干扰素α-2b联合小剂量阿糖胞苷治疗CML的临床研究

目的：探讨干扰素α-2b（IFNα-2b）和小剂量阿糖胞苷（LD Ara-C)联合治疗慢性粒细胞白血病（CML）的血液学和细胞遗传学缓解率，寻找治疗CML的新途径。方法：采用IFNα-2b（300万U/d)和Ara-C(20mg/m^-2.d^-2)，每月用10d)联合治疗CML慢性期患者17例，检测治疗后血液学缓解和Ph染色体阳性细胞下降情况，并与IFNα-2b治疗组和羟基脲（Hu)治疗组作对照。结果：IFNα-2bLD Ara-C治疗组治疗6个月，CHR率和总CHR率分别为76．47％和88．24％，47．06％的患者治疗7－32个月（中位数14个月），pH染色体阳性细胞下降至38％－90％，仅1例（5．88％）在34个月发生急变，治疗6个月CHR率，总CHR率和Ph染色体阳性细胞下降病例百分数均显著高于IFNα-2b治疗组（P＝0．0095，P＜0．005和P＝0．043）和Hu治疗组（P＝0．014，P＜0．005和P＜0．005），CML急变发生率较低（P＝0．03和P＜0．05），而且发生急变的时间较晚，结论：对CML慢性期患者采用IFNα-2b和LD Ara-C联合治疗，可显著提高CML患者的CHR率，减少Ph染色体阳性细胞，提高CML患者的细胞遗传学解率，延长CML患者的生存期。     

甲磺酸伊马替尼治疗慢性粒细胞白血病附加异常Ph阳性克隆的预后意义

目的探讨甲磺酸伊马替尼（伊马替尼）治疗后慢性粒细胞白血病（CML）具有附加异常的Ph阳性克隆的演变及其预后意义。方法收集37例CML加速期和急变期患者的骨髓标本培养24h,G显带进行核型分析。结果伊马替尼治疗前患者的附加染色体种类主要有双Ph、＋8、i（17q）等,其次还有-Y、除i（17q）外17号的异常、inv（3q）等,以及少见的易位和其他异常。伊马替尼治疗后具有附加异常的Ph阳性克隆比例发生扩增、基本不变、比例下降、完全消失等4种形式的演变。24例加速期患者中有2例获得完全细胞遗传学缓解（CCyR）,13例急变期患者中2例获CCyR。附加异常克隆扩增／不变组的中位生存时间和无疾病进展时间显著短于比例下降／完全消失组（P〈0．05）。结论有附加染色体异常的Ph阳性CML患者伊马替尼治疗后附加异常克隆比例可以下降甚至完全消失,获得CCyR,并伴生存期延长。     

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慢性粒细胞白血病(CML)是具有特征性细胞遗传学改变(Ph染色体)和分子生物学特征(BCR-ABL表达)的干细胞克隆性疾病,临床主要表现为白细胞升高、外周血细胞核左移和脾肿大,分慢性期、加速期和急变期3个病期.1 造血干细胞移植治疗CML的机制     

76例慢性粒细胞白血病患者细胞遗传学分析

目的:观察服用甲磺酸伊马替尼(IM)治疗的76例慢性粒细胞白血病患者(CML)不同病期染色体克隆演变特点。方法:对我院76例应用IM治疗CML患者的染色体核型进行回顾性分析,染色体的检测采用G显带技术。结果:IM治疗前CML患者的核型除了典型Ph易位,还有变异Ph易位、Ph+附加异常(Ph+ACA)、Ph-附加异常(Ph-ACA)。少数IM治疗前未检出ACA的患者在治疗后可检测出Ph+ACA或Ph-ACA。伴有ACA的CML患者IM治疗后仍有可能获得完全细胞遗传学缓解(CCyR)。结论:CML患者在IM治疗前后核型均有可能伴有ACA,但是治疗后ACA克隆比例可以下降甚至完全消失,获得CCyR。     

慢性粒细胞白血病BCR/ABL融合基因及复杂变异的染色体核型分析

目的探讨慢性粒细胞白血病(CML)患者BCR/ABL融合基因及其复杂变异的染色体核型变化及临床意义。方法在常规细胞遗传学(CC)方法检测基础上,运用分子生物学方法——荧光原位杂交(FISH)技术,采用多种位点特异性DNA探针(染色体全染、特殊位点、双色易位融合探针),对2002年9月至2007年2月中国医科大学附属第一临床学院血液科56例门诊及住院CML患者(慢性期51例,加速及急变期5例)进行染色体核型分析。结果56例CML患者有5例为细胞培养失败,均为慢性期患者,该5例细胞培养失败病例经FISH技术证实均出现Ph 染色体,余46例慢性期患者中有42例出现Ph 染色体,其中2例为双Ph 染色体;3例合并有复杂的染色体变化,包括染色体数目及结构的异常,分别为-2,-6,-19,-16,-20,-Y, 8以及t(2;4)(p16;p15)。CML慢性期共有47例患者出现Ph 染色体,总阳性率为92.17%。5例加速及急变期患者均出现Ph 染色体,其中3例患者合并有复杂的染色体核型变化:-Y,del(10),I(9)。结论染色体核型分析对CML的疾病分期、进展、治疗及预后有重要的临床意义。FISH技术在CML染色体核型分析上可作为重要技术补充手段弥补CC检查的不足。     

Ph（＋）急性白血病：附二例报告

自1960年 Nowell 和 Hungerford 发现 Ph 染色体以来,一直认为该染色体是慢粒(CML)特殊的细胞遗传学标记。但近年来国内外文献均报告在急性白血病(AL)中也观察到 Ph 染色体。现将我院近年来发现的2例 Ph(+)AML 及随访观察报告如下,并复习文献,着重就 Ph(+)AL 与 Ph(+)CML 急变的鉴别诊断作一讨论。病例报告     

慢性髓细胞白血病急变期形态学及免疫学和细胞遗传学特征研究

目的：探讨慢性髓细胞白血病急变期（CML－BC）的形态学、免疫表型和细胞遗传学法及流式细胞仪进行细胞免疫分型,细胞遗传滂采用直接法或短期培养法制备染色体标本,采用R显带技术进行核型分析。结果：免疫分型结果显示：急变为急性髓细胞白血病（AML）23例占74．2％;急性淋巴细胞白血病（ALL）5例占16．1％,均为B系ALL,其中4例同时伴有髓系表达;急性未分化细胞白血病1例,B系和髓系急性混合细胞白血病（AMLL）2例。31例CML－BC中21例（67．7％）的急变患者CD34^ ,其中4／5（80．0％）ALL,15／23（65。2％）,2／2AMLL均为CD34^ 。AML急变患者中具有CD7和CD34共表达者为8／23（占34．8％）。细胞遗传学分析表明,14／27（51．9％）和急变期患者出现Ph染色体以外的附加核型异常,其中有＋8（3／14）,＋Ph(3/14),i(17q)(2/14),Y染色体丢失（1／14）及复杂易位5／14）。结论：CML－BC是一干细胞疾病,原始细胞分化阻滞在早期阶段,故预后差。MIC分型在CML－BC诊断,预后判断及指导治疗方面均有重要价值。     

应用间期荧光原位杂交技术评估干扰素治疗慢性粒细胞白血病的疗效

目的　探讨间期荧光原位杂交技术 (FISH)检测慢性粒细胞白血病 (CML)干扰素 (IFN)治疗后体内残留Ph阳性细胞的可行性。方法　应用间期FISH对 7例未治疗CML患者和 17例IFN α 2b长期治疗CML患者检测体内Ph阳性细胞变化情况。结果　正常对照组假阳性率为 ( 3 87± 0 94 ) % ,确定正常值为小于 6 68% (x± 3s)。未治疗组Ph阳性细胞平均为 89 2 1%。干扰素治疗组Ph阳性细胞平均为 4 4 86% ,与未治疗组相比无显著性差异 ( P >0 0 5 )。细胞遗传学有效患者 (CGR 4例 ,PGR 2例 ,共 8个标本 )Ph阳性细胞平均为 2 6 3 0 % ,与未治疗组相比有显著性差异 (P <0 0 5 )。而且Ph阳性细胞的减少与INF用药总剂量具有相关性 (r =-0 666,P =0 0 0 2 )。结论　间期FISH检测比染色体核型、RT PCR技术更能准确地评价干扰素治疗后体内存有的白血病细胞的负荷量 ,评价干扰素治疗CML的疗效     

378例白血病患者染色体核型分析及其临床意义

目的探讨白血病患者染色体改变及其在诊断、治疗及预后判断中的意义。方法采用短期培养法制备骨髓细胞染色体标本,以R显带技术用显微镜对240例急性白血病(AL)患者、138例慢性粒细胞白血病患者(CML)进行常规染色体核型分析,每例患者分析10～20个中期分裂细胞,并动态观察部分患者病程进展中染色体核型的变化。结果 240例AL中核型异常182例,占75.83%,其中单纯数目异常占20.33%(37/182),以多倍体和非整倍体为主;结构异常113例,占62.08%,主要为特异性染色体重排且与分型有关。138例CML患者中Ph染色体阳性(Ph+)127例,占92.03%;其中90.55%(115/127)为典型易位,9.45%(12/127)为变异易位。127例Ph+患者中22例(13.39%)出现额外染色体,加速期和急变期额外染色体的检出率明显高于慢性期(P<0.05)。结论染色体核型分析对白血病的诊断、鉴别诊断、治疗及预后判断具有重要意义。     

应用RT-nest-PCR法检测慢性髓细胞白血病非亲缘异基因骨髓移植后微小残留病变

目的：应用筑巢式RT—PCR（RT—nest-PCR）法检测慢性髓细胞性白血病（CML）患者非亲缘异基因骨髓移植（URD）后微小残留病变（MRD），并探讨它与复发的相关性。方法：分别采用RT-nest—PCR法和常规细胞遗传学方法检测bcr／abl融合基因和Ph染色体。结果：20例CML行URD患者术前Ph染色体和bcr／abl融合基因检测均为阳性，移植术后30dPh染色体皆转为阴性，bcr／abl融合基因完全转阴时间为1～3个月，中位时间2个月；在随防的18例CML患者中，有16例患者bcr／abl融合基因完全转阴后没再转为阳性。在1例复发的CML患者中可见到血型、Ph染色体和bcr／abl融合基因动态变化，另1例CML患者在移植成功后的21个月和36个月检测到bcr／abl融合基因，经随访未见临床和血液学复发征象。结论：检测bcr／abl融合基因是目前观察CML患者非亲缘异基因骨髓移植后微小残留病变最敏感的方法之一，非亲缘异基因骨髓移植能最大限度地消除CML患者体内残留病变，患者能长期无病生存。     

Ph-negative chronic myeloid leukaemia

An analysis of five patients with Philadelphia chromosome (Ph) negative chronic myeloid leukaemia (CML) revealed that two were clinically and haematologically identical to Ph-positive CML whereas three should be reclassified as chronic myelomonocytic leukaemia (CMML). At a molecular level the first two patients showed the same juxtaposition of c-abl and bcr genes as is seen in Ph-positive CML. These genomic changes were not seen in the other three patients. Observations on these five patients suggest that the clinical course and prognosis of the rare patient who carries the Ph 'molecular defect' but lacks the Philadelphia chromosome is no different from Ph-positive CML.     

Blast Crisis of Chronic Myeloid Leukaemia: The Effect of Intensive Chemotherapy

24 patients with Philadelphia chromosome positive chronic myeloid leukaemia (CML) in blast crisis were treated with intensive chemotherapy. 16 patients showed either partial or complete response to this treatment, but median survival remained short (13 weeks), and much of this time was spent in hospital. These results were not significantly better than those obtained by others using vincristine and prednisolone alone, and this combination of drugs can often be given on an outpatient basis. It is concluded that until more effective intensive therapy becomes available patients in CML blast crisis should be managed in such a way that the quality of life is not impaired; and that at present vincristine and prednisolone appears to be the most appropriate initial treatment, though even this is far from satisfactory.     

DETECTION OF REARRANGEMENT WITHIN THE BREAKPOINT CLUSTER REGION OF CHROMOSOME 22 IN THE DIAGNOSIS OF CHRONIC MYELOID LEUKEMIA

Chronic myeloid leukemia (CML) is characterised by the presence of a Philadelphia (Ph) chromosome in approximately 95% of patients. Molecular analysis has shown that the Ph chromosome translocation breakpoints are clustered within 5.8kb on chromosome 22 (breakpoint cluster region or bcr). This has facilitated the diagnosis of CML by nucleic acid hybridisation using probes specific for the bcr to detect DNA rearrangement in this region. Forty patients diagnosed with CML, including four with variant Ph chromosome translocations and three with normal karyotypes were analysed for rearrangement within the bcr. All except one patient with Ph negative CML had rearrangement within the bcr. In contrast, none of the patients diagnosed with other hematological disorders such as the myelodysplastic or myeloproliferative syndromes (16 patients), acute myeloid leukemia (AML) (six patients), acute lymphoblastic leukemia (ALL) (five patients), including Ph positive ALL (two patients), showed rearrangement within the bcr. Analysis for rearrangement within the bcr is useful in the diagnosis of CML, especially when cytogenetic analysis is unsuccessful or in patients with normal karyotypes or variant Ph chromosome translocations.     

Blast crisis of chronic myeloid leukaemia: the effect of intensive chemotherapy.

24 patients with Philadelphia chromosome positive chronic myeloid leukaemia (CML) in blast crisis were treated with intensive chemotherapy. 16 patients showed either partial or complete response to this treatment, but median survival remained short (13 weeks), and much of this time was spent in hospital. These results were not significantly better than those obtained by others using vincristine and prednisolone alone, and this combination of drugs can often be given on an outpatient basis. It is concluded that until more effective intensive therapy becomes available patients in CML blast crisis should be managed in such a way that the quality of life is not impaired; and that at present vincristine and prednisolone appears to be the most impaired; and that at present vincristine and prednisolone appears to be the most appropriate initial treatment, though even this is far from satisfactory.     

Randomized study on the treatment of chronic myeloid leukemia (CML) in chronic phase with busulfan versus hydroxyurea versus interferon-alpha

Summary For palliative therapy during the chronic phase of CML busulfan has proved to be the drug of choice. During the past years hydroxyurea and also interferon-alpha have gained increasing significance since they might prolong the duration of the chronic phase. In a multicenter study it is being determined, whether the use of hydroxyurea or of interferon-alpha instead of busulfan prolongs the duration of the chronic phase of Philadelphia positive CML. Additional goals are the examination of whether the types of disease evolution and the terminal phases differ between the treatment groups, and the prospective recognition of prognostic criteria for the duration of the chronic phase of CML. By December 31, 1987, 326 CML-patients had been randomized, 150 for busulfan, 150 for hydroxyurea and 26 for interferon-alpha. The average age is 50 years. 59 patients reached the end of the chronic phase, 55 died. The mean observation time of all patients is 1.34 years. At present no significant difference in survival is recognizable between the busulfan and hydroxyurea groups. Fewer adverse effects have been observed in the hydroxyurea group. Philadelphia chromosome negative patients show a higher average age and tend to have lower white blood cell and platelet counts. The number of patients having received interferon-alpha is still too small to allow evaluation. This report intends to document organization and progress of this study which to our knowledge is, at present, the largest ongoing prospective multicenter study on the therapy of CML.     

The age incidence of chronic myeloid leukemia can be explained by a one-mutation model

Chronic myeloid leukemia (CML) is associated with the Philadelphia chromosome, which arises by a reciprocal translocation between chromosomes 9 and 22 and harbors the BCR-ABL fusion oncogene. It is unknown whether any other mutations are needed for the chronic phase of the disease. The CML incidence increases as a function of age with an exponent of approximately 3. A slope of 3 could indicate that there are two mutations, in addition to the Philadelphia translocation, that have not yet been discovered. In this work, we explore an alternative hypothesis: We study a model of cancer initiation requiring only a single mutation. A mutated cell has a net reproductive advantage over normal cells and, therefore, might give rise to clonal expansion. The cancer is detected with a probability that is proportional to the size of the mutated cell clone. This model has three waiting times: (i) the time until a mutated cell is produced, (ii) the time of clonal expansion, and (iii) the time until the clone is detected. Surprisingly, this simple process can give rise to cancer incidence curves with exponents up to 3. Therefore, the CML incidence data are consistent with the hypothesis that the Philadelphia translocation alone is sufficient to cause chronic phase CML.     

A neutrophil membrane marker reveals two groups of chronic myelogenous leukemia and its absence may be a marker of disease progression

An IgG1 monoclonal antibody, 31D8, that recognizes normal neutrophil (PMN) membranes, was used to study PMN from patients with chronic myelogenous leukemia (CML). Nineteen patients with Philadelphia chromosome positive CML were followed over a ten-month period and compared with 23 normals, six patients with leukemoid reactions, and eight patients with phagocytic cell defects. The percentage of PMN binding of 31D8 among normal subjects was variable about a normal distribution with an average of 95 +/- 2% of cells binding 31D8. In contrast, there were two groups of CML patients: in 14 patients 88 +/- 3% PMN bound 31D8 while in the remaining five patients only 6 +/- 6% PMN bound 31D8. PMN 31D8 binding was normal in the control patient groups. Control antibodies 7C3 (binds to PMN precursors) and OKM1 (binds to the CR3 (iC3b) receptor) bound normally to CML neutrophils. Functionally, CML cells had normal chemotaxis to several stimuli and normal superoxide generation to phorbol myristate acetate. However, superoxide production in response to fmet-leu-phe was significantly less in 31D8 negative CML PMN than both 31D8 positive CML PMN and normal PMN which contained 85% 31D8 positive and 15% 31D8 negative PMN. Clinically, 2 of 14 CML patients with 31D8 positive PMN were in blast crisis (one extramedullary) at the time of study and the other 12 patients remained clinically stable in the chronic phase during the ten months of study. In contrast, one of five patients with 31D8 negative PMN was in blast crisis at the time of study and all four of the remaining patients progressed to either the accelerated phase or blast crisis. Three of these patients died of their disease eight to ten months after their initial study. Thus, failure of CML cells to bind 31D8 may be useful for predicting which patients are likely to progress to the accelerated phase or blast crisis.     

IN VIVO MOBILIZATION OF KARYOTyPICALLY NORMAL PERIPHERAL BLOOD PROGENITOR CELLS IN HIGH-RISK MDS, SECONDARY OR THERAPY-RELATED ACUTE MYELOGENOUS LEUKAEMIA

We have previously reported that mobilization of Philadelphia (Ph) chromosome-negative progenitors is possible in a significant number of Ph¹-positive acute lymphoblastic leukaemia (ALL) and chronic myelogenous leukaemia (CML) patients. In this pilot study we employed the same approach for patients with RAEB-t, secondary AML (sAML) and therapy-related AML (t-AML). All patients except one had double or complex cytogenetic abnormalities in marrow cells before mobilization therapy. All patients received an idarubicin-containing regimen (mini-ICE protocol) followed by rh-G-CSF and the first leukapheresis was performed as they were recovering from aplasia. In six out of nine patients the leukapheresis product was entirely karyotypically normal, combined with a significant number of CFU-GM, CD34⁺ cells and LTC-IC. Recovery time from mobilization therapy was short and no patient died as a result of the procedure. To date, three patients have undergone autografting using their karyotypically normal collections, of which two (sAML) are alive with karyotypically normal marrow a few months after autografting.     

The bcr gene in Philadelphia chromosome positive acute lymphoblastic leukemia

In chronic myelogenous leukemia (CML) and in a percentage of childhood and adult acute lymphoblastic leukemia (ALL) the Philadelphia (Ph') chromosome is present in the leukemic cells of patients. This chromosome is the result of a reciprocal translocation between chromosomes 9 and 22. In CML the break on chromosome 22 occurs within the major breakpoint cluster region (Mbcr) of the bcr gene. In this study, we report on the examination of DNAs from nine Ph'-chromosome positive ALL patients for rearrangements within the bcr gene using Southern blot analysis. Of nine patients having a karyotypically identifiable Ph'-chromosome, only five exhibited rearrangements of the bcr gene. This could indicate that in ALL, chromosome 22 sequences other than the bcr gene are involved in the Ph'-translocation. Within the group of Ph'-positive ALL patients having a bcr gene breakpoint, a correlation appears to exist between the age of the patient and the location of the breakpoint within the gene: all or the vast majority of pediatric patients analyzed to date do not have a Mbcr breakpoint as found in CML and in adult ALL.     

The correlation of breakpoint cluster region rearrangement and p210 phl/abl expression with morphological analysis of Ph-negative chronic myeloid leukemia and other myeloproliferative diseases

The chromosome 22 derivative, the Philadelphia (Ph) chromosome, results from a reciprocal translocation t(9;22) (q34;q11) and is associated with chronic myeloid leukemia (CML). The translocation can be identified at the DNA level in Ph-positive CML by using a probe to the breakpoint cluster region (bcr). In addition, as a result of this translocation an abl-related 210-kd protein with protein tyrosine kinase (PTK) activity is produced. We analyzed 28 cases of Ph-negative CML for rearrangement of the chromosome 22 sequences and found that eight of the 28 show rearrangement of the bcr. When 12 of the Ph-negative cases were independently reviewed, five were indistinguishable from Ph-positive CML on the basis of morphology, peripheral blood film and clinical details. These five also showed bcr rearrangement. The other seven were reclassified as six atypical CML (aCML) and one chronic myelomonocytic leukemia (CMML). None of these seven showed bcr rearrangement. In addition 11 cases of bcr- CML were assayed for abl-related PTK, and no detectable activity was present, whereas p210 phl/abl PTK was observed both in Ph-positive (three cases examined) and Ph-negative, bcr + (four cases examined) CML. Therefore, bcr + CML, whether or not the Ph chromosome is cytogenetically apparent, involves a similar molecular alteration and produces the 210-kd protein with enhanced PTK activity. Furthermore, these cases can be distinguished from Ph-negative bcr- CML by careful evaluation of clinical and hematologic data.