Natural history of chronic myelomonocytic leukemia: gene sequencing identifies multiple clonal molecular abnormalities associated with rapid progression to acute myeloid leukemia

Gene panel sequencing in a CMML patient without any detectable genetic abnormality by conventional genetic studies identified four concurrent somatic mutations in three genes. Gene panel mutation analysis is a rapidly emerging clinical tool to demonstrate the clonality in hematologic malignancies, and to identify the potential targets for therapy.     

MLL‐ELL fusion gene in an acute myelomonocytic leukemia patient transformed from acute promyelocytic leukemia

We report an extremely rare case of acute myelomonocytic leukemia (M4) with an MLL‐ELL fusion gene lacking the PML‐RARα rearrangement that transformed from hypergranular acute promyelocytic leukemia (APL) without showing any karyotypic evolution. The treatment was effective with chemotherapy for M4 and idarubicin plus a cytarabine‐based chemotherapy protocol without ATRA.     

伊马替尼耐药CML患者ABL基因激酶区突变检测

目的 研究伊马替尼(imatinib,IM)治疗慢性粒细胞白血病(chronic myeloid leukemia,CML)耐药患者ABL酪氨酸激酶区突变情况.方法 用巢式PCR扩增对IM治疗耐药的56例CML患者骨髓样本ABL基因激酶区序列,通过测序和序列同源性检索分析ABL激酶区突变情况.结果 56例患者检出突变1...     

急性和慢性髓系白血病患者中螺旋酶抗原基因表达的研究(英文)

本研究旨在探讨螺旋酶抗原基因(HAGE)在急性髓系白血病(AML)和慢性髓系白血病(CML)中的表达状况和临床意义。应用实时定量PCR(RQ-PCR)方法检测AML和CML患者骨髓单个核细胞中HAGE cDNA的表达。结果表明:74例AML患者中11例(14.8%)存在HAGE过表达(117.12%-9842.70%,中位434.96%);HAGE过表达患者年龄显著高于HAGE阴性者(中位年龄分别为67和45岁,p=0.001)。HAGE表达在单核细胞亚型AML(M4和M5,7/20,35.0%)中明显高于其它亚型AML(4/54,7.4%)(p=0.007)。28例核型正常的AML患者中8例(28.6%)呈HAGE过表达,而40例核型异常的AML中仅3例(7.5%)存在HAGE表达(p=0.041)。9/26例(34.6%)CML患者存在HAGE过表达,加速期和急变期患者中HAGE表达率(4/4,100%)明显高于慢性期患者(5/22,22.7%)(p=0.008)。结论:HAGE cDNA表达与AML单核细胞亚型类别相关,且与CML疾病进展相关。     

基因突变筛查对急性髓性白血病患者临床诊疗的获益对比分析

目的 对比分析三种包含不同基因数目基因突变筛查在急性髓性白血病(AML)患者中的应用及帮助临床诊疗获益的情况.方法 采用靶向扩增子高通量测序方法,对721例初诊AML患者分别进行包括了9种、16种和58种基因的突变检测.结果 筛查9种、16种和58种基因的突变阳性率分别为66.2％、79.6％和86.4％;分别有23....     

Monocyte subsets to differentiate chronic myelomonocytic leukemia from reactive monocytosis

BackgroundChronic myelomonocytic leukemia (CMML) is characterized by persistent monocytosis and dysplastic features of blood cells. No specific genetic abnormalities are present in CMML, and reactive monocytosis should be excluded. An increase in classical monocytes (MO1) has been suggested as a screening tool for CMML.MethodsWe evaluated monocyte subsets in the peripheral blood of patients with CMML (n = 16), patients with reactive monocytosis (n = 19), and normal controls (n = 15) with flow cytometry using antibodies against CD14, CD16, CD56, CD24, CD45, and CD2. The cutoff of MO1 ≥94% was validated, and the optimal cutoff was analyzed with receiver operating curve analysis.ResultsThe sensitivity of monocyte subset testing for screening for CMML was 0.938 (0.717‐0.997), and the specificity was 0.882 (0.734 ‐ 0.953) using the cutoff of MO1 ≥94%. Serial samples from patients who responded to hypomethylating therapy showed an MO1 < 94%. However, few patients with reactive monocytosis, including patients with nonhematologic malignancies and acute myeloid leukemia, showed an increase in the MO1 ≥ 94%. Monocyte subset results were correlated with the response to hypomethylating therapy in follow‐up samples.ConclusionMonocyte subset analysis is useful in screening for and monitoring CMML. Harmonization of the protocols for monocyte subset analysis is required.     

DNMT3A基因对非M3型急性髓系白血病患者预后的预测价值

目的通过分析非M3型急性髓系白血病(AML)患者的临床和实验室资料,进一步阐明DNMT3A基因突变在非M3型AML患者预后中的意义及其影响AML发生发展的可能机制。方法采用R语言3.5.1版本RTCGAToolbox包下载癌症基因组图谱数据库180例非M3型AML患者临床及突变信息,数据为开放性数据。将患者按照突变状态进行分组,比较各组患者外周血白细胞计数、骨髓原始细胞比例、无事件生存期以及总体生存期有无差别。将患者按照年龄分为<60岁组和≥60岁组,使用Kaplan-Meier方法绘制生存曲线,并运用Log-rank检验进行<60岁和≥60岁患者、DNMT3A突变组及野生组患者生存率的比较。采用Cox比例风险模型进行DNMT3A突变和其伴随突变及年龄分层等因素对患者总体生存期的单因素和多因素分析。结果共纳入非M3型AML患者180例,DNMT3A突变组与野生组患者临床特征比较发现突变组白细胞计数显著高于野生组(Z=-2.606,P=0.009),且DNMT3A突变多见于中危患者。值得注意的是,DNMT3A突变常伴随FLT3(P=0.025)、NPM1(P<0.001)、IDH1(P=0.002)突变的发生,且DNMT3Awt/FLT3wt组无事件生存期显著高于DNMT3Amut/FLT3mut组(11.00个月vs 6.15个月,P=0.005),而与DNMT3Amut/FLT3wt、DNMT3Awt/FLT3mut组之间的差异无统计学意义。Cox多因素分析结果显示,高龄是AML患者总体生存的独立危险因素(HR=2.974,95%CI:1.966~4.500,P<0.001);另外,DNMT3A R882突变是AML患者预后不良的独立预测因子(HR=1.937,95%CI:1.179~3.182,P=0.009)。结论高龄(≥60岁)和DNMT3A R882突变为预后不良的独立预测因子。DNMT3Amut/FLT3mut亚型与DNMT3Awt/FLT3wt、DNMT3Amut/FLT3wt、DNMT3Awt/FLT3mut相比,临床预后更差。     

移植性慢性髓系白血病裸鼠模型的初步建立

慢性髓系白血病（chronic myeloid leukemia,CML）是一种起源于造血干细胞的恶性克隆性疾病,CML干细胞被认为是导致疾病发生、发展并最终急变的根源,目前尚缺乏稳定的动物模型证明CML干细胞的存在。本研究旨在通过建立CML裸鼠模型,探讨人CML细胞在BABL/c裸小鼠体内的生物学行为,并使CML干细胞在裸鼠体内富集成为可能。对4至6周龄的BALB/c裸鼠进行切脾（splenectomy,S）,环磷酰胺腹腔注射（cytoxan intrap-eritoneal injection,C）及全身亚致死剂量照射（sublethal irradiation,I）等预处理（SCI）后,经尾静脉接种（5-8）×10^7个人CML慢性期患者单个核细胞。对4至6周龄的BALB/c裸鼠进行全身致死剂量照射（lethal irradiation）后,经尾静脉接种5×10^6同源裸鼠骨髓细胞和（5-8）×10^7个人CML慢性期患者单个核细胞。应用RT-PCR、塑胶包埋病理切片以及流式细胞术等检测裸鼠各脏器及骨髓中人CML细胞浸润情况,并比较两种建模方法的优劣。结果表明,CML细胞能浸润至经SCI预处理的裸鼠骨髓体内,但目前成功率还很低,仅为通过BABL/c裸鼠建立人CML动物模型的一个开端。而经致死剂量预处理裸鼠,CML细胞未能浸润至骨髓。结论：人CML慢性期白血病细胞能在经SCI预处理的裸鼠体内形成白血病,为建立CML动物模型寻找到新的方向。     

Therapy-related myelodysplastic syndrome and acute myeloid leukemia in patients with chronic lymphocytic leukemia treated with fludarabine and cyclophosphamide

We retrospectively studied four cases of t-MDS/AML among 210 (1.9%) consecutive patients with CLL treated at a single center with fludarabine and cyclophosphamide (FC) either as the first- or second-line therapy. The median follow-up of the whole cohort of patients was 46 months (range: 7-60). Two of these patients (2/130, 1.7%) had been treated with FC only, and two more (2/80, 2.3%) with CHOP and CHOP + FND, respectively, prior to FC. The median age was 61.5 years (range: 49-71); three were male. They developed t-MDS/AML after a median latency period of 41 months (range: 7-56) from the FC completion. Chromosomal aberrations with an adverse prognostic impact were present in the karyotype of all four patients, including abnormalities of chromosome 5 in three of them, and a rare chromosomal translocation in one patient. Median survival after t-MDS/AML diagnosis was 4 months (range: 2-8). Although the agents administered prior to FC make it difficult to assess the risk of t-MDS/AML attributable to FC, this report might be a valuable addition to the literature.     

化疗联合阿米福汀在急性髓性白血病中的病例对照研究

目的探讨阿米福汀在急性髓性白血病化疗中是否具有正常造血干细胞保护作用同时不造成复发率的升高。方法前瞻、非随机、病例对照研究142例急性髓性白血病巩固化疗患者血液学毒性及非血液学毒性、缓解率、缓解持续时间。结果阿米福汀联合化疗组56例[男30例,女26例;高危18例,中危32例,低危6例;平均年龄（35．14±14．42）岁],单独化疗组86例[男58例,女28例;高危14例,中危64例,低危8例;平均年龄（46．58±16．99）岁]。两组间性别（P=0．318）、危险度（P=0．262）差异无统计学意义。年龄两组间有统计学意义（P=0．004）,使用阿米福汀联合化疗组年轻患者多。阿米福汀联合化疗组中剂量阿糖胞苷[联合组24例（42．9％）,单独化疗组12例（14．9％）]以及HAA方案[联合组18例（32．1％）,单独化疗组18例（20．9％）]更多。阿米福汀联合化疗相较于单独使用化疗组,血小板〈20×109／L持续时间短[联合组0（0,7）d,单独化疗组9（4,14）d,P=0．01）、输注血小板数少[联合组0（0,3）U,单独化疗组4（1,6）U,P=0．02]。缓解率以及缓解持续时间两组差异无统计学意义,联合组化疗前缓解率为96．4％（54／56）,化疗后缓解率仍为96．4％（54／56）,单独化疗组1例治疗前未获得缓解的患者化疗后仍未缓解,化疗前缓解率为98．8％（85／86）,化疗后仍为98．8％（85／86）,两组间缓解率差值相比差异无统计学意义（P=0．062）。结论阿米福汀可用于急性髓性白血病化疗后的防护,血小板减少持续时间短,血小板输注减少,其他副作用未见明显差别。     

多参数流式细胞术在慢性粒单核细胞白血病、骨髓增生异常综合症及急性单核细胞白血病免疫表型鉴别中的应用及其意义

本研究应用多参数流式细胞术分析慢性粒单核细胞白血病(CMML),骨髓增生异常综合症(DMS)以及急性单核细胞白血病(AML-M5b)的免疫表型特点,探究其在诊断及鉴别诊断上述疾病中的意义和价值。应用多参数流式细胞术比较分析14例CMML患者、48例MDS患者、46例AML-M5b患者及18例正常人骨髓标本的免疫分型特点。结果表明,CMML患者单核细胞比例明显高于MDS、AML-M5b患者及正常人骨髓(P<0.05),后3者之间无显著差别。MDS患者骨髓原始细胞比例明显高于正常骨髓标本(P<0.05),但与CMML患者无明显差别。AML-M5b患者骨髓成熟粒细胞比例较CMML、MDS患者及正常骨髓标本明显减低(P<0.05)。MDS、AML-M5b及CMML患者骨髓CD45/SSC特点与正常骨髓标本均存在一定差异。CMML患者骨髓具有CD2、CD56异常表达及CD14拖尾现象,与MDS、AML-M5b及正常骨髓标本相比差异显著(P<0.05)。MDS与CMML患者骨髓单核细胞CD15表达缺失或减低现象较正常骨髓标本及AML-M 5b患者显著,且CMML患者异常率高于MDS患者(P<0.05),两者粒细胞群均有显著CD13/CD11b/CD16表达规律异常现象,但两者间无显著差异。其他抗原表达呈不同程度异常,无统计学差异。结论 MDS、CMML及AML-M5b骨髓细胞免疫表型均具有各自的特点及不同程度的相似处。多参数流式细胞术综合分析其免疫表型,对于区分CMML、MDS以及AML-M5b具有重要鉴别意义。其中单核细胞比例增高,伴有CD2、CD56异常表达,CD14拖尾现象,CD15缺失或减低及成熟粒细胞CD13-CD11b-CD16表达规律异常,对CMML诊断具有重要意义。     

CML患者骨髓间质干细胞的干细胞因子mRNA表达水平检测

目的 研究慢性粒细胞白血病(CML)患者骨髓间质干细胞(MSCs)生长活性及干细胞因子(SCF)表达水平,探讨MSCs在CML发病中的作用.方法 以慢性期CML患者为实验组,健康人为对照组,抽取骨髓液行MSCs体外培养,动态观察细胞形态并进行计数、绘制生长曲线;取第3、4代MSCs提取总RNA,逆转录,real-time PCR法检测SCF mRNA表达水平.结果 慢性期CML患者骨髓MSCs生长活性较健康人无明显差别;实验组MSCs表达SCF mRNA水平较对照组明显高(P＜0.05).结论 CML患者骨髓MSCs异常表达SCF参与CML发病,对其检测有指导诊断意义.     

RUNX1基因突变对成人急性髓系白血病患者临床特征、疗效及预后的影响

目的探讨Runt相关转录因子1(RUNX1)基因对成人急性髓系白血病(AML)患者临床特征、疗效及预后的影响。 方法利用二代测序方法检测2017年4月至2021年10月于济宁市第一人民医院血液内科就诊的145例初诊AML患者中RUNX1、FLT3、NPM1等在内的25种AML相关基因突变情况,按照有无RUNX1基因突变将患者分为RUNX1基因突变(RUNX1^mut)组及RUNX1基因野生型(RUNX1^wt)组,比较两组在年龄、性别、初诊时外周血细胞计数、骨髓原始细胞比例、FAB分型、细胞遗传学分层、AML细胞免疫表型、伴发基因突变、治疗疗效及生存期方面的差异。 结果15例(10.34%)患者中检出RUNX1突变。与RUNX1^wt组(n＝130)患者相比,RUNX1^mut组(n＝15)患者的年龄更大[(61.00±10.42)岁,(49.92±16.33)岁](t＝3.63,P＝0.001),骨髓原始细胞比例更低[34.01(22.60,45.00)%,55.91(33.44,77.95)%,U＝827.00,P＝0.013],AML细胞表达CD15[0%(0/15),26.15%(34/130),P＝0.022]和CD64[6.67%(1/15),39.23%(51/130),χ²＝6.20,P＝0.013]的阳性率更低,合并其他基因突变个数更多[5.00(3.00,6.00),3.00(2.75,5.00),U＝650.50,P＝0.032],且更易伴发EZH2突变[20.00%(3/15),1.54%(2/130),P＝0.008]及8号染色体三体(+8)异常[21.43%(3/14),3.31%(4/121),P＝0.025]。两组在性别、初诊时外周血细胞计数、FAB分型、细胞遗传学分层及诱导治疗反应率方面均差异无统计学意义(均P>0.05)。另外,RUNX1^mut组患者1年总生存期显著低于RUNX1^wt组[40.00%(6/15),66.15%(86/130),χ²＝3.97,P＝0.046]。 结论在AML患者中RUNX1基因突变与高龄、低骨髓原始细胞比例、AML细胞低表达CD15和CD64及伴发更多的基因突变相关,RUNX1突变易合并EZH2突变及8号染色体异常。携带有RUNX1突变的患者可能生存期更短,预后更差。     

EVI1 阳性急性髓细胞白血病临床及预后分析

目的分析EVIl（ectotropicviralintegrationsite1）基因在急性髓细胞白血病（AML）中的表达及意义。方法应用相对荧光定量PCR检测145例AML患者EVIl基因的表达,并观察其诱导缓解及生存情况。结果28例AML患者表达EV11基因,阳性表达率19．3％;AML各亚型间比较,M4、M5的EV11基因阳性率高于M1、M2（x2=16．47,P〈0．05）。EVIl阳性与阴性患者年龄、外周血白细胞、血红蛋白、血小板、骨髓原始幼稚细胞比例及完全缓解率等比较,差异均无统计学意义（P〉0．05）。但EV11阳性患者的1年内病死率明显高于EVIl阴性患者（x2=9．68,P〈0．05）。结论EVIl基因在AML的发病中起一定作用,可作为判断AML预后不良的一个指标。     

急性髓性白血病并发肿瘤溶解综合征

目的：探讨肿瘤溶解综合征在急性髓性白血病的发病率、生化特点、高危因素、预防及治疗。方法：回顾性分析84例急性髓性白血病化疗前、后血液、生化指标等临床资料。结果：84例患者中8例（9．5％）并发肿瘤溶解综合征,其中5例（6．0％）为实验室肿瘤溶解综合征,3例（3．6％）为临床肿瘤溶解综合征;临床、生化特点表现为高钾血症、高磷血症、高尿酸血症、低钙血症和急性肾功能衰竭;化疗前白细胞计数、乳酸脱氢酶水平高的患者易并发。结论：肿瘤溶解综合征在急性髓性白血病并不罕见,前期预防及早期诊治是降低该综合征病死率的关键。     

细胞免疫表型检测在慢性粒单核细胞白血病诊断和治疗监测中的应用

目的评估流式细胞仪细胞免疫表型检测(FCI)在慢性粒单核细胞白血病(CMML)诊断和监测治疗反应中的临床价值和意义。方法采用多色FCI分析法和形态学观察法对109例CMML患者和39例随访患者的骨髓标本的免疫表型和形态学进行检测和评价,并对结果进行统计学分析。结果采用FCI测得骨髓单核细胞百分比为15%。与形态学分出的单核细胞百分比相关(r=0.35,P=0.000 3)。96%患者单核细胞FCI发生改变;FCI观察到的CMML粒细胞生成障碍为91.7%明显高于形态学方法测得的82.6%(χ~2=4.10,P0.05)。CMML患者FCI CD34+细胞测定结果为中位数0.7%(范围0.15%~11.60%),但其免疫表型改变非常显著改变个数的中位数为7(范围1~11个)。91%患者出现1阶段原始血细胞缺失或明显减少。39例随访患者中35例使用低甲基化剂(HMA)治疗和4例等待治疗患者的骨髓样品CD34+原始细胞均被检测到持续的免疫表型改变,对HMA治疗有应答的13例患者单核细胞CD14表达均正常;而40.9%(9/22)HMA治疗无应答者单核细胞CD14表达发生改变(P=0.030),4例接受造血干细胞移植治疗的患者免疫表型于移植后均正常。结论 CMML患者的CD34+细胞,单核细胞和粒细胞表现出多种FCI异常,FCI能够将恶性增生从反应性单核细胞增多中区分出来,同时也可用于监测CMML患者治疗反应。     

Programmed death-1 checkpoint blockade in acute myeloid leukemia

Introduction: Immune checkpoints are regulatory pathways induced in activated T lymphocytes that regulate antigen responsiveness. These immune checkpoints are hijacked by tumors to promote dysfunction of anti-tumor effector cells and consequently of tumor escape from the host immune system.

Areas covered: Programmed death-1/programmed death ligand (PD-1/PDL-1), a checkpoint pathway, has been extensively investigated in leukemia mouse models. Expression of PD-1 on the surface of activated immune cells and of its ligands, PD-L1 and PD-L2, on leukemic blasts has been documented. Clinical trials with PD-1 inhibitors in patients with hematological malignancies are ongoing with promising clinical responses.

Expert opinion: Therapy of hematological cancers with antibodies blocking inhibitory receptors is expected to be highly clinically effective. Checkpoint inhibitory receptors and their ligands are co-expressed on hematopoietic cells found in the leukemic milieu. Several distinct immunological mechanisms are likely to be engaged by antibody-based checkpoint blockade. Co-expression of multiple inhibitory receptors on hematopoietic cells offers an opportunity for combining blocking antibodies to achieve more effective therapy. Up-regulation of receptor/ligand expression in the leukemic milieu may provide a blood marker predictive of response. Finally, chemotherapy-induced up-regulation of PD-1 on T cells after conventional leukemia therapy creates a solid rationale for application of checkpoint blockade as a follow-up therapy.     

急性髓系白血病治疗进展

近年来的研究对于急性髓系白血病(AML)发病机制的理解已经有了显著的进步,导致AML发病的许多分子学异常逐渐明晰,因此对于AML的本质认识越来越深刻。与此同时大量临床试验的开展也获得了相当的成功,AML的诊治方案已经进展到了个体化阶段。