Chronic Granulocytic Leukemia without the Philadelphia Chromosome GEORGE P. CANELLOS, M.D., JACQUELINE WHANG-PENG, AND VINCENT T. DEVITA,
M.D.,
M.D.
Medicine Branch, National Cancer Institute, Bethesda, Maryland, and Division of Medicine, Sidney Farber Cancer Center, Harvard Medical School, Boston, Massachusetts
ABSTRACT
I T HAS BEEN 16 YEARS since the discovery lute specificity for CGL is questioned by the of the Philadelphia chromosome. This observations that cases with the classic feacytogenetic abnormality is now well known tures of CGL can occur without the Ph' to occur in the marrow and peripheral chromosome. 1,5,10 blood cells of most patients who have Some of the earlier series included cases chronic granulocytic leukemia (CGL). Al- of atypical myeloproliferative disorders though the majority of patients manifest such as granulocytic leukemia of childhood well-defined hematologic characteristics, and eosinophilic leukemia. Over the past the Ph 1 chromosome has been reported to 12 years, 20 of our patients have had occur in scattered cases of unusual forms clinical and morphologic criteria of CGL, of myeloproliferative disorders. 2 - 4 Itsabso- but the Ph 1 chromosome was not found in multiple determinations during the courses Received May 6, 1975; received revised manuscript lune 19, 1975; accepted for publication June 19,
Qf
clinit h e i r iHness. T h e distinguishing . „ . . ? . ° r
Division of Medicine, Sidney Farber Cancer Center, Harvard Medical School, 35 Binney Street, Boston! Massachusetts 02115.
„ •• • . r tl u. S o m e - p o s i t i v e p a t i e n t s a r e t h e Subject o f this r e p o r t .
1975 cal features or this group or patients cornAddress reprint requests to Dr. Canellos: Chief, pared with a larger number of Ph 1 chromo-
467
Downloaded from http://ajcp.oxfordjournals.org/ by guest on June 6, 2016
Canellos, George P., Whang-Peng, Jacqueline, and DeVita, Vincent T.: Chronic granulocytic leukemia without the Philadelphia chromosome. Am J Clin Pathol 65: 467-470, 1976. Cytogenetic studies of bone marrow were performed in 230 consecutive cases of patients with chronic granulocytic leukemia (CGL) admitted to the National Cancer Institute since 1961. Twenty patients lacked the Philadelphia (Ph1) chromosome. All were previously untreated. When compared with Ph'-positive patients, CGL patients with Ph 1 negative disease had a higher median age (60 compared with 42 years) and were diagnosed at lower median leukocyte (75,000) and platelet counts (170,000). Their response to chemotherapy was generally poor, with a median survival of 15 months compared with 44 months for the Ph'-positive group. Four patients survived more than 5 years and two, more than 10 years. Thirtyfive per cent of the Ph'-negative patients had aneuploid cell lines of various percentages. Absence of the Ph 1 chromosome in patients with the hematologic characteristics of CGL is a bad prognostic sign. (Key words: Philadelphia chromosome; Chronic granulocytic leukemia; Leukemia survival.)
468
CANELLOS, WHANG-PENG, AND DEVITA
Table 1. Chronic Granulocytic Leukemia: Hematologic Findings at Diagnosis* Philadelphia Chromosome Positive
two patients in the Ph'-negative group were initially treated with busulfan but received other drugs during the courses of their illnesses.
Negative
Results 120
10.3 (6.2-16.2)
210 (17.6-609) 77%
400
(102-1,800) 0
20
11(5.9-12.4)
75 (25-218) 35%
170 (62-973) 30%
Age T h e median age for the group was 60 years, with a range of 2 0 - 8 5 years. There were 9 women. The median age for the Ph^negative group was considerably higher than the median age for the Ph 1 positive group (42 years). Only 10/120 Ph 1 positive patients were more than 60 years of age at the time of diagnosis.
* Blood counts include median and nmge.
Hematologic Features Methods T h e hematologic criteria for the diagnosis of CGL at the National Cancer Institute include (1) an unexplained persistent granulocytic leukocytosis, and a leukocyte count of 20,000 per mm. or more; (2) granulocytic hyperplasia of the bone marrow; (3) immature granulocytes in the peripheral blood; (4) absence of histologic evidence of myelosclerosis; (5) less than 20% blasts and promyelocyte cells in the marrow. Since 1961, cytogenetic studies have been performed on all new patients at the National Cancer Institute with the presumptive diagnosis of CGL. Twenty patients previously untreated with cytotoxic drugs or radiotherapy manifested the hematologic features of CGL but were Philadelphia chromosome-negative. T h e clinical and hematologic features are compared with those of a series of 120 previously untreated patients with Ph'-positive CGL. Complete follow-up information is available in all cases. Leukocyte alkaline phosphatase was determined in all cases by histochemical or biochemical methods. 6 ' 9 Chromosome studies were performed by the method of Tjio and Whang. 11 All but
T h e initial hematologic values are shown on Table 1. Sixty-five per cent of the patients had leukocyte counts > 100,000 per mm. 3 at the time of diagnosis, whereas 22% of a series of 120 consecutive previously untreated Ph'-positive patients had leukocyte counts 100,000 per mm. 3 at diagnosis, and in the latter cases the elevated counts were detected in asymptomatic patients. Thrombocytopenia, with platelet counts of less than 100,000 per mm. 3 , was found in 30% of the Ph^negative patients at diagnosis. A platelet count below 100,000 per mm. 3 was not seen in any of the Ph 1 positive patients at the time of diagnosis. T h e hemoglobin levels were comparable to those seen in Ph'-positive disease. Leukocyte alkaline phosphatase was low or absent in 94 of 101 cases of Ph•-positive CGL in the chronic phase. In the remainder the values were in the normal range. All 20 Ph^negative cases were studied, with 16 values in the low range or absent. Two patients' values were in the normal range, and two were elevated. T h e Ph'-negative cases were found to be generally refractory to therapy, with only 30% of the patients achieving good hematologic remissions. Progressive anemia and
Downloaded from http://ajcp.oxfordjournals.org/ by guest on June 6, 2016
Number of Patients Hemoglobin (Gm. per 100 ml.) Leukocyte count X 103 per mm. 3 > 100,000 Platelet count X 103 per mm. 3 < 100,000
A.J.C.P. —Vol. 65
April 1976
469
PHILADELPHIA-NEGATIVE CGL
t h r o m b o c y t o p e n i a complicated their courses, and all but two patients have died. With the exception of three patients, all died with hematologic features of blastic transformation. In one patient, a terminal aplastic anemia unrelated to chemotherapy developed. Sepsis and massive intestinal bleeding were the causes of death in the remaining two cases. Cytogenetics
Survival T h e median survival from diagnosis was 15 months, in contrast to the median of 44 months for Ph'-positive CGL (Fig. 1). There is a plateau at the bottom of the survival curve, with four patients (20%) surviving more than 5 years. T h e majority of patients die before 20 months have elapsed.
There are few prognostic indicators of the course of chronic granulocytic leukemia at the time of initial diagnosis. A few patients manifest hematologic evidence of blastic transformation. For the remainder, who have the characteristic features of the chronic phase of CGL, blastic transformation may supervene at any time in the course of the illness, usually in a median time of 3 6 - 4 0 months. T h e marrow cytogenetics do have a predictive value when there is evidence of additional aneuploidy. The latter abnormality is frequently associated with blastic transformation, and may even precede the characteristic hematologic changes. 13 Recent investigations have shed new light on the structural basis of the Ph 1 chromosome. Chromosomal material deleted from the G-22 autosome has been identified on the number 9 (group C) chromosome. 8 T h e present series of Ph 1 chromosomenegative cases has been followed for a sufficient period to define two patterns of survival. Most patients responded poorly to therapy, and within a year about half entered the blastic phase of the disease. Four patients in this series survived more than 5 years, with one patient surviving more than 144 months. T h e diagnosis of this variant of the
Chromosome Positive CGL (210 patients)
FIG. 1. Actuarial survival in 230 cases of chronic granulocytic leukemia according to the presence ol the Philadelphia chromosome. All cases followed at NCI.
o - o Chromosome Negolive (20 patients)
60 80 100 MONTHS FROM DIAGNOSIS
204
Downloaded from http://ajcp.oxfordjournals.org/ by guest on June 6, 2016
Although none of the 20 patients had the Ph 1 chromosome at any time, aneuploid cell lines were found in seven patients during the courses of their illnesses. Two patients had hypoploidy (44 chromosomes) in 10 and 100% of the metaphases, respectively. One patient had pseudodiploidy, and the remaining four patients had hyperdiploid cells of 47 chromosomes (C+) in 1, 2, 4 and 67% of the metaphases, respectively.
Discussion
470
CANELLOS, WHANG-PENG, AND DEV1TA
chronic myeloproliferative disorders entails a needle biopsy of the bone marrow to exclude the presence of myelosclerosis. T h e median survival of patients with Ph 1 chromosome-negative CGL is considerably shorter than that in previously reported series of myelosclerosis with metaplasia. 12 T h e latter disorder, with a median survival of 4 years, is more like Ph 1 chromosomepositive CGL. Thus, with respect to response to therapy and survival, the absence of the Ph 1 chromosome appears to be a poor prognostic sign.
References 1. Ezdinli EZ, Sokal JE, Crosswhite L, et al: Philadelphia chromosome-positive and -negative
3. 4. 5.
6.
7.
8.
9.
10. 11.
12.
13.
chronic myelocytic leukemia. Ann Intern Med 72:175-182, 1970 Forrester RH, Louro JM: Philadelphia chromosome abnormality in agnogenic myeloid metaplasia. Ann Intern Med 64:622-627, 1966 Heath CW, Moloney WC: T h e Philadelphia chromosome in an unusual case of myeloproliferative disease. Blood 26:471-478, 1965 Krauss S: Chronic myelocytic leukemia with features simulating myelofibrosis with myeloid metaplasia. Cancer 1:1321-1322, 1966 Krauss S, Sokal JE, Sandberg AA: Comparison of Philadelphia chromosome-positive and -negative patients with chronic myelocytic leukemia. Ann Intern Med 61:625-635, 1964 Peacock AC, Brecher G, Highsmith E: A simplified procedure for quantitative measurement of alkaline phosphatase in white blood cells. Am J Clin Pathol 29:80-85, 1958 Perillie PE, Finch SC: Muramidase studies in Philadelphia-chromosome-positive and chromosome-negative chronic granulocytic leukemia. N Engl J Med 283:456-458, 1970 Rowley JD: A new consistent chromosomal abnormality in chronic myelogenous leukemia identified by quinacrine fluorescence and Giemsa staining. Nature 243:290-293, 1973 Rutenberg AS, Rosales J, Bennett JM: An improved histochemical method for the demonstration of leukocyte alkaline phosphatase. J Lab Clin Med 65:698-705, 1965 T j i o J H , Carbone PP, Whang J, et al: T h e Philadelphia chromosome and chronic myelogenous leukemia.J Natl Cancer Inst 36:567-584, 1966 TjioJH, W h a n g J : Chromosome preparations of bone marrow cells without prior in vitro culture in vivo colchicine administration. Stain Technol 37:17-20, 1962 Ward HP, Block MH: T h e natural history of agnogenic myeloid metaplasia (AMM) and a critical evaluation of its relationship with the myeloproliferative syndrome. Medicine 50: 357-420, 1971 Whang-Peng J, Canellos GP, Carbone PP, et al: Clinical implications of cytogenetic variants in chronic myelocytic leukemia (CML). Blood 32: 755-766, 1968
Downloaded from http://ajcp.oxfordjournals.org/ by guest on June 6, 2016
T h e Rosewell Park Memorial Institute experience is consistent with these observations: in their series, the Ph'-negative patients had a median age of 66 years, and an 8-month median survival. 1 With the exception of chromosomal constitution, there is no other abnormality that characterizes adult Ph'-negative patients. It has been suggested that high urinary levels of the enzyme, muramidase or lysozyme, could be used to identify patients who are likely to be Ph'-negative. 7 This enzyme is especially abundant in monocytes, but the absolute percentage of these cells is not increased in the Ph'-negative patients. Further studies are required before this assay can be substituted for karyotypic analysis.
2.
A.J.C.P. —Vol. 65
M.D.,
M.D.
Medicine Branch, National Cancer Institute, Bethesda, Maryland, and Division of Medicine, Sidney Farber Cancer Center, Harvard Medical School, Boston, Massachusetts
ABSTRACT
I T HAS BEEN 16 YEARS since the discovery lute specificity for CGL is questioned by the of the Philadelphia chromosome. This observations that cases with the classic feacytogenetic abnormality is now well known tures of CGL can occur without the Ph' to occur in the marrow and peripheral chromosome. 1,5,10 blood cells of most patients who have Some of the earlier series included cases chronic granulocytic leukemia (CGL). Al- of atypical myeloproliferative disorders though the majority of patients manifest such as granulocytic leukemia of childhood well-defined hematologic characteristics, and eosinophilic leukemia. Over the past the Ph 1 chromosome has been reported to 12 years, 20 of our patients have had occur in scattered cases of unusual forms clinical and morphologic criteria of CGL, of myeloproliferative disorders. 2 - 4 Itsabso- but the Ph 1 chromosome was not found in multiple determinations during the courses Received May 6, 1975; received revised manuscript lune 19, 1975; accepted for publication June 19,
Qf
clinit h e i r iHness. T h e distinguishing . „ . . ? . ° r
Division of Medicine, Sidney Farber Cancer Center, Harvard Medical School, 35 Binney Street, Boston! Massachusetts 02115.
„ •• • . r tl u. S o m e - p o s i t i v e p a t i e n t s a r e t h e Subject o f this r e p o r t .
1975 cal features or this group or patients cornAddress reprint requests to Dr. Canellos: Chief, pared with a larger number of Ph 1 chromo-
467
Downloaded from http://ajcp.oxfordjournals.org/ by guest on June 6, 2016
Canellos, George P., Whang-Peng, Jacqueline, and DeVita, Vincent T.: Chronic granulocytic leukemia without the Philadelphia chromosome. Am J Clin Pathol 65: 467-470, 1976. Cytogenetic studies of bone marrow were performed in 230 consecutive cases of patients with chronic granulocytic leukemia (CGL) admitted to the National Cancer Institute since 1961. Twenty patients lacked the Philadelphia (Ph1) chromosome. All were previously untreated. When compared with Ph'-positive patients, CGL patients with Ph 1 negative disease had a higher median age (60 compared with 42 years) and were diagnosed at lower median leukocyte (75,000) and platelet counts (170,000). Their response to chemotherapy was generally poor, with a median survival of 15 months compared with 44 months for the Ph'-positive group. Four patients survived more than 5 years and two, more than 10 years. Thirtyfive per cent of the Ph'-negative patients had aneuploid cell lines of various percentages. Absence of the Ph 1 chromosome in patients with the hematologic characteristics of CGL is a bad prognostic sign. (Key words: Philadelphia chromosome; Chronic granulocytic leukemia; Leukemia survival.)
468
CANELLOS, WHANG-PENG, AND DEVITA
Table 1. Chronic Granulocytic Leukemia: Hematologic Findings at Diagnosis* Philadelphia Chromosome Positive
two patients in the Ph'-negative group were initially treated with busulfan but received other drugs during the courses of their illnesses.
Negative
Results 120
10.3 (6.2-16.2)
210 (17.6-609) 77%
400
(102-1,800) 0
20
11(5.9-12.4)
75 (25-218) 35%
170 (62-973) 30%
Age T h e median age for the group was 60 years, with a range of 2 0 - 8 5 years. There were 9 women. The median age for the Ph^negative group was considerably higher than the median age for the Ph 1 positive group (42 years). Only 10/120 Ph 1 positive patients were more than 60 years of age at the time of diagnosis.
* Blood counts include median and nmge.
Hematologic Features Methods T h e hematologic criteria for the diagnosis of CGL at the National Cancer Institute include (1) an unexplained persistent granulocytic leukocytosis, and a leukocyte count of 20,000 per mm. or more; (2) granulocytic hyperplasia of the bone marrow; (3) immature granulocytes in the peripheral blood; (4) absence of histologic evidence of myelosclerosis; (5) less than 20% blasts and promyelocyte cells in the marrow. Since 1961, cytogenetic studies have been performed on all new patients at the National Cancer Institute with the presumptive diagnosis of CGL. Twenty patients previously untreated with cytotoxic drugs or radiotherapy manifested the hematologic features of CGL but were Philadelphia chromosome-negative. T h e clinical and hematologic features are compared with those of a series of 120 previously untreated patients with Ph'-positive CGL. Complete follow-up information is available in all cases. Leukocyte alkaline phosphatase was determined in all cases by histochemical or biochemical methods. 6 ' 9 Chromosome studies were performed by the method of Tjio and Whang. 11 All but
T h e initial hematologic values are shown on Table 1. Sixty-five per cent of the patients had leukocyte counts > 100,000 per mm. 3 at the time of diagnosis, whereas 22% of a series of 120 consecutive previously untreated Ph'-positive patients had leukocyte counts 100,000 per mm. 3 at diagnosis, and in the latter cases the elevated counts were detected in asymptomatic patients. Thrombocytopenia, with platelet counts of less than 100,000 per mm. 3 , was found in 30% of the Ph^negative patients at diagnosis. A platelet count below 100,000 per mm. 3 was not seen in any of the Ph 1 positive patients at the time of diagnosis. T h e hemoglobin levels were comparable to those seen in Ph'-positive disease. Leukocyte alkaline phosphatase was low or absent in 94 of 101 cases of Ph•-positive CGL in the chronic phase. In the remainder the values were in the normal range. All 20 Ph^negative cases were studied, with 16 values in the low range or absent. Two patients' values were in the normal range, and two were elevated. T h e Ph'-negative cases were found to be generally refractory to therapy, with only 30% of the patients achieving good hematologic remissions. Progressive anemia and
Downloaded from http://ajcp.oxfordjournals.org/ by guest on June 6, 2016
Number of Patients Hemoglobin (Gm. per 100 ml.) Leukocyte count X 103 per mm. 3 > 100,000 Platelet count X 103 per mm. 3 < 100,000
A.J.C.P. —Vol. 65
April 1976
469
PHILADELPHIA-NEGATIVE CGL
t h r o m b o c y t o p e n i a complicated their courses, and all but two patients have died. With the exception of three patients, all died with hematologic features of blastic transformation. In one patient, a terminal aplastic anemia unrelated to chemotherapy developed. Sepsis and massive intestinal bleeding were the causes of death in the remaining two cases. Cytogenetics
Survival T h e median survival from diagnosis was 15 months, in contrast to the median of 44 months for Ph'-positive CGL (Fig. 1). There is a plateau at the bottom of the survival curve, with four patients (20%) surviving more than 5 years. T h e majority of patients die before 20 months have elapsed.
There are few prognostic indicators of the course of chronic granulocytic leukemia at the time of initial diagnosis. A few patients manifest hematologic evidence of blastic transformation. For the remainder, who have the characteristic features of the chronic phase of CGL, blastic transformation may supervene at any time in the course of the illness, usually in a median time of 3 6 - 4 0 months. T h e marrow cytogenetics do have a predictive value when there is evidence of additional aneuploidy. The latter abnormality is frequently associated with blastic transformation, and may even precede the characteristic hematologic changes. 13 Recent investigations have shed new light on the structural basis of the Ph 1 chromosome. Chromosomal material deleted from the G-22 autosome has been identified on the number 9 (group C) chromosome. 8 T h e present series of Ph 1 chromosomenegative cases has been followed for a sufficient period to define two patterns of survival. Most patients responded poorly to therapy, and within a year about half entered the blastic phase of the disease. Four patients in this series survived more than 5 years, with one patient surviving more than 144 months. T h e diagnosis of this variant of the
Chromosome Positive CGL (210 patients)
FIG. 1. Actuarial survival in 230 cases of chronic granulocytic leukemia according to the presence ol the Philadelphia chromosome. All cases followed at NCI.
o - o Chromosome Negolive (20 patients)
60 80 100 MONTHS FROM DIAGNOSIS
204
Downloaded from http://ajcp.oxfordjournals.org/ by guest on June 6, 2016
Although none of the 20 patients had the Ph 1 chromosome at any time, aneuploid cell lines were found in seven patients during the courses of their illnesses. Two patients had hypoploidy (44 chromosomes) in 10 and 100% of the metaphases, respectively. One patient had pseudodiploidy, and the remaining four patients had hyperdiploid cells of 47 chromosomes (C+) in 1, 2, 4 and 67% of the metaphases, respectively.
Discussion
470
CANELLOS, WHANG-PENG, AND DEV1TA
chronic myeloproliferative disorders entails a needle biopsy of the bone marrow to exclude the presence of myelosclerosis. T h e median survival of patients with Ph 1 chromosome-negative CGL is considerably shorter than that in previously reported series of myelosclerosis with metaplasia. 12 T h e latter disorder, with a median survival of 4 years, is more like Ph 1 chromosomepositive CGL. Thus, with respect to response to therapy and survival, the absence of the Ph 1 chromosome appears to be a poor prognostic sign.
References 1. Ezdinli EZ, Sokal JE, Crosswhite L, et al: Philadelphia chromosome-positive and -negative
3. 4. 5.
6.
7.
8.
9.
10. 11.
12.
13.
chronic myelocytic leukemia. Ann Intern Med 72:175-182, 1970 Forrester RH, Louro JM: Philadelphia chromosome abnormality in agnogenic myeloid metaplasia. Ann Intern Med 64:622-627, 1966 Heath CW, Moloney WC: T h e Philadelphia chromosome in an unusual case of myeloproliferative disease. Blood 26:471-478, 1965 Krauss S: Chronic myelocytic leukemia with features simulating myelofibrosis with myeloid metaplasia. Cancer 1:1321-1322, 1966 Krauss S, Sokal JE, Sandberg AA: Comparison of Philadelphia chromosome-positive and -negative patients with chronic myelocytic leukemia. Ann Intern Med 61:625-635, 1964 Peacock AC, Brecher G, Highsmith E: A simplified procedure for quantitative measurement of alkaline phosphatase in white blood cells. Am J Clin Pathol 29:80-85, 1958 Perillie PE, Finch SC: Muramidase studies in Philadelphia-chromosome-positive and chromosome-negative chronic granulocytic leukemia. N Engl J Med 283:456-458, 1970 Rowley JD: A new consistent chromosomal abnormality in chronic myelogenous leukemia identified by quinacrine fluorescence and Giemsa staining. Nature 243:290-293, 1973 Rutenberg AS, Rosales J, Bennett JM: An improved histochemical method for the demonstration of leukocyte alkaline phosphatase. J Lab Clin Med 65:698-705, 1965 T j i o J H , Carbone PP, Whang J, et al: T h e Philadelphia chromosome and chronic myelogenous leukemia.J Natl Cancer Inst 36:567-584, 1966 TjioJH, W h a n g J : Chromosome preparations of bone marrow cells without prior in vitro culture in vivo colchicine administration. Stain Technol 37:17-20, 1962 Ward HP, Block MH: T h e natural history of agnogenic myeloid metaplasia (AMM) and a critical evaluation of its relationship with the myeloproliferative syndrome. Medicine 50: 357-420, 1971 Whang-Peng J, Canellos GP, Carbone PP, et al: Clinical implications of cytogenetic variants in chronic myelocytic leukemia (CML). Blood 32: 755-766, 1968
Downloaded from http://ajcp.oxfordjournals.org/ by guest on June 6, 2016
T h e Rosewell Park Memorial Institute experience is consistent with these observations: in their series, the Ph'-negative patients had a median age of 66 years, and an 8-month median survival. 1 With the exception of chromosomal constitution, there is no other abnormality that characterizes adult Ph'-negative patients. It has been suggested that high urinary levels of the enzyme, muramidase or lysozyme, could be used to identify patients who are likely to be Ph'-negative. 7 This enzyme is especially abundant in monocytes, but the absolute percentage of these cells is not increased in the Ph'-negative patients. Further studies are required before this assay can be substituted for karyotypic analysis.
2.
A.J.C.P. —Vol. 65
