Importance of the detection of minimal residual disease in the management of acute leukemia

Between 1984-1988, 57 adult acute leukemic patients were treated with intensive combined chemotherapy in the National Institute of Haematology and Blood Transfusion. For the evaluation of response to therapy, 4 investigations were performed in parallel: bone marrow aspirate, bone marrow biopsy, cytogenetic analysis and bone marrow culture. Nonparametric test for samples taken for the evaluation of remission status showed that bone marrow biopsy was significantly the most sensitive method for the detection of residual disease. The bone marrow culture was also on the borderline of significance, but the low CFU-GM level did not always correlate with the further clinical course. Occasionally, karyotypic abnormality was the only sign of the residual disease. It would be of great importance to quantitate the minimal residual disease in order to evaluate and compare the various intensive postinduction therapeutic strategies.     

儿童急性白血病微小残留病的研究进展

近20年来,随着白血病治疗水平的提高,儿童急性白血病的完全缓解率和生存时间明显延长,但仍有部分患儿复发,导致死亡,引起死亡的主要原因是微小残留病的存在.该文综述了微小残留病的检测方法包括形态学方法、细胞培养法、单克隆抗体法、代谢酶测定、细胞遗传学方法、荧光原位杂交、免疫双标记分析、流式细胞仪检测技术、多聚酶联反应等,并阐述了临床检测的意义.     

应用流式细胞技术(FCM)检测儿童APL微小残留病

目的研究应用流式细胞技术(FCM)检测APL病人的白血病微小残留病(MRD),评价其临床意义。方法应用FCM检测和分析36例APL病儿在初发期和完全缓解期的CD13、CD33、CD34和TdT表达,全部APL病人每日输入AS2O3治疗,直到完全缓解(CR)。结果36例APL病人在初发期CD13、CD33表达均明显高于对照组(P<0.05),其阳性表达率分别为63.88%(23/36)和80.55%(29/36),CD34和TdT均为低表达,经AS2O3治疗的CR期有34例APL病人CD13和CD34阳性细胞为10‰左右,其余2例仍为高表达(CD13和CD33抗原阳性细胞>10%~20%),并于3个月内复发。结论研究结果推断,应用FCM检测APL病人CD13和CD33表达可预测复发,FCM分析结果可提高检测MRD的敏感性并可估计APL病人的预后,CD13和CD33双表达可能预后不良。     

外周血涂片镜检联合微小残留病检测在急性髓系白血病复发诊断中的应用

目的分析急性髓系白血病(AML)患者完全缓解(CR)后外周血涂片镜检情况和微小残留病(MRD)检测水平,探讨两者在判断AML复发中的应用价值。方法回顾性分析36例AML复发患者的外周血涂片原始细胞检出情况和MRD值,MRD<0.1%为阴性、MRD≥0.1%为阳性。结果 36例复发患者中,外周血涂片检出原始细胞31例,其中21例报告时间早于骨髓送检时间;原始细胞检出患者中最常见的复检类型是血小板计数降低、单核细胞百分比增高和白细胞计数降低。MRD检测阳性29例,阴性7例,阳性明显多于阴性;复发期与缓解期相比,MRD显著增高,差异有统计学意义(P<0.05)。外周血涂片镜检和MRD检测对AML复发的诊断符合率分别为86.11%和80.55%,2种方法联合检测的符合率为94.44%。结论外周血涂片镜检联合MRD检测对早期发现急性髓系白血病的复发具有临床意义。     

Application of the polymerase chain reaction for detection of minimal residual disease of hematologic malignancies

Current induction therapies for acute and chronic leukemias and the lymphomas have achieved significant complete remission rates. Despite this initial success, disease recurrence remains a major problem. Relapse from clinically undetectable residual malignant cells is the most likely mechanism of recurrence. Of crucial importance to the clinician is the accurate detection of residual malignant cells prior to clinical relapse. Standard approaches to evaluate for this minimal residual disease (MRD) allow detection only when the malignant clone exceeds 1%. Patients in remission, however, may frequently have residual neoplastic cells that are far below this level. Recently, several investigators have adapted the polymerase chain reaction (PCR) to detect tumor-specific DNA or RNA sequences. This approach is highly sensitive (able to detect 1 malignant cell in 10(6) normal cells). The application of this technique to the study of MRD thus far has been limited to tumors in which specific DNA or RNA sequence data are available. This review describes the application of PCR to the detection of MRD in patients with chronic myelogenous leukemia, acute lymphoblastic leukemia, and follicular small cleaved cell lymphoma. Because the number of clinical studies and length of follow-up is limited, detection of MRD by PCR is at present largely a research tool and the biological significance of MRD as determined by PCR must await further studies.     

使用Taqman技术监测慢性粒细胞白血病患者微小残留病灶

目的动态的监测bcr-abl融合基因mRNA表达水平以及评估经格列卫治疗后的慢性粒细胞白血病(CML)患者微小残留病灶。方法荧光定量RT-PCR法(Q-RT-PCR)检测bcr-abl融合基因mRNA表达水平,收集来自广州金域的34例CML患者(包括经格列卫治疗后缓解病人17例,未经治疗病人17例)。CML患者的检测结果与其他良性血液病患者进行比较,并且结合临床表现,得到CML和其它非白血病病人中bcr-abl L表达信息,以及在慢性粒细胞白血病的治疗中微小残留病灶的重要意义。结果在CML病人中bcr-abl融合基因表达阳性率为88.3%(30/34),在其他的良性血液病中无表达。我们也能观察到经格列卫治疗的病人有一定的治疗效果,经格列卫治疗的病人bcr-abl融合基因的表达水平较未经治疗者明显降低(P<0.05)。结论 Q-RT-PCR法是检测慢性粒细胞白血病微小残留病灶的重要方法,BCR-ABL融合基因可以做为CML的分子标志。     

Secondary acute leukemia in Hodgkin's disease]

Two secondary acute leukaemias out of 166 patients with Hodgkin's disease were detected. At a young female patient treated only with chemotherapy the acute leukaemia developed 39 months following the diagnosis of Hodgkin's disease. Phenotype of leukaemic blast cells could not be determined exactly. After a short complete remission (1,5 month) the patient died because of the progression of her leukaemic process. The other young male patient treated with radio- and chemotherapy had six years disease free interval between the diagnosis of two malignant diseases. The combined cytostatic treatment of his acute lymphoblastic leukaemia resulted complete remission that lasted for one year but later the progression of leukaemia caused death. In connection with these cases the authors reviewed the current questions of treatment related acute leukaemias in Hodgkin's disease.     

急性白血病患者血浆纤维蛋白原检测的临床意义

目的探讨急性白血病患者血浆纤维蛋白原水平的变化及其临床意义。方法采用Sysmex CA-1500全自动血凝仪对急性白血病患者治疗前后以及健康人血浆纤维蛋白原水平进行检测并比较差异。结果急性白血病初治患者纤维蛋白原水平明显增高,与对照组比较,差异有统计学意义(P<0.01),经治疗后达缓解者纤维蛋白原水平明显下降,与治疗前比较差异有统计学意义(P0.05)。结论血浆纤维蛋白原在急性白血病的诊断及疗效判断中有一定的临床意义。     

细胞免疫表型检测在急性白血病分型诊断中的应用价值

目的：探讨细胞免疫表型检测在急性白血病（AL）免疫分型和亚型诊断中的应用价值。方法：选择临床常用的12种单抗,应用流式细胞术（FCM）对形态学分型初诊的56例急性髓细胞白血病（AML）和28例急性淋巴细胞白血病（ALL）进行免疫表型检测与分析。结果：（1）有54例AML与免疫表型检测结果相符（符合率为96.4%）,且各型均表达3种及以上髓系抗原,约90%以上AML不表达淋系抗原。（2）在2例与免疫表型检测结果不符的AML中,1例以巨核细胞抗原特异表达为主,被纠正为M7;另1例因同时表达2种髓系和淋系抗原而确诊为急性混合性白血病（HAL）。（3）经免疫表型检测能将28例ALL精确区分为T-ALL、B-ALL和T/B-ALL 3型,除后者外,B系抗原与T系抗原均不互相表达,具有较强系列专一性表达特点;T/B-ALL同时表达T系与B系抗原。结论：细胞免疫表型检测能为AL分型和亚型诊断提供客观而精确的依据,弥补并纠正形态学分型的不足与误诊,并在AML与ALL鉴别、ALL亚型区分和发现HAL、M7等方面具有较高的特异性和独特的临床应用价值。     

Childhood acute lymphoblastic leukemia: genetic determinants of susceptibility and disease outcome

The origin of acute lymphoblastic leukemia (ALL), the most common pediatric cancer, can be explained by a combination of genetic factors and environmental exposure. The environmental toxicants to which an individual is exposed are biotransformed and eliminated from the body after metabolic conversion mediated by Phase I and Phase II xenobiotic-metabolizing enzymes. Phase I enzymes catalyze hydroxylation, reduction and oxidation reactions of xenobiotics (carcinogens/drugs), often converting them into more active or toxic compounds. Phase II enzymes catalyze conjugation reactions (glucuronidation, acetylation, methylation), thereby converting the metabolites into non-reactive, water-soluble products that are eliminated from the organism. The genetic polymorphism underlying the variation in enzyme activity can modify susceptibility to diverse adult cancers, probably by influencing the activation and removal of toxicants or drugs. Here we present an overview of the role of genetic variants of certain Phase I and Phase II enzymes in the development of childhood ALL, a good model for such studies because of its short latency period. The genetic contribution to the development of ALL is examined by association studies that analyze the loci of Phase I enzymes (cytochrome P-450, myeloperoxidase) and Phase II enzymes (quinone-oxidoreductase, glutathione-S-transferase, N-acetyltransferase). The loci of the enzyme variants CYPlA1, CYP2E1, NQO1, GSTM1, GSTP1, NAT2 are associated with disease development, and evidence of gene-gene interactions has emerged as well. Despite the improvements in treatment, resistant cases of ALL remain a leading cause of cancer-related death in children. Although the underlying mechanism of drug resistance is not well understood, differences in the capacity of ALL patients to process drugs and environmental carcinogens could play a role by modifying the risk of recurrent malignancy, as well as the response to therapy. Therefore, polymorphic genes encoding carcinogen- and drug-metabolizing enzymes may not only increase the risk of ALL but also influence the risk of relapse in patients. We found that the prognosis of patients with CYPlA1 and NQO1 variants was worse than that of patients who lack these variants. We conclude that genotyping ALL patients for functional polymorphisms of candidate genes can become an important tool in predicting disease outcome.     

Detection and diagnostic value of t(14;18) translocation in minimal residual disease of follicular lymphoma

The minimal residual disease is important in several malignant diseases, such as in hematopoietic malignancies (e.g. in follicular lymphoma) or in solid tumors, due to the presence of a tumor burden following a treatment of these diseases. In case of t(14;18) chromosome translocation, which characterizes most of the follicular lymphomas, the bcl-2 gene translocates to the joining region of the immunoglobulin heavy chain of chromosome 14. The expression of bcl-2 gene alters due to the translocation, and this change results in the inhibition of cellular apoptotic processes, and in turn these series of events may finally lead to the development of lymphoma. It is inevitable to learn the results of radio- and/or chemotherapy, i.e. whether the translocation-bearing cells disappeared from the lymphocytes of peripheral blood as well as from that of bone marrow, or we have to take into account the minimal residual disease. Using nested-PCR one can detect the translocation in 1 out of 10(5) cells, this way the results of the treatments can be controlled: one can establish the emergence of remissions; and the relapses could also be detected earlier than by using conventional diagnostic methods. Our experience, yielded by the follow up studies of follicular lymphoma patients, shows that the results of PCR detection correlate excellently with the conclusions of other diagnostic techniques. Nevertheless, the t(14;18) translocation-bearing cells can also be detected in peripheral lymphocytes of healthy donors as well as in that of different diseases of other types than lymphoma, but not in bone marrow. Therefore we emphasize the importance of the translocation-detection in the bone marrow of the patients of follicular lymphoma. More and more advanced techniques have made it possible to detect the minimal residual disease, this way it will be easier to diagnose and to predict the outcome of different malignant diseases.     

Recurrent leukemia cutis in acute myeloblastic leukemia

We report the case of a 64-year-old female with acute myeloblastic leukemia (French-American-British classification: M2) who developed two specific cutaneous manifestations during her illness. She presented with extensive cellulitis involving the face, neck, and upper chest wall. While the cellulitis resolved with antibiotic therapy, a fungating ulcerated nodule remained on the lower lip which proved to be leukemic on biopsy. Concomitant blood and bone marrow findings were diagnostic of acute myeloblastic leukemia. The lip lesion cleared with a course of chemotherapy. An erythematous macular rash subsequently developed over the lower trunk which was thought to be an allergic reaction to the penicillin treatment. However, biopsy results were consistent with leukemia cutis. A repeat bone marrow examination revealed excessive blasts. Our observations emphasize the various presentations of leukemia cutis and the need to biopsy any cutaneous lesion of unclear etiology in the setting of acute leukemia.     

一例急性非淋巴细胞性白血病的职业病诊断分析

目的探讨职业性苯致白血病的接触时间、潜隐期在职业病诊断中的应用问题。方法依据职业性肿瘤的诊断标准针对急性非淋巴细胞性白血病的诊断过程中职业史采信、接触时间、潜隐期应用等问题进行分析和探讨。结果认为《职业性肿瘤诊断标准》标准中的累计工龄计算、潜隐期的概念存在不适宜性。结论建议对《职业性肿瘤诊断标准》中工龄计算、亚急性苯致白血病诊断标准、潜隐期的概念等内容进行补充和完善。     

Aleukemic leukemia cutis preceding acute monocytic leukemia: a case report

Aleukemic leukemia cutis is an extremely rare clinical presentation in patients who eventually develop acute leukemia, usually of monocytic lineage. This condition is associated with a very poor prognosis and is often difficult to diagnose. We report a case of a 33 years old female with leukemia cutis preceding the onset of acute monocytic leukemia by four months. The patient received induction and consolidation chemotherapy followed by allogeneic bone marrow transplant and has been free of disease for six years. To our knowledge, this is the first documented case in Puerto Rico with the diagnosis of leukemia cutis preceding acute monocytic leukemia.