Sequential changes in the bone marrow trephine biopsy in B-cell chronic lymphocytic leukaemia

Background: Trephine biopsy of the bone marrow is integral to both diagnosis and prognosis in B-cell lymphocytic leukaemia (B-CLL), but its usefulness would be enhanced by more information on the type, degree and rate of change that occur over time in histologic pattern and lymphocytic infiltration.
Aims: To investigate these changes by serial trephine biopsy in totally untreated patients, in treatment-free intervals in treated patients and during intervals of treatment.
Methods: In 82 patients with predominantly early B-CLL observed for a median of 65 months (13–331), 309 trephine biopsies were carried out, a median of three (two to eight) per patient. The biopsies were classified into nodular, interstitial, mixed and diffuse patterns. Lymphocytic infiltration was subjectively graded into minimal (< 20%), intermediate (20–50%) and majority (> 50%) categories and all changes were compared.
Results : Intensity of infiltration increased through this histologic range, as did the relative risk of death. Survival of patients with > 50% involvement was significantly poorer than those with < 50%. Changes in both lymphocyte numbers and pattern occurred slowly in early disease but quickened as the leukaemia advanced. Under treatment, lymphocytes decreased but the histology did not alter significantly. Examining the marrow for disease progression should be part of regular follow-up. It may help identify the minority of patients with early disease which will run a more active course and in whom early therapy may yet be indicated. We recommend biopsy at two-yearly intervals in early disease, more frequently as the leukaemia advances. The minimal, intermediate and majority classification in addition to the histologic pattern is a useful grading. (Aust NZ J Med 1993; 23: 470–476.)     

Bone marrow trephine findings in acute myeloid leukaemia with multilineage dysplasia

Acute myeloid leukaemia (AML) with multilineage dysplasia (MD) is one of the four main categories of AML in the World Health Organization (WHO) classification. The role of bone marrow trephine biopsy (BMTB) histology and immunohistochemistry in the diagnosis of AML-MD is currently unclear. BMTBs were studied in 11 cases of AML-MD and two cases of myelodysplasia that subsequently transformed to AML. Among them, six cases showed trilineage dysplasia and seven showed bilineage dysplasia. With respect to conforming to the WHO definition of AML, documentation of an increased proportion of immature myeloid cells was possible on morphology and counting of immature cells following immunostaining with CD34, CD117 or HLA-DR antibodies. Recognition and quantification of dysplastic features in the haemopoietic lineages was made easier by immunohistochemistry with antibodies to ret40f (glycophorin C), myeloperoxidase, CD61 and/or CD42b, CD34, CD117 and HLA-DR. Based on this relatively small series of cases we show the utility of BMTB and immunohistochemistry as an aid to the diagnosis of AML-MD. This has to be seen not just in light of its utility at diagnosis, but also the role the diagnostic BMTB would play for purposes of comparison when follow-up BMTBs are submitted in this group of patients.     

Unrelated donor bone marrow transplantation for children with juvenile myelomonocytic leukaemia

Children with juvenile myelomonocytic leukaemia (JMML) have a poor outcome, with survival in a minority of patients. The major limitation on success of sibling donor bone marrow transplantation for JMML has been reported to be relapse. A total of 46 children with a diagnosis of JMML underwent unrelated donor marrow (URD) transplantation facilitated by the National Marrow Donor Program. Forty-three of 46 patients had neutrophil engraftment at a median of 20 d post transplant, with platelet recovery in 28 of 40 evaluable patients at a median of 34.5 d. Thirty-two of 44 evaluable patients developed acute graft-versus-host-disease (GVHD) (Grades 2-4) and chronic GVHD developed in 14 of 35 evaluable patients. At a median follow-up of 2.0 years, probabilities of survival and disease-free survival were 42% and 24% respectively. The probability of relapse was 58% at 2 years and represents the major cause of treatment failure. Multivariate analysis revealed that chronic GVHD was associated with reduced relapse [risk ratio 0.20 (95% CI 0.04-1.02, P=0.05)] improved survival [risk ratio 0.13 (95% CI 0.03-0.68, P=0.02)] and event-free survival [risk ratio 0.23 (95% CI 0.06-0.94, P=0.04)]. This study demonstrates that relapse is the major cause of treatment failure in patients with JMML undergoing URD transplantation. With lower relapse observed in patients with chronic GVHD, new treatment strategies that focus on enhancing the graft-versus-leukaemia effect may improve survival.     

Multiple myeloma and chronic myelomonocytic leukaemia developing in a patient with autoimmune disease

A 64-year-old lady with a personal and family history of autoimmune disease developed chronic myelomonocytic leukaemia and multiple myeloma simultaneously. Her sister died of acute myelomonocytic leukaemia, but showed no evidence of autoimmune disease. It is possible that chronic immunological stimulation, perhaps by an autoantigen, may predispose toward malignant transformation in both plasma cell and monocyte series. However, the present observations raise the alternative possibility of a primary disorder of monocytes that predisposes toward both autoimmune disease and a clonal disorder of plasma cells.     

Bone marrow mononuclear cell thymidine uptake in chronic B-lymphocytic leukaemia: Relation to prognosis

The uptake of tritium-labelled thymidine in bone marrow mononuclear cells from 22 untreated patients with Rai stage 0-II chronic B-lymphocytic leukaemia was analysed in 4-d in vitro cultures. The thymidine uptakes showed a great interindividual variability; the counts per min ranged from 1100 to 80000 (mean 26360 ± 21800 cpm). Bone marrow cells from patients who needed treatment within 1 yr from diagnosis had a lower thymidine uptake than those from patients who were untreated for more than 2 yr (7820 ± 7420 and 34 300 ± 23 200 cpm, respectively, p < 0.001). Patients with low uptake cells had poorer prognosis than those with high uptake cells, both regarding survival (5-yr probability: 0.6 and 1.0, respectively; p < 0.03) and therapy-free survival (5-yr probability: 0.36 and 1.0, respectively; p < 0.02).     

Acute transformation of chronic myelomonocytic leukaemia: a multivariate study of predictive factors

In an attempt to determine the possible predictive value of the main clinical and haematological initial features of chronic myelomonocytic leukaemia (CMML) on the evolution to acute leukaemia, as well as the real impact of such an event on survival, 35 such patients were submitted to multiple regression analyses. At the time of the study 30 out of the 35 patients had died, with a median survival of 8.2 months for the whole series. 12 patients (34%) developed acute leukaemia, between 1.5 and 42.1 months from diagnosis of CMML, the actuarial median time of acute transformation being 29.4 months. The initial bone marrow blast cell percentage was the only factor influencing the development of acute leukaemia. On the other hand, the multivariate survival study showed that acute transformation introduced in the model as a time-dependent variable had a clear-cut unfavourable influence on the outcome of CMML patients, as did palpable spleen, advanced age and marked monocytosis.     

Role of allogeneic bone marrow transplantation from an HLA-identical sibling or a matched unrelated donor in the treatment of children with juvenile chronic myeloid leukaemia

Seven children (age range 1.8–11 years) with juvenile chronic myelomonocytic leukaemia (JCML) received an allogeneic bone marrow transplantation (BMT), four from an HLA-identical sibling and three from a matched unrelated donor. In the four children transplanted using an HLA-identical sibling, conditioning regimen included busulfan (BU), cyclophosphamide (CY) and melphalan (L-PAM), whereas graft-versus-host disease (GVHD) prophylaxis consisted of cyclosporine-A (Cs-A). The preparative regimen was well tolerated and all patients engrafted promptly. None of the patients have relapsed and all four children remain in haematological remission after an observation time of 7, 24, 25 and 48 months, respectively. Of the three children given BMT from an unrelated volunteer, one was <2 years of age and she received the BU/CY/L-PAM regimen. In view of the increased risk of graft rejection described in patients transplanted from unrelated donors, we chose to prepare the other two patients with fractionated total body irradiation (TBI), thiotepa and CY. Cs-A, short-term methotrexate and Campath-1G in vivo were employed to prevent GVHD in this group of patients. Graft failure with autologous reconstitution of haemopoiesis occurred in the child given the chemotherapy-based regimen. One of the two girls given TBI relapsed after BMT; therefore only one of the three patients who received a marrow transplant from a matched unrelated donor survives in complete haematological remission 10 months after BMT. Our study suggests that the conditioning regimen we employed for allogeneic BMT from a compatible sibling is an effective means of eradicating the leukaemic clone. In our experience, results obtained using unrelated donors are less satisfactory and, at present, the use of such donors seems to be riskier and associated with a lower success rate as compared with BMT from an HLA-identical sibling.     

Role of allogeneic bone marrow transplantation from an HLA-identical sibling or a matched unrelated donor in the treatment of children with juvenile chronic myeloid leukaemia

Seven children (age range 1.8–11 years) with juvenile chronic myelomonocytic leukaemia (JCML) received an allogeneic bone marrow transplantation (BMT), four from an HLA-identical sibling and three from a matched unrelated donor. In the four children transplanted using an HLA-identical sibling, conditioning regimen included busulfan (BU), cyclophosphamide (CY) and melphalan (L-PAM), whereas graft-versus-host disease (GVHD) prophylaxis consisted of cyclosporine-A (Cs-A). The preparative regimen was well tolerated and all patients engrafted promptly. None of the patients have relapsed and all four children remain in haematological remission after an observation time of 7, 24, 25 and 48 months, respectively. Of the three children given BMT from an unrelated volunteer, one was <2 years of age and she received the BU/CY/L-PAM regimen. In view of the increased risk of graft rejection described in patients transplanted from unrelated donors, we chose to prepare the other two patients with fractionated total body irradiation (TBI), thiotepa and CY. Cs-A, short-term methotrexate and Campath-1G in vivo were employed to prevent GVHD in this group of patients. Graft failure with autologous reconstitution of haemopoiesis occurred in the child given the chemotherapy-based regimen. One of the two girls given TBI relapsed after BMT; therefore only one of the three patients who received a marrow transplant from a matched unrelated donor survives in complete haematological remission 10 months after BMT. Our study suggests that the conditioning regimen we employed for allogeneic BMT from a compatible sibling is an effective means of eradicating the leukaemic clone. In our experience, results obtained using unrelated donors are less satisfactory and, at present, the use of such donors seems to be riskier and associated with a lower success rate as compared with BMT from an HLA-identical sibling.     

Bone marrow assessment in B-cell chronic lymphocytic leukaemia: aspirate or biopsy? A comparative study in 258 patients

To evaluate the relative merits and prognostic value of bone marrow aspirate and bone marrow biopsy in the assessment of bone marrow infiltration in B-cell chronic lymphocytic leukaemia (CLL), two observers independently reviewed the percentage of lymphocytes in bone marrow aspirate (lymphocytic infiltration, LI) and the bone marrow histological pattern (BMP) in 258 patients. The inter-observer reproducibility and agreement was higher for BMP than for LI. BMP was an independent prognostic factor for survival in the whole series, whereas LI only had independent predictive value in stage A patients. In the entire series, disease progression was predicted by either BMP and LI, whereas in stage A patients only by BMP. Regarding low-risk CLL (smouldering CLL or A'1 substage), BMP led to a more reproducible identification of these clinical forms than LI. In conclusion, although both BMP and LI are of value to estimate bone marrow infiltration in CLL and to predict the outcome of the disease, BMP is more reliable and reproducible than LI.     

Bone marrow transplantation for chronic myeloid leukaemia: the effects of differing criteria for defining chronic phase on probabilities of survival and relapse

We studied actuarial survival and relapse in 251 patients with chronic myeloid leukaemia (CML) treated by bone marrow transplantation (BMT) from HLA-identical sibling donors at a single institution. According to the institutional criteria used to define disease phase at the time of BMT, the 5-year probabilities of survival were 58.1% (95% confidence interval 50–66%) for 205 chronic-phase patients and 21.5% (95%CI 12–37%) for 46 advanced-phase patients ( P  < 0.00001); the corresponding values for relapse were 34.8% (95%CI 27–44%) versus 72.7% (95%CI 46–89%). When disease phase was defined strictly according to the criteria of the International Bone Marrow Transplant Registry, the survival for 154 chronic-phase patients increased to 60.1% (95%CI 51–69%) and that for 97 advanced-phase patients increased to 37.6% (95%CI 28–48%). There was a parallel change in probabilities of relapse in the two patient groups (33.9% [95%CI 25–44%] and 51.3% [95%CI 37–66%], respectively). We also observed that patients transplanted in advanced phase had a higher incidence of grades III–IV acute graft-versus-host disease ( P  = 0.001) and transplant-related mortality ( P  = 0.02) than those undergoing BMT for chronic-phase disease. We recommend that transplant centres reporting results of BMT should always specify the precise criteria used for defining disease phase in order to ensure that results between different centres are strictly comparable.     

Successive transformation of chronic myelomonocytic leukaemia into acute myeloblastic then lymphoblastic leukaemia, both with minor-bcr rearrangement

We report a case of chronic myelomonocytic leukaemia (CMML), which transformed first into acute myeloblastic leukaemia (AML) and then into acute lymphoblastic leukaemia (ALL). In the AML and ALL phases, chromosome analysis showed a classic Philadelphia chromosome (Ph) t(9;22)(q34;q11). Molecular studies showed breakpoint cluster region rearrangement between exons e1 and a2 compatible with a p190^bcr/abl breakpoint as observed in Ph-positive lymphoblastic acute leukaemia. The minor (m-bcr) rearrangement was also detected during complete remission.
This observation supports a multistep pathogenesis of leukaemias, and that the p190^bcr/abl breakpoint may influence the course of the disease.     

Matched and mismatched unrelated donor bone marrow transplantation for juvenile chronic myeloid leukaemia

Juvenile chronic myeloid leukaemia (JCML) is a rare haematological condition of childhood curable only by bone marrow transplantation (BMT). We report our experience using matched and mismatched unrelated donor BMT for JCML in five patients. Although the procedure is hazardous in terms of toxicity and relapse, two patients are alive and disease-free 28 and 49 months post BMT.     

Splenic irradiation before bone marrow transplantation for chronic myeloid leukaemia

A total of 229 patients with chronic myeloid leukaemia (CML) in chronic phase were randomized between 1986 and 1990 to receive or not receive additional splenic irradiation as part of their conditioning prior to bone marrow transplantation (BMT). Both groups, 115 patients with and 114 patients without splenic irradiation, were very similar regarding distribution of age, sex, donor/recipient sex combination, conditioning, graft-versus-host disease (GvHD) prevention method and blood counts at diagnosis or prior to transplant. 135 patients (59%) are alive as of October 1995 with a minimum follow-up of 5 years. 52 patients have relapsed (23%), 26 patients in the irradiated, 26 patients in the non-irradiated group (n.s.) with a relapse incidence at 6 years of 28%. The main risk factor for relapse was T-cell depletion as the method for GvHD prevention, and an elevated basophil count in the peripheral blood prior to transplant. Relapse incidence between patients with or without splenic irradiation was no different in patients at high risk for relapse, e.g. patients transplanted with T-cell- depleted marrows ( P  = n.s.) and in patients with low risk for relapse, e.g. patients transplanted with non-T-cell-depleted transplants and basophil counts <3% prior to transplant ( P  = n.s.). However, relapse incidence differed significantly in patients with non-T-cell-depleted transplants and high basophil counts (> 3% basophils in peripheral blood). In this patient group, relapse incidence was 11% at 6 years with splenic irradiation but 32% in the non-irradiated group ( P  = 0.05). Transplant-related mortality was similar whether patients received splenic irradiation or not. This study suggests an advantage in splenic irradiation prior to transplantation for CML in this subgroup of patients and illustrates the need for tailored therapy.     

Recent advances in diagnosis, molecular pathology and therapy of chronic myelomonocytic leukaemia

The clinical, morphological, and genetic heterogeneity of chronic myelomonocytic leukaemia (CMML), has made it difficult to clearly assign this entity to a distinct haematological category. In 2001, the World Health Organization transferred CMML to a new category of mixed myeloproliferative/myelodysplastic disorders, which was maintained in the last revision in 2008. Considering the rare occurrence of CMML, most pharmacotherapeutic and transplant studies combined CMML with myelodysplastic syndrome cases, but some clinical trials specifically investigated the use of demethylating agents in CMML and demonstrated stabilization of the haematological situation or even complete remission in subsets of patients. Information on the significance of other drugs is very limited. Allogeneic haematopoietic stem cell transplantation (HSCT) remains the only curative option for patients with CMML. Molecular studies revealed various novel genetic alterations in CMML - notably of the JAK2, TET2, CBL, IDH, or RUNX1 and RAS genes. This review summarizes the current status of pharmacotherapy and transplantation in CMML and outlines recent results of molecular research for diagnosis of this heterogeneous entity.     

Iron stores in chronic granulocytic leukaemia at presentation

In 87 patients with Ph¹ positive chronic granulocytic leukaemia (CGL), the bone marrow iron content was studied on smears obtained at diagnosis. A low sideroblast score and a decreased or absent marrow iron on semiquantitative estimation were found in 91 % and 85 % of cases, respectively. These findings did not correlate with blood parameters reflecting iron status such as Hb concentration, mean corpuscular volume, mean corpuscular haemoglobin, serum iron, total iron-binding capacity and transferrin saturation, which were normal in most cases. In 30 patients, initial serum ferritin was estimated, normal or slightly increased levels being as a rule found. In 24 of such patients, serum ferritin was again measured in remission following busulphan and, although values remained normal, a significant decrease was observed with respect to the initial levels (P < 0.001). Thus, in spite of the consistent marrow pattern of iron depletion, initial iron stores appear to be normal in CGL. It seems, however, that the disease activity may partially influence the serum ferritin levels.     

A new translocation,t(3;6)(q12;24) associated with chronic myelomonocytic leukaemia and marrow fibrosis

This report describes a 75-year-old man with chronic myelomonocytic leukaemia (CMML) and marked marrow fibrosis associated with t(3;6)(ql2;24). Although structural abnormalities of 3q occur in haematological neoplasia, this particular chromosomal translocation has not been previously described in CMML. Karyotypic abnormalities involving 3q and marrow fibrosis may affect prognosis in CMML.     

Five year leukaemia-free survival of 72% and 77% for early stage acute and chronic myeloid leukaemia treated by HLA-identical sibling bone marrow transplantation

Background: HLA-identical sibling bone marrow transplantation is an accepted treatment for patients with acute myeloid leukaemia (AML) and chronic myeloid leukaemia (CML). We have recently reported improving results in HLA-identical sibling transplant over the ten year period 1981-1990. In this report we described the outcome in patients transplanted at St Vincent's Hospital, Sydney between 1989 and 1993. Aims: To determine the leukaemia-free survival, transplant-related mortality rate, and relapse rate for patients with AML or CML given HLA-identical sibling marrow transplants between 1989 and 1993. Methods: Sixty-two patients with AML or CML received high dose busulphan/cyclophos-phamide chemotherapy followed by infusion of T replete, HLA-identical sibling bone marrow. Cyclosporin/short methotrexate was utilised as prophylaxis for graft-versus-host disease, ganciclovir as prophylaxis for cytomegalovirus disease and cotrimoxazole as prophylaxis for Pneumocystis carinii pneumonia. Low dose intravenous heparin was used as prophylaxis for hepatic veno-occlusive disease. Results: The five year disease-free survival for patients with AML transplanted in first complete remission was 72% and for those with CML transplanted in first chronic phase was 77%. The relapse rate for AML transplanted in first complete remission was 15% and for CML in first chronic phase 0%. The transplant-related mortality for AML transplanted in first complete remission was 16% and for CML transplanted in first chronic phase 23%. In contrast, the disease-free survival, relapse rate and transplant-related mortality for patients with AML transplanted outside first complete remission and for CML transplanted beyond first chronic phase was 17%, 57% and 57% respectively. Conclusions: The outcome for patients transplanted for early AML or early CML continues to improve and exceeds that obtainable by conventional therapy. The salvage rate is so low for patients transplanted in later stages of AML or CML that all patients less than 55 years of age with these diseases, who have a HLA-identical sibling donor, should be offered bone marrow transplantation early in their disease course.