Growth rate and sister chromatid exchange (SCE) incidence of bone marrow cells in Acute Myeloblastic Leukemia (AML)

The sister chromatid exchange (SCE) incidence and growth kinetics have been studied by means of an in vitro bromodeoxyuridine (BrdU) chromosome labeling method in the bone marrow cells of 17 acute myeloblastic leukemia (AML) patients with only diploid cells at diagnosis, remission, and relapse of the disease. At diagnosis, the cells tended to exhibit a low SCE frequency as compared to that during remission. An increased SCE frequency was observed after chemotherapy during remission or relapse. At diagnosis and relapse, when leukemic blast cells predominated in the marrow, they were characterized by the predominance of cells that had undergone only one cell cycle after BrdU exposure. In contrast, the marrow cells during remission tended to resemble the control pattern of growth kinetics, with a predominance of cells undergoing second and third cell cycles in the presence of BrdU. These results suggest that the growth rate of leukemic and nonleukemic cells is different, and that chemotherapy can cause an increased SCE frequency in the marrow cells of AML patients irrespective of the state of the disease.     

Translocation 1;19--a new cytogenetic abnormality in acute lymphocytic leukemia

A study of the chromosomes of 125 consecutive patients with acute lymphocytic leukemia (ALL) showed the same translocation between chromosomes #1 and #19 in 5 patients. In 4 of the 5, the t(1;19)(q21;q13) was present at diagnosis. The fifth patient, who had Philadelphia chromosome positive (Ph1+) ALL, developed t(1;19) in first relapse. Trisomy 1q was involved in 2 of the 5 patients; 3 patients had additional abnormalities. All patients had low white cell counts at presentation (less than 35 X 10(9)/L), and the 4 patients tested had common ALL antigen (CALLA) positive leukemic blast cells. All achieved complete remission, including the Ph1+ ALL patient in first relapse, and survival times ranged from 4 to 21+ mo from the time the t(1;19) first appeared. Our data suggest that t(1;19) is a previously unrecognized nonrandom structural abnormality in ALL that is also found in other lymphoid malignancies. Unlike the other specific translocations, it is not associated with a poor prognosis.     

Full pancreatic endocrine differentiation in a mediastinal teratoma

In a mediastinal teratoma containing pancreatic tissue rich in islet cells, immunofluorescence studies showed a high degree of differentiation of the endocrine tissue. Insulin-, glucagon-, somatostatin-, and pancreatic polypeptide(PP)-containing cells were all consistently represented. They showed the same precise topographic distribution that is seen in normal islets (i.e., a central core of insulin-containing cells with the other cell types in a peripheral position) and that is thought to be important for the integrated function of the islets. This may explain the absence of clinical symptoms of hypoglycemia. In addition, a nonrandom distribution of endocrine cell types, with PP-rich and PP-poor areas, similar to that found in pancreatic regions embryologically derived from the ventral and dorsal anlagen, respectively, was observed. This finding suggests that the unknown mechanisms responsible for the dissimilar endocrine cell contents in pancreatic regions of different embryologic origins were operating in the teratoma.     

Phenotypic changes in acute myeloid leukaemia: implications in the detection of minimal residual disease.

AIM: To explore the role of phenotypic changes as possible limiting factors in the immunological detection of minimal residual disease in patients with acute myeloid leukaemia (AML). METHODS: 20 relapses were evaluated, with special attention to changes in the criteria used for the definition of a phenotype as "aberrant". In all cases the same monoclonal antibody and fluorochrome were used at diagnosis and in relapse. RESULTS: Six out of the 16 patients showed aberrant phenotypes at diagnosis. At relapse, no changes in the aberrant phenotypes were detected in most of the patients; nevertheless, in two of the four patients with asynchronous antigen expression this aberration disappeared at relapse. At diagnosis in both cases there were already small blast cell subpopulations showing the phenotype of leukaemic cells at relapse. Ten out of the 16 cases analysed showed significant changes in the expression of at least one of the markers analysed. CONCLUSIONS: At relapse in AML the "leukaemic phenotypes" usually remained unaltered, while other phenotypic features--not relevant for distinguishing leukaemic blast cells among normal progenitors--changed frequently; however, they were not a major limitation in the immunological detection of minimal residual disease.     

Pretreatment CD34+/CD38– Cell Burden as Prognostic Factor in Myelodysplastic Syndrome Patients Receiving Allogeneic Stem Cell Transplantation

Myelodysplastic syndrome (MDS) is a highly heterogeneous clonal hematopoietic disorder. Allogeneic hematopoietic stem cell transplantation (HSCT) remains the only curative treatment and is of particular interest in patients at high risk for progression to acute myeloid leukemia (AML). In MDS, CD34⁺/CD38^– cells possess MDS stem cell potential, and secondary AML (sAML) clones originate from the MDS disease stage. However, the prognostic impact of the pretreatment stem cell population burden in MDS remains unknown. We retrospectively analyzed the prognostic impact of the pretreatment CD34⁺/CD38^– cell burden in 124 MDS patients who received allogeneic HSCT at our institution. A high pretreatment bone marrow CD34⁺/CD38^– cell burden (≥1%) was associated with worse genetic risk and a higher incidence of blast excess. Patients with a high CD34⁺/CD38^– cell burden had a significantly higher cumulative incidence of MDS relapse, a higher cumulative incidence of secondary AML, and a trend for shorter overall survival after allogeneic HSCT. In multivariable analyses this prognostic impact was shown to be independent of other clinical and cytogenetic risk factors in MDS. Patients suffering MDS relapse or progression to AML also had a higher pre-treatment CD34⁺/CD38^– cell burden as a continuous variable. The observed prognostic impact is likely mediated by MDS stem cells within the CD34⁺/CD38^– cell population initiating MDS relapse or progression to AML. New therapeutic strategies targeting MDS stem cells might improve outcomes.     

Cell kinetics and diagnosis of residual disease of a tumor in bone marrow

Cell-cycle studies of bone marrow do not allow the detection of minimal residual disease in lymphoma or carcinoma. However, cell kinetics in acute myeloid leukemia may be a predictive test for relapse. Detection of minimal residual disease is all the more difficult that leukemic blast cells can differentiate to form mature cells.     

Impending relapse of myelodysplastic syndrome after allogeneic transplant is difficult to diagnose and requires a multi-modal approach

Background

The only potentially curative therapy for myelodysplastic syndrome is allogeneic hematopoietic cell transplant; unfortunately, there is a high relapse rate. The objective of this study was to perform a detailed clinicopathologic study of patients with relapsed myeloid neoplasm following allogeneic hematopoietic cell transplant for myelodysplastic syndrome.

Methods

Pre-transplant, post-transplant, and relapse bone marrow and peripheral blood morphologic features (including dysplasia) were retrospectively evaluated by study authors. Clinical features and results of cytogenetic analysis and engraftment/chimerism studies were obtained from the medical record.

Results

Our study describes 21 patients with a median time to relapse of 6 months (range 2–82). Ten of the patients relapsed with higher grade disease, including six with overt acute myeloid leukemia. Pre-transplant megakaryocyte dysplasia was associated with dysplastic megakaryocytes in the relapse specimen; however, neither erythroid dysplasia nor granulocytic dysplasia were associated with their counterpart in the relapse specimen. Relapse specimens had a lower marrow cellularity and higher blast percentage than pre-transplant disease. Cytogenetic comparisons before and after transplant showed variety, including clonal evolution (22%), the same abnormal clone (33%), or a different abnormal clone (22%).

Conclusions

Our detailed review of post-transplant marrow biopsies prior to relapse highlights the difficulty in diagnosing relapse and particularly impending relapse.

     

Correlation between chromosomal abnormalities and blast phenotype in the blast crisis of Ph-positive CGL

We carried out cytogenetic analysis in 23 patients with Ph-positive chronic granulocytic leukemia in blast crisis. In all cases the type of blast cell was characterized by cytochemistry, immunologic markers, and ultrastructural studies. Twelve cases were classified as myeloid transformation, six as lymphoid, two as mixed (lymphoid and myeloid), and two were unclassifiable. Duplication of Ph was the most frequent abnormality in the whole series. Trisomy 8, i(17q) and trisomy 19 were seen only in patients with myeloid blast crisis (53%, 30%, and 23%, respectively). Our findings suggest that the nature of additional chromosome abnormalities arising in blasts with features of myeloid differentiation are different from those in blasts showing lymphoid differentiation.     

Unusual myeloid leukaemia in patient with Hodgkin''s disease.

An unusual case of leukaemia in a patient with Hodgkin's disease is described. The leukaemic blast cell population was typified by the presence of a substantial proportion of binucleate and multinucleate cells, many of which had the morphological features of Sternberg-Reed cells. The circulating and bone marrow blast cells were shown by immunophenotyping to be of myeloid origin.     

Routine bone marrow examination in the management of acute lymphoblastic leukaemia of childhood.

Eighty-four children with acute lymphoblastic leukaemia (ALL) who had relapsed in bone marrow were studied to assess whether treatment would be more successful if relapse was detected before the disease became clinically evident. Patients whose relapse was detected by routine bone marrow examination before the disease became apparent were compared with those whose relapse was suspected from clinical examination or peripheral blood findings. In the former there was a lower percentage of blast cells in the marrow (p less than 0.02) and the patients suffered less from complications of the disease, but there was no difference in the incidence or duration of second remissions between the two groups.     

Blast crisis of chronic myelogenous leukemia. Morphologic and immunological features

The morphological and immunological features of 22 patients with transformation of Philadelphia chromosome (Ph1) positive chronic myelogenous leukemia (CML) were evaluated. Patterns of differentiation in blast crisis were as follows: myeloblastic 5 cases, lymphoblastic 6 cases, basophil differentiation 4 cases, monoblastic 3 cases, megakaryoblastic 1 case, and mixed 3 cases (myeloblastic and lymphoblastic, monoblastic and lymphoblastic and panmyelosis). Three cases were diagnosed as acute lymphoblastic leukemia (ALL) in early stage. After complete remission was achieved rapidly with vincristine and prednisolone, the hematological findings showed CML features. The immunological phenotype of lymphoblasts in lymphoid crisis was Ia+, CALLA+, surface and intracytoplasmic immunoglobulin negative. It was suggested that the neoplastic cells in two cases had B cell differentiation because of B1 or B4 positive. The terminal deoxynucleodidyl transferase (TdT) activity was examined by immunoperoxidase and immunofluorescence techniques on 11 cases. All TdT+ cells were the small lymphoid cells in 5 cases of lymphoid crisis and one case in mixed type. Heterogeneity of the terminal phase of CML was recognized. It was thus suggested that blast crisis of CML occurred in the pluripotent stem cell.     

Variability in morphology and cell proliferation in sequential biopsies of mantle cell lymphoma at diagnosis and relapse: clinical correlation and insights into disease progression

Aims: The variable morphology of mantle cell lymphoma (MCL) is assumed to reflect progression from an early form with classical cytology and mantle zone or nodular growth to a later, more aggressive variant of the disease with blastoid cytology and a diffuse growth pattern. However, studies of sequential biopsies of MCL are very limited, and we therefore undertook to carry out such a study. Methods and results: We analysed a cohort of 47 MCLs at primary diagnosis and relapse for cytology, growth pattern, and Ki67 index, and correlated the findings with outcome. In the majority of cases, the mantle zone growth pattern was lost, but it had been reacquired in a small subset of MCLs at relapse. Twenty‐two per cent of MCLs with classical/small cell cytology acquired blastoid features during the course of the disease. However, 50% of MCLs with blastoid cytology at primary diagnosis recurred as a classical variant. The Ki67 index increased over time, and was associated with prognosis in the primary and the relapse biopsy specimens. Conclusions: This is the first study to show, in a large cohort of MCLs, that the Ki67 index increases over time in MCL. Assessment of the Ki67 index remains a useful prognostic tool if assessment is performed in the relapse situation.     

Treatment of acute lymphocytic leukemia using zinc adjuvant with chemotherapy and radiation--a case history and hypothesis

Low blood levels of zinc are often noted in acute lymphocytic leukemia (ALL), but zinc is not administered as part of any modern chemotherapy program in the treatment of ALL. Upon noting low blood levels of zinc in a 3-year-old 11.3 kg girl, zinc at the rate of 3.18 mg/kg body weight/day was administered from the start of chemotherapy through the full 3 years of maintenance therapy. Dosage was split with 18 mg given at breakfast and 18 mg zinc with supper. The result was a bone marrow remission from 95+% blast cells to an observed zero blast cell count in both hips within the first 14 days of treatment which never relapsed. In addition to the reduction of blast cells to an observed count of zero (not a single leukemic or normal blast), red blood cell production and other hemopoietic functions returned to normal at a clinically remarkable rate. There were no side effects from zinc or chemotherapy at any time, and zinc is hypothesized to have improved the patient's overall ability to withstand toxic effects of chemotherapy. This report identifies zinc treatment as being vital to rapid and permanent recovery from ALL. The extremely broad role of zinc in pre-leukemic adverse health conditions, viral, fungal and tumoral immunity, hemopoietics, cell growth, division and differentiation, genetics and chemotherapy interactions are considered. If a nutrient such as zinc could be shown to strengthen the function of chemotherapy and immune function, then it could be hypothesized that the relapse rate would be lessened since the relapse rate is related to both the rate at which a remission is obtained and the thoroughness of the elimination of leukemic blasts. Identical results also occurred in 13 other children with ALL whose parents chose to treat with zinc adjuvant. Since treatment with zinc and other identified deficient nutrients, particularly magnesium, did not appear injurious in ALL and they appear to be highly beneficial, controlled clinical studies of zinc (3.18 mg/kg body weight/day) with magnesium (8.0 mg/kg body weight/day) as adjuvants to chemotherapy in the treatment of childhood ALL are suggested. Treatment with zinc adjuvant is hypothesized to accelerate recovery from ALL, and in conjunction with chemotherapy, cure ALL.     

Karyotype evolution in a case of chronic myelogenous leukemia with an unusual Philadelphia chromosome translocation,t(4;22), and an additional translocation,t(3;5)

A patient with chronic myelogenous leukemia was found, at the time of diagnosis, to have an unusual Philadelphia chromosome translocation, t(4;22) (q35;q11) and an additional previously unreported translocation, t(3;5) (q27;q22). The blastic crisis, which occurred after 14 months, was characterized by the appearance of i(17q). Ten months later, two different hyperdiploid cell lines with 50 chromosomes were found in about 20% of the metaphases examined.     

Clinical and pathologic analysis of 16 cases of relapsed chronic myeloid leukemia after stem cell transplantation

Chronic myeloid leukemia (CML) is a myeloproliferative disease that originates in an abnormal pluripotent bone marrow stem cell and is characteristically associated with the Philadelphia chromosome and/or the bcr/abl fusion gene. Despite the exciting success of the bcr/abl tyrosine kinase-specific inhibitor imatinib for CML treatment, hematopoietic stem cell (bone marrow or peripheral blood stem cell) transplantation (HCT) remains the only "curative" approach for the majority of patients. Although HCT outcomes for patients with CML have improved considerably during the past 2 decades, relapse after HCT may occur. We analyzed the clinical and pathologic features of 16 cases of hematologically relapsed CML after HCT during a 5-year period at City of Hope National Medical Center, Duarte, CA. The results of our analysis showed that relapsed CML after HCT frequently manifested with advanced disease with a more aggressive clinical course and was often refractory to therapy. The frequency of acute leukemic transformation at time of relapse was largely associated with pre-HCT disease status and acquired secondary cytogenetic abnormalities. Disease mortality in patients with relapsed CML after HCT was closely associated with advanced disease and HCT-related complications.     

Monosomy 20 in childhood acute lymphoblastic leukemia.

We report two cases of acute lymphoblastic leukemia (ALL) with loss of chromosome 20 as the only karyotypic abnormality detected in the blast cells. The first patient is a 12-year-old boy studied at diagnosis. He represents the only case of monosomy 20 in our series of 90 pediatric ALL successfully karyotyped at diagnosis. In the second patient, monosomy 20 was detected at the second hematologic relapse, 12 years after the initial diagnosis; cytogenetic studies were not performed at disease onset.     

BLAST GRISIS OF CHRONIC MYELOGENOUS LEUKEMIA| Morphologic and Immunological Features

The morphological and immunological features of 22 patients with transformation of Philadelphia chromosome (Ph¹) positive chronic myelogenous leukemia (CML) were evaluated. Patterns of differentiation in blast crisis were as follows: myeloblastic 5 cases, lymphoblastic 6 cases, basophil differentiation 4 cases, monoblastic 3 cases, megakaryoblastic 1 case, and mixed 3 cases (myeloblastic and lymphoblastic, monoblastic and lymphoblastic and panmyelosis). Three cases were diagnosed as acute lymphoblastic leukemia (ALL) in early stage. After complete remission was achieved rapidly with vincristine and prednisolone, the hematological findings showed CML features. The immunological phenotype of lymphoblasts in lymphoid crisis was Ia⁺, CALLA⁺, surface and intracytoplasmic immunoglobulin negative. It was suggested that the neoplastic cells in two cases had B cell differentiation because of B1 or B4 positive. The terminal deoxynucleodidyl transferase (TdT) activity was examined by immunoperoxidase and immunofluorescence techniques on 11 cases. All TdT⁺ cells were the small lymphoid cells in 5 cases of lymphoid crisis and one case in mixed type. Heterogeneity of the terminal phase of CML was recognized. It was thus suggested that blast crisis of CML occurred in the pluripotent stem cell. ACTA PATHOL. JPN. 36: 1441-1454, 1986     

Thiotepa,Fludarabine, and Busulfan Conditioning Regimen before T Cell–Replete Haploidentical Transplantation with Post-Transplant Cyclophosphamide for Acute Myeloid Leukemia: A Bicentric Experience of 100 Patients

Haploidentical stem cell transplantation (haplo-SCT) with post-transplant cyclophosphamide (PT-Cy) is an alternative treatment for acute myeloid leukemia (AML) patients who lack HLA-matched donors. Relapse after haplo-SCT remains a major concern, especially after nonmyeloablative conditioning regimens. Promising results were reported for TBF-based conditioning regimens (thiotepa, busulfan, and fludarabine) in patients transplanted from different categories of donors and for various disease types but not specifically in PT-Cy haplo-SCT for AML. Here we evaluate the outcome of 100 AML patients who received haplo-SCT with PT-Cy after TBF conditioning regimens (reduced-intensity conditioning, n = 77; myeloablative conditioning, n = 23) in 2 transplant programs. Cumulative incidences of grades III to IV acute and moderate or severe chronic graft-versus-host disease (GVHD) were 7% and 14%, respectively. NRM at 2 years was 28%, significantly influenced by disease status at haplo-SCT (first complete response [CR1] versus advanced AML: 16% versus 38%, P = .016) but not by conditioning intensity or age. The cumulative incidences of relapse at 2 years were 17% and 24% in CR1 and advanced AML, respectively (not significant). Progression-free survival, overall survival, and GVHD and relapse-free survival at 2 years were 67%, 71%, and 49% in CR1 patients, respectively, whereas comparative values in patients with advanced disease were 37%, 41%, and 32%. Our study suggests that TBF conditioning for PT-Cy haplo-SCT is safe and effective for AML patients in CR1. In patients with more advanced disease, the relatively low incidence of relapse seems counterbalanced by a high nonrelapse mortality, underlining the need for alternative strategies to decrease relapse risk, without increasing the intensity of conditioning regimen.     

Terminal deoxynucleotidyl transferase-positive lymphadenopathy in acute-phase chronic granulocytic leukemia

A patient who had Philadelphia chromosome-positive chronic granulocytic leukemia had generalized lymphadenopathy. The lymph node biopsy revealed blast cells with small numbers of eosinophilic myelocytes indicative of granulocytic differentiation. In addition, the blast cells were found to have Philadelphia (Ph1) chromosome and extremely high levels of terminal deoxynucleotidyl transferase (TdT). The patient's peripheral blood and bone marrow reverted to the chronic phase, and the lymphadenopathy disappeared on two occasions with vincristine and prednisone therapy. The extramedullary proliferation of blastic chronic granulocytic leukemia, therefore, seems to share the histologic, cytogenetic biochemical, and chemotherapeutic sensitivity features of the basic disease process. TdT assay of enlarged lymph nodes in acute-phase chronic granulocytic leukemia might be used to identify the patients responsive to vincristine and prednisone despite the granulocytic histologic features of their lymph nodes.     

Stem cell regulation and the development of blast crisis in chronic myeloid leukemia: Implications for the outcome of Imatinib treatment and discontinuation

Chronic myeloid leukemia (CML) is a cancer of the hematopoietic system that is initiated by a single genetic alteration (the BCR-ABL fusion gene or Philadelphia chromosome) and progresses in several phases: during the chronic phase the number of cells grows slowly and the fraction of immature cells is low. During the accelerated phase and blast crisis, the population of CML cells and the fraction of immature cells rises sharply. The mechanisms that drive the transition from the chronic phase to blast crisis are not understood, and the requirement of genetic instability and further mutations has been suggested. Using mathematical models, I describe a theory that can account for the transition from the chronic phase to blast crisis without the need to invoke further mutations. The transition to blast crisis can be explained solely by feedback mechanisms that regulate the patterns of stem cell division, in particular the occurrence of symmetric versus asymmetric cell division. The model also has implications for the outcome of Imatinib treatment. According to the model, treatment can lead to the low level persistence of CML stem cells without assuming that these cells are less susceptible to drug-mediated activity, and this might explain why disease tends to relapse after treatment discontinuation even in the absence of acquired drug resistance. Further, the model defines conditions when Imatinib treatment might lead to the eradication of CML, which is relevant in the context of recent data that show absence of relapse as long as two years after treatment cessation.