High incidence of meningeal leukemia in lymphoid blast crisis of chronic myelogenous leukemia

Fifteen patients with lymphoid blast crisis of chronic myelogenous leukemia (LyBC-CML) and five patients with acute lymphoblastic leukemia converting to Philadelphia-positive (Ph+) chronic myeloid leukemia (ALL Ph + CML) were followed. Seven of 15 (46.7%) LyBC-CML patients developed meningeal leukemia within a median period of 6 months (range 2–11 months), while there was no medullary relapse. Five of these responded well to triple intrathecal therapy. In the ALL Ph + CML patients, in spite of central nervous system (CNS) prophylaxis with IT MTX and 18 Gy cranial radiation, two of five patients (40%) experienced meningeal leukemia, one isolated and the other with medullary relapse. The data confirm that LyBC-CML patients experience a high incidence of meningeal leukemia. The role of CNS prophylaxis is not very clear, but its use may delay development and reduce morbidity due to CNS disease.     

Chronic myelogenous leukemia in blast crisis. Analysis of 242 patients

Two hundred forty-two patients with Philadelphia chromosome-positive chronic myelogenous leukemia in blast crisis were reviewed to identify significant biologic and prognostic associations. Twenty percent of patients had lymphoid blast crisis. Clonal evolution was present in 60 percent of patients at blast crisis and involved most frequently the development of a double Philadelphia chromosome, trisomy 8, or isochromosome 17. The overall median survival from blast crisis was 18 weeks. Patient characteristics demonstrated to have significant association with short survival were: anemia; thrombocytopenia; myeloid or undifferentiated blast cell morphology; clonal evolution involving the presence of a double Philadelphia chromosome, trisomy 8, or isochromosome 17; and low marrow blast percentage. Of 195 patients who received therapy for blast crisis, complete remission was achieved in 44 (23 percent) patients, and 24 (13 percent) patients had a partial remission or hematologic improvement. Lower complete remission rates were associated with old age, thrombocytopenia, myeloid or undifferentiated blast cell morphology, clonal evolution--especially isochromosome 17 and trisomy 8--and long interval from diagnosis to onset of blast crisis. A multivariate analysis identified two characteristics to have independent prognostic importance for both survival and remission: platelet counts and blast cell morphology. In addition, clonal evolution had additive prognostic value for survival (double Philadelphia chromosome) and for response (isochromosome 17). The beneficial association of therapy with survival was demonstrated by the significantly longer median survival of patients treated since 1981 compared with those treated earlier, even after accounting for the pretreatment prognostic factors, and by the significant improvement in survival of patients achieving remission using the "landmark" analysis technique.     

Complex chromosomal abnormalities in a patient with lymphoid blast crisis of chronic myelogenous leukemia

A 46-year-old Chinese man underwent lymphoid blast crisis (Ia+, CALLA+, TdT+) after 5 years of chronic phase, Philadelphia-chromosome positive chronic myelogenous leukemia. Chromosome analysis revealed a hyperdiploid karyotype, including two Philadelphia chromosomes--55,XY,t(9;22) (q34;q11), +2, +5, +5, +6, +10, +18, +19, +21, +del(22)(qll----qter)--in the majority of the leukemic blasts. The constellation of a lymphoid blast crisis and complex chromosomal abnormalities usually associated with myeloid blast crisis as well as the clinical data are discussed.     

Chronic myelomonocytic leukemia in childhood

A four-year-old child with recurrent infections and increasing hepatosplenomegaly over a three-year period was evaluated. Increased numbers of myeloid precursors packed the bone marrow and infiltrated the peripheral blood. A diagnosis of chronic myelogenous leukemia (CML) was considered but could not be confirmed by laboratory studies appropriate for the types of CML usually observed in childhood. Examination of the patient's peripheral blood smears revealed many atypical monocytoid cells with unipolar hairy projections. Scanning electron microscopy showed these to be leukemic monoblasts with characteristic broad-based ruffles on the cell surface. A population of myeloid precursors possessing narrow ridge-like profiles was also observed. Progressive infiltration of the spleen caused hypersplenism which necessitated splenectomy. Subsequently, massive liver and bone marrow involvement led to the patient's death. Terminally, the proliferating blast cells were demonstrated to be leukemic monoblasts by analysis of cytochemical staining patterns, surface immunoglobulins, serum lysozyme levels, and monocyte-mediated antibody-dependent cellular cytotoxicity studies. The findings in this case are most compatible with a diagnosis of chronic myelomonocytic leukemia (CMML), a condition not previously described in childhood. Several myeloproliferative disorders with prolonged survival have been reported in children, but special studies were not performed to determine which cell lines were abnormally proliferating. The similarities between these children and our patient with CMML suggest that monocyte studies may be useful in the diagnosis of these unusual disorders, provide insights into their pathogenesis, and aid in the selection of appropriate therapy.     

Chronic myelogenous leukemia.

Over the past year, new information has been reported on the biology and treatment of chronic myelogenous leukemia (CML). Chronic myelogenous leukemia is characterized by the breakpoint cluster region (BCR-ABL) chimeric gene, the product of which is p210BCR-ABL, a tyrosine kinase that gives hematopoietic cells the characteristics of excessive proliferation, resistance to physiologic apoptotic signals, and resistance to chemotherapy. Recently, investigators have attempted to 1) elucidate the mechanisms by which the BCR-ABL gene and its product initiate and maintain the malignant phenotype, 2) improve the use of the BCR-ABL gene as a diagnostic marker of disease, and 3) inhibit the expression of this gene as a therapeutic maneuver. Other investigators have tried to explain interferon's mechanism of action in the treatment of CML and to improve the safety and applicability of stem cell transplantation (SCT) as a therapy for CML.     

Chronic myelogenous leukemia complicated by drug-induced agranulocytosis

We describe a patient with chronic myelogenous leukemia (CML) who developed drug-induced agranulocytosis. A 75-year-old female was diagnosed with CML in December 2001. She had been receiving imatinib therapy for more than five years. In August 2007, she was hospitalized due to a severe neutropenia 10 days after colonoscopy. She was diagnosed as having agranulocytosis induced by colonoscopy premedication including scopolamine butylbromide and flumazenil. Severe neutropenia was resolved by G-CSF treatment without CML progression. Agranulocytosis in patients with CML is rare, but potentially lethal. Here, we report the clinical course in this patient.     

Chronic myelogenous leukemia blast cell proliferation is inhibited by peptides that disrupt Grb2-SoS complexes

Chronic myelogenous leukemia (CML) is commonly characterized by the presence of the p210(Bcr-Abl) oncoprotein. Many downstream effectors of Bcr-Abl have been described, including activation of the Grb2-SoS-Ras-MAP kinase (Erk) pathway. The precise contributions of these signal-transduction proteins in CML blast cells in human patients are not yet well defined. To gain further insight into the importance of Grb2 for CML, peptides that disrupt Grb2-SoS complexes were tested. These high-affinity Grb2-binding peptides (HAGBPs) can autonomously shuttle into cells and function by binding to the N-terminal SH3 domain of Grb2. The HAGBPs were analyzed for their effects on Bcr-Abl-expressing cell lines and freshly isolated CML blast cells from patients. They induced a dramatic decrease in the proliferation of CML cell lines. This was not observed with point-mutated control peptides with abolished Grb2SH3(N) binding. As expected, Grb2-SoS complexes were greatly diminished in the HAGBP-treated cells, and MAP kinase activity was significantly reduced as determined by an activation-specific phospho-MAPK antibody. Furthermore, cell fractions that are enriched for blast cells from CML patients with active disease were also incubated with the Grb2 blocker peptides. The HAGBPs led to a significant proliferation reduction of these cells in the majority of the isolates, but not in all patients' cells. These results show that, in addition to the direct targeting of Bcr-Abl, selective inhibition of Grb2 protein complexes may be a therapeutic option for a significant number of CML patients.     

Erythroid blast crisis in chronic myelogenous leukemia

Blood or bone marrow specimens from 22 patients with chronic myelogenous leukemia in blast crisis were studied for the surface expression of glycophorin-A, a marker for early erythroid differentiation. The leukemic blasts were stained with rabbit anti- glycophorin-A antiserum. The glycophorin-A molecules detected by the rabbit antiserum were identified by polyacrylamide slab gel electrophoresis of the immunoprecipitates from the membrane lysates of surface-labeled blasts. Blasts expressing surface glycophorin-A were found in 9 of the 22 patients. In 4 patients, almost all blasts were glycophorin-A positive, and in 5 patients, less than half of the blast population expressed glycophorin-A. The present study shows that when glycophorin-A is used as a marker for erythroid blasts, involvement of the erythroid lineage during blast crisis of chronic myelogenous leukemia seems to occur more frequently than previously recognized.     

Juvenile myelomonocytic leukemia characterized by cutaneous lesion containing Langerhans cell histiocytosis-like cells

We present a 1-year-old boy who developed a cutaneous lesion on the trunk and hepatosplenomegaly. Laboratory examination showed leukocytosis with peripheral blasts, atypical monocytosis, anemia, hyper IgG, and a mild elevation of C-reactive protein. Clinical features and skin biopsy findings matched the diagnostic criteria of both juvenile myelomonocytic leukemia (JMML) and Langerhans cell histiocytosis (LCH). Histopathology revealed atypical mononuclear cells that had infiltrated around vessels throughout the dermis in a skin biopsy specimen. These cells were CD1a (+), S-100 (+), CD68 (+), CD207 (−), lysozyme (+), and myeloperoxidase (−). The diagnosis of JMML was confirmed by detection of spontaneous colony formation and granulocyte–macrophage colony-stimulating factor hypersensitivity in vitro, and a somatic NRAS point mutation. Transplantation of bone marrow from an HLA-matched unrelated donor was performed, and the marrow was successfully engrafted. The cutaneous lesion and hepatosplenomegaly were improved at the time of discharge. It is often difficult to distinguish between JMML and LCH-like infiltrates by assessing clinical and light microscopic features of various cutaneous lesions. In the current case, molecular biological analysis enabled us to develop a precise diagnosis.     

Chronic myelomonocytic leukemia: myeloproliferative variant

Chronic myelomonocytic leukemia (CMML) has been classified into a new category of myelodysplastic and myeloproliferative diseases by the last World Health Organization classification of myeloid malignancies. However, a large fraction of patients with CMML show unequivocal prevalence of proliferative features, often with conspicuous leukocytosis and organomegaly, making any distinction with atypical chronic myeloid leukemia problematic. Although transformation into acute myeloid leukemia does not seem to be more frequent, prognosis in the proliferative variant of CMML (MP-CMML) is generally worse compared to dysplastic CMML (MD-CMML). Occurrence of mutations in the NRAS and KRAS oncogenes is significantly higher in MP-CMML compared to MD-CMML, whereas cytogenetic abnormalities seem to be less frequent. Constitutively activated platelet-derived growth factor-b receptor tyrosine kinase caused by specific chromosomal aberrations have been documented in a very small proportion of patients with MP-CMML whose malignant cell proliferation have been shown to be inhibited by imatinib mesylate. Treatment of MP-CMML remains challenging, with no strategy proven effective in prolonging survival. While waiting for novel potential targets by further understanding of cell proliferation molecular pathways, new strategies, including stem cell transplant, should be considered in treating patients with MP-CMML.     

Chronic myelogenous leukemia and Klinefelter's syndrome

A case of chronic myelogenous leukemia with Klinefelter's syndrome mosaicism in a 27-yr-old male is reported. Cytogenetic analysis provided evidence that the Philadelphia chromosome occurred monoclonally in the XXY cells but not in the XY cells.     

Chronic myelogenous leukemia and Sweet syndrome

We report a 64-year-old woman with chronic myelogenous leukemia of 3 years duration who developed Sweet syndrome. Improvement in her blood counts after hydroxyurea was not associated with a decrease in size of the skin lesions. However, the cutaneous lesions of Sweet syndrome quickly resolved with systemic prednisone. Sweet syndrome has only been documented in the literature for five other chronic myelogenous leukemia patients. The characteristics, treatment, and differential diagnosis of this disorder in chronic myelogenous leukemia patients are reviewed.     

Possible effect of medroxyprogesterone acetate (MPA) in lymphoid blast crisis of chronic myelogenous leukemia

Summary A patient with a lymphoid blast crisis of a chronic myelogenous leukemia (CML) was treated with vindesine, vincristine and prednisone. Blasts disappeared from the peripheral blood but persisted at a level of 60% in the bone marrow. After 5 weeks of continuous therapy, the patient became thrombopenic, and 2 weeks later blasts rose to 31%. After 7 weeks, 1 g MPA was given daily p.o. and weekly vincristine treatment was resumed. Blasts disappeared again from the peripheral blood, thrombocytes rose to a maximum of 274 g/l, and a remission with less than 5% blasts was demonstrated in the bone marrow. In another relapse after withdrawal of MPA, estrogen and progesterone receptors (PR) were found in the leukemic cells. Thus, a remission was seen during treatment with vincristine, prednisone, and MPA after a deterioration with vincristine and prednisone alone in a PR-positive leukemia, and an effect of MPA in this lymphoid blast crisis of a CML has to be discussed.This work was presented at the Annual Congress of the German and the Austrian Society of Hematology and Oncology, Essen, 10–13 October 1993