had revealed one of the characteristic abnormalities of chromosome 16. PATIENTS AND METHODS
Between January 1982 and December 1987, 452 patients with ANLL and over 1,500 patients with a myelodysplastic syndrome (MDS) had bone marrow cytogenetic analyses performed in the St. Vincent’s Hospital Department of Cytogenetics. Twenty-six patients were found to have either inv(l6) or t(16;16) and they form the basis of this study. Cytogenetic analysis was performed on Gbanded preparations of bone marrow in all cases. Routine culturing and banding techniques were used as previously described (Webber and Garson, 1983). Clinical details were obtained from a review of the medical records of each patient and followReceived January 30, 1990; accepted October 10, 1990. Address reprint requests to Associate Professor 0. Margaret Garson, Director, Department of Cytogenetics, St. Vincent’s Hospital, Victoria Parade, Fitzroy, Victoria, Australia, 3065.
56
CAMPBELL E T AL.
up was available on all but one patient (Patient No. 15). T h e diagnostic marrow aspirates were reviewed for all but one patient (Patient No. 24) by LJC and their FAB classification affirmed or revised according to Bennett et al. (1982, 1985). Actuarial patient survival analysis was done using statistical software (EPILOG PLUS, Los Angeles) and the logrank statistics (EPILOG PLUS 1988). Multivariate analysis was performed using the Cox model. Differences at the level of P < 0.05 were considered significant. RESULTS
Clinical details of the 26 patients are summarised
in Table 1 . Their ages ranged from 1 to 71 years with a median age of 33 years and the group comprised 13 males and 13 females. Sixteen patients had the hematological features of AMML M4Eo and a further two patients (Nos. 18 and 22) with a diagnosis of refractory anemia with excess blasts in transformation (RAEB-T) on the basis of less than 30% blast cells in the bone marrow, had the other features of M4Eo, namely monocytoid cells, bone marrow eosinophilia, and abnormal eosinophils. Three patients had AMoL M5, all of whom had abnormal eosinophils in the bone marrow and two patients had AML MZ, one with abnormal eosinophils. One patient had AMML M4 with only 4%
TABLE I. Clinical, Hematological, and Survival Data for All Patients
Patient No.
Age (years)
Diagnosis (F.A.B.)
% BM blasts
WCC at diagnosis ( X IO’hter)
I 2
I.5 2
80
88.5 48.4
3
8
44
64.2
4
II
35
37. I
5
13
55
8.5
6
13
63
92. I
7
13
53
79.6
8 9 10
16 19 25
45 40 43
30.3 21.3 83.8
II
29
35
22.2
12 13
30 32
90 60
325.0 87.9
14 15 16 17 18 19 20 21 22 23 24 25 26
34 40 47 48 50 52 53 54 54 62 65 65 71
35 86 35 60 30 45 53 52 29 65 15 32
16.7 41.2 9. I 8.6 6. I 3.9 4. I 41.9 13.2 31.8 3.6 11.6 I.8
50
% BM eosinophils (and presence of abn. eos.)
Disease
Treatment’ Ara-C, DNR Ara-C, DNR, 6TG Auto Tx Ara-C, DNR, 6TG Allo-TX Ara-C, DNR, VP- I6 Auto-Tx Ara-C, DNR Auto-Tx Ara-C, DNR, 6TG Auto-Tx Ara-C, DNR, 6TG Auto-Tx Ara-C, DNR, VP16 Ara-C, DNR Ara-C, DNR Allo-Tx in 3rd CR Ara-C, DNR, VP I6 Allo-TX Nil Ara-C, DNR, VP I6 Allo-TX Ara-C, DNR, 6TG Ara-C, DNR Ara-C, DNR, VP16 Ara-C, DNR, VP16 Nil Ara-C, DNR, VP16 Ara-C, ADR Ara-C, AMSA, 6TG Ara-C, DNR, VP16 Ara-C, DNR, 6TG Low dose Ara-C Nil Low Dose Ara-C
free survival (weeks)
Overall survival (weeks)
161+
12 I68+
43
50
+
303+
I72+
179+
93+
Ioo+
145+
+ 87 + 274 +
295
41 260+ 22
151
237+
24
33
54
0.4 58
48 62+ 6 69
188 69 + II I18+ 3 6 21 I26 211+ 362+ 35 19 80
-
9 60 207 35 -
+
32
An-C, cfiosine arabinoside; ADR adriamycin; DNR, daunorubicin; 6TG, 6-thioguanine; Auto Tx, autologous bone marrow transplant; Allo Tx, allogeneic bone marrow transplant; CR, complete remission. Transformed to AML (M4) as terminal event. NR, not recorded.
57
CHROMOSOME 16 ABNORMALITIES IN ANLL AND MDS
bone marrow eosinophils and no evidence of abnormal eosinophils morphologically or on chloroacetate-stained slides. T h e remaining two patients had refractory anemia with excess blasts (RAEB), one of whom developed AMML M4 but without abnormal eosinophils as a terminal event. T h e ten patients who did not have M4Eo included 6 with abnormal eosinophils in their diagnostic bone marrow aspirates. Thus, abnormal eosinophils were present in 22 of 26 patients (85%). T h e cytogenetic data are presented in Table 2 . Twenty-five patients had inv( 16)(p13qZ2) and one patient had a translocation involving both 16 chromosomes, viz. t( 16; 16)(p13;q22). Thirteen patients (50%) had an additional chromosome abnormality at diagnosis. T h e most common additional numerical abnormality was trisomy 8, which oc-
curred in 5 patients, in 3 of whom it was the only additional abnormality. Trisomy 21 occurred in 3 patients, and was the sole additional abnormality in one. A partial deletion of the long arms of chromosome 7 was the most common additional structural abnormality occurring in 4 patients, with breakpoints at q22 in two patients and q32 in two others. There were two additional translocations which involved chromosome 17 but at different sites. Patients 16 and 18 presented with two apparently independent clones in addition to the inv 16. Both contained a del(7q) in one clone and trisomy 8 in the other, but in patient 18 there was an extra 9 and 21 as well. Twenty-three patients received active treatment and 20 (87%) achieved complete remission. Of the five patients who received no chemotherapy, Pa-
TABLE 2. Chromosome Abnormalities in Bone Marrow Cells Patient No.
Diagnosis
Total No. of cells analysed II 21 14 21 17 17 20 35
II 13 13 10 II 10 10 23
9 10 II 12 13 14 15 16
M4Eo WEB-T
17 18
20 23
20 19 21 20 II
19 20 21 22 23 24
WEB-M4
13
16 21
25 26 Developed +8 (80%) at relapse. Developed +8, +9, 14, +21 at relapse.
+
Karyotype at diagnosis 46,XX,inv( I6)(p I 3q22) 46,XX,de1(7)(q22),inv( I6)(p I3q22) 46,XY,inv( I6)(pl3q22) 46,XY,inv( I6)(pl3q22) 46,XX(50%)/47,XX,+21 ,inv( I6)(pl3q22) (50%) 46,XX,inv( I6)(p I3q22) 46,XY(5%)/46,XY,inv( I6)(pl3q22) (95%) 46,XY,t( 16; I6)(p I 3;q22) (44%)/ 45,XY.- 20,inv(2 I)(p I2q I I), t( I 6; I6)(p I 3;q22) (56%) 46,XX,inv( I6)(p I 3q22),t(8; I7)(q22;q I I) 46,XY,inv( I6)(pl3q22),t( 16;17)(p12;q2S) 47,XY,+8,inv( 16)(pl3q22) 46,XY,inv( I6)(pl3q22) 46,XY,inv( I6)(pl3q22) 46,XX(50%)/46,XX,inv( I6)(p I 3q22) (50%)a 47,XY,+22,deI(7)(q32),inv( I6)(p I 3q22) 46,XY,inv( I6)(p I3q22)(20%)/ 46,XY,de1(7)(q32),inv( I6)(p I 3q22)(40%)/ 47,XY,+8,inv( 16)(pl3q22) (40%) 49,XX,+8,+ I3,+21,inv(16)(pl3q22) 46.XX(2 I %)/46,XX,inv( I6)(p I 3q22)(44%)/ 46,XX,del(7)(q22),inv( I6)(p I 3q22)(22%)1 49,XX,+8,+9,+21,inv(I6)(p13q22) (13%) 46,XX,inv( I6)(p I3q22) 46,XX,inv( I6)(p I3q22) 46,XX,inv( I6)(p I3q22) 46,XY,inv( I6)(pl3q22) 46,XY,inv( Ib)(pl3q22)(50%)/ 47,XY,+8,inv( I6)(pl3q22) (50%) 46,XX,inv( I6)(p I3q22)(50%)b/ 46,XX,-2,inv( 16)(pl3q22), +der(Z)t(Z!)(p23;?) (50%) 46,XX(87%)/46,XX,inv( I6)(p I 3q22) (I 3%) 48,XX,+9,+22,inv( I6)(pl3q22)
58
CAMPBELL ET AL.
tient 9 died within 3 days of diagnosis with severe sepsis, Patient 18 had coexistent disseminated adenocarcinoma of the cervix, and Patient 25 had a myelodysplastic syndrome and died of hemorrhagic complications after symptomatic treatment only. Several different therapeutic regimens were utilised as patients were managed in different institutions. However, 21 (91%) received variations of standard induction regimens which included daunarubicin and cytosine arabinoside and 19 achieved complete remission. Two patients were treated with low dose cytosine arabinoside only (Patient No. 26 with ANLL and Patient 24 with RAEB). Patient 26 achieved complete remission on this regime. T h e median survival of the treated group was 188 weeks with a 61% 2-year and 45% 5-year survival (Fig. 1). Patients 2,4, 5, 6, and 7 were all children treated in the same institution with similar induction and consolidation therapy followed by high dose melphalan and autologous bone marrow transplantation. These patients all remain disease free, a median of 143 weeks posttransplant (range 41-274 weeks). Four patients received allogeneic bone marrow transplants. Patients 3, 11, and 13 died in remission of transplant-related complications, whereas patient 10, transplanted in third remission, remains disease free at 237 weeks postdiagnosis and 136 weeks posttransplant.
T h e survival of those patients with all the features of M4Eo was compared to the survival of patients with other diagnoses and no significant difference was observed ( P = 0.5278) (Fig. 2). Furthermore, no difference in survival was observed between patients with chromosome 16 abnormalities only and patients with additional chromosome abnormalities at diagnosis ( P = 0.9889) (Fig. 3). Leukemic involvement of the central nervous system (CNS) was not evident in any patient at diagnosis clinically nor on lumbar puncture (10 patients had cerebrospinal fluid examined at diagnosis). Of the patients who relapsed after attaining complete remission, only two (Patients 14 and 22) developed CNS as well as bone marrow disease at first and second relapse respectively. Both patients achieved further remissions but died of progressive disease a t 188 and 126 weeks after diagnosis. DISCUSSION
Since Arthur and Bloomfield’s first description (1983) of the association of a subset of ANLL with bone marrow eosinophilia and a cytogenetic abnormality involving chromosome 16, over 120 cases of M4 with abnormalities of chromosome 16 at the breakpoints p13 and q22 have been published (Mitelman, 1988). Most cases have had all the features of M4Eo although occasional cases of M2, M4
+ Disease Free Survival (N=20)
-
0
50
100
150
200
Survival (N=26)
250
3 00
350
WEEKS Figure I.
Overall survival curve for all 26 patients and disease free survival curve for those patients who achieved CR.
400
59
CHROMOSOME 16 ABNORMALITIES IN ANLL AND MDS
1.00
0.75
p = 0.5278
0.50
M4Eo N=16
0.25
I
I
I
I
1
1
Other Diagnosis N=4
I
0.00 1
0 Figure 2.
2
YEARS
3
4
5
6
Survival curves of treated patients with the diagnosis of M4Eo compared with other diagnoses.
cluded 10 patients with inv(l6) or del(l6q) with diagnoses of M1, M2 and M5. Of our 26 patients, only 16 had all the features of M4Eo. T h e remaining 10 patients had other FAB types of ANLL or
without abnormal eosinophils, and M5 have been described with inversion 16 (Bernard et al., 1989; Larson eta]., 1986; Yunis, 1984). A recent report of childhood ANLL by Raimondi et a]. (1989) in-
-
- chromosome 16 abnormality only (N=12) additional abnormalities (N=l1)
p=0.9889
I I
0.00
I
I
A
1 1
I
I
1
1
1
1
60
CAMPBELL ET AL.
myelodysplastic syndromes, although 6 of these had either a bone marrow eosinophilia or abnormal eosinophils. T h e survival of our group was significantly improved compared with the published survival data for ANLL in general (Arthur et al., 1989), and no difference in survival was observed between those patients with M4Eo and those with other diagnoses. Therefore, the presence of a specific abnormality of chromosome 16 appears to be the feature which confers a good prognosis to this group rather than the M4Eo subgroup of the FAB classification. Thirteen of our 26 patients (50%)had additional cytogenetic abnormalities present at diagnosis, the most frequent being trisomy 8 in 5 patients, deletion of the long arm of 7 in 4 patients, and trisomy 21 in 3 patients. Abnormalities additional to those involving 16 have frequently been described in the literature. Larson et al. (1986) described 6 patients with trisomy 22, 4 patients with trisomy 8, and 3 patients with del(7q) in addition to chromosome 16 abnormalities, and Holmes et al. (1985) also reported trisomy 8 and trisomy 22 as frequent additions. Two of our patients had trisomy 22 and a further 2 had trisomy 9. Comparing the survival data for those patients with chromosome 16 abnormalities alone with those patients with additional abnormalities at diagnosis revealed no significant difference, indicating that the presence of additional abnormalities at diagnosis does not adversely affect prognosis. CNS involvement is an uncommon complication of ANLL, reported in only 7-1 1% of cases (Stewart et al, 1981). However, it has been reported in the M4Eo subgroup at relapse in up to 35% of cases (Holmes et al., 1985) characteristically with mass lesions demonstrable on CT scanning (Glass et al., 1987). T h e incidence of 8% in our series is comparable with that of ANLL in general. Larson et al. (1986) also failed to observe a marked increase in the incidence of this complication. However, preparatory chemotherapy and/or radiotherapy regimens for autologous and allogeneic bone marrow transplants received by 9 of our patients may have affected the incidence of CNS relapse in these patients. Ohyashiki et al. (1988) suggested that the presence of additional chromosome abnormalities at diagnosis increased the likelihood of CNS relapse but we found no evidence to support this suggestion. In conclusion, we have found that myeloid malignancies with associated bone marrow eosinophilia, abnormal eosinophils, and inv( 16) or t( 16; 16) are a morphologically diverse group en-
compassing several FAB subtypes of ANLL and MDS. Our patients, however, share the good prognosis ascribed to M4Eo, thus emphasising the importance of a classification of leukemias based on cytogenetic data rather than strict adherence to morphological criteria. ACKNOWLEDGMENTS
This study was performed while LJC, JC, and OMG were members of the staff of the Cytogenetics Department of St. Vincent’s Hospital. We are indebted to the hospital for permission to publish. T h e authors wish to thank Miss J. Osbourne for typing the manuscript and Dr. W. Kelly for assistance with the illustrations. OMG is in receipt of grants from the Anti-Cancer Council of Victoria and LJC is the Anti-Cancer Council of Victoria Keogh Fellow in cytogenetics. REFERENCES Arthur DC, Berger R, Golomb HM, Swansbury GJ, Reeves BR, Alimena G, Van Den Berghe H , Bloomfield CD, d e la Chapelle A, Dewald GW, Garson O M , Hagemeijer A, Kaneko Y, Mitelman F, Pierre RV, Ruutu T, Sakurai M, Lawler SD, Rowley J D (1989) T h e clinical significance of karyotype in acute myelogenous leukemia. Cancer Genet Cytogenet 40203-216. Arthur DC, Bloomfield C D (1983) Partial deletion of the long arm of chromosome 16 and bone marrow eosinophilia in acute nonlymphocytic leukemia: A new association. Blood 61:994-998. Bennett JM, Catovsky D, Daniel M T , Flandrin G, Galton DAG, Gralnick HR, Sultan C (1982) Proposals for the classification of the myelodysplastic syndromes. Br J Haematol 51: 189-199. Bennett JM, Catovsky D, Daniel M T , Flandrin G, Galton DAG, Gralnick HR, Sultan C (1985) Proposed revised criteria for the classification of acute myeloid leukemia: A report of the FrenchAmerican-British Cooperative Group. Ann Intern Med 103:62& 625. Bernard P, Dachary D, Reiffers J , Marit G, Wen 2, Jonveaux P, David B, Lacombe F , Broustet A (1989) Acute nonlymphocytic leukemia with marrow eosinophilia and chromosome 16 abnormality: A report of 18 cases. Leukemia 3:740-745. Glass JP, Van Tassel P, Keating MJ, Cork A, Trujillo J. Holmes R (1987) Central nervous system complications of a newly recognised subtype of leukemia: AMML with a pericentric inversion of chromosome 16. Neurology 37:639-644. Hogge D E , Misawa S, Parsa NZ, Pollak A, Testa JR (1984) Abnormalities of chromosome 16 in association with acute myelomonocytic leukemia and dysplastic bone marrow eosinophils. J Clin Oncol 6:55&557. Holmes R, Keating MJ, Cork A, Broach Y, Trujillo J, Dalton WT, McCredie KB, Freireich EJ (1985) A unique pattern of central nervous system leukemia in acute myelomonocytic leukemia associated with inv(16)(p13q22). Blood 65:1071-1978. Larson RA, Williams SF, Le Beau MM, Bitter MA, Vardiman JW, Rowley J D (1986) Acute myelomonocytic leukemia with abnormal eosinophils and inv( 16) or t(16; 16) has a favorable prognosis. Blood 68:1242-1249. L e Beau MM, Larson RA, Bitter MA, Vardiman JW, Golomb HM, Rowley J D (1983) Association of an inversion of chromosome 16 with abnormal marrow eosinophils in acute myelomonocytic leukemia. N Engl J Med 309:63&363. Mitelman F (1988) Catalog of Chromosome Aberrations in Cancer, 3rd ed. New York: Alan R Liss, pp 675-685.
CHROMOSOME 16 ABNORMALITIES IN ANLL AND MDS
Ohyashiki K, Ohyashiki JH, Iwabuchi A, Ito H, Toyama K (1988) Central nervous system involvement in acute nonlymphocytic leukemia with inv(16)(p13q22). Leukemia 2398-399. Raimondi SC, Kalwinsky DK, Hayashi Y, Behm FG, Mirro J. Williams DL (1989) Cytogenetics of childhood acute nonlymphocytic leukemia. Cancer Genet Cytogenet 4 0 13-27. Stewart DJ. Keating MJ, McCredie KB, Smith T L , Youness E, Murphy SG, Bodey GP, Freireich EJ (1981) Natural history of
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central nervous system acute leukemia in adults. Cancer 47: 184196. Webber LM, Garson OM (1983) Fluorodeoxyuridine synchronization of bone marrow cultures. Cancer Genet Cytogenet 8: 123132. Yunis JJ (1984) Recurrent chromosomal defects are found in most patients with acute nonlymphocytic leukemia. Cancer Genet Cytogenet 11:125-137.
