Mixed lineage leukemia with cytogenetically unrelated abnormal clones

We present a case of acute leukemia with morphologic, cytochemical, and immunophenotypic markers indicating that the population of blasts have characteristics of lymphoid and myelomonocytic origin. The cytogenetic study revealed the following mosaic abnormal karyotype: 46XX,dup(1)(q21----32)/46,XX,dup(11)(q13----25)/47,XX,trip(11) (q13----25),+der(17)t(17;?) (q24;?). The two clones involving #11 are obviously related. It is reasonable to assume that the third clone is an evolutionary result of the second one. Because no cytogenetic similarities were found among the first clone and the other two, we suggest that this mixed leukemia was of biclonal origin. To our knowledge, acute leukemia with mixed lineage characteristics and with the simultaneous presence of cytogenetically unrelated clones has not previously been reported.

No correlation between locations of bcr breakpoints and clinical states in Ph1-positive CML patients

The majority of patients with chronic myelogenous leukemia (CML) have a characteristic reciprocal translocation between chromosome 9 and 22, resulting in the Philadelphia (Ph1) chromosome. During this translocation, the c-abl oncogene on chromosome 9 is transferred to the Ph1 chromosome and linked to a breakpoint cluster region (bcr), which is part of a large bcr gene. This phenomenon results in the formation of a bcr-c-abl fusion gene, which is transcribed into an 8.5 kb chimeric mRNA encoding a 210 kd bcr-c-abl fusion protein. The fusion protein has tyrosine kinase activity implicated in the pathogenesis of CML. The breakpoint near the c-abl locus on chromosome 9 can occur within a large area. In contrast, the breakpoints on chromosome 22 cluster within the bcr region of 5.8 kb. A chronic phase lasts for an average of 2 to 3 years; and, subsequently, most patients enter blast crisis. In the present study, we examined 15 Ph1-positive CML patients (eight in chronic phase, one in accelerated phase, and six in blast crises) as to whether the identifiable difference in the locations of the bcr breakpoints exist between CML patients in chronic phase and those in blast crisis. In seven of eight CML patients in chronic phase, in one in accelerated phase, and in four out of six CML patients in blast crisis, the bcr breakpoints clustered in the 3' portion of the bcr. Thus, we could not find out the correlation between the locations of the bcr breakpoints and the clinical stage of the CML patients. This might imply that blastic transformation in Ph1-positive CML was caused by other mechanisms than the transition of the bcr breakpoints.

Erythroleukaemic blast crisis in chronic granulocytic leukaemia

A rare instance of erythroleukaemic blast crisis in chronic granulocytic leukaemia is described in a 22 years old male. A combination of morphology and a battery of cytochemical stains helped us to make this diagnosis.

[Changes in serum RNase activities in chronic phase and acute crisis of chronic myelocytic leukemia]

We investigated serum acid and alkaline RNase activities in 16 cases of acute crisis of chronic myelocytic leukemia (CML), 21 cases of untreated CML, and 13 cases of treated CML, to clarify clinical significance of the determination of RNase activities in acute crisis of CML. We obtained results as follows; the ratio of acid to alkaline Rnase activities (Ac/Al ratio) of chronic phase of CML was 1.64 +/- 0.47 (mean +/- SD) in the untreated cases, and was 1.32 +/- 0.16 in the treated cases. The Ac/Al ratio always indicated over 1.0 in the chronic phase of CML without any relationship to treatments. On the other hand, in the cases of acute crisis, the Ac/Al ratio was significantly lowered (0.94 +/- 0.22) as compared to the chronic phase of CML (p less than 0.001), and was similar to that of acute leukemia. The acid and alkaline RNase activities of the blast from the patients with acute crisis of CML showed remarkably lower value than those of leukemic cells from patients with chronic phase of CML. Therefore, it was Suggested that the return to normal range of Ac/Al ratio in acute crisis of CML depended on marked decrease of RNase activities of blasts. Thus, serial determinations of the enzyme activities are considered to be one of useful tools for prediction of acute crisis of CML.

Extramedullary blast crisis and hemolytic anemia in a patient with t(3p+;4q-) and rapidly evolving myelogenous leukemia

We have reported the case of a patient with a rapidly evolving myelogenous leukemia associated with hemolytic anemia, extramedullary evolution, and an isolated translocation of the long arm of chromosome 4 to the short arm of chromosome 3. The hemolytic process was primarily extravascular and was not associated with pyruvate kinase or glucose-6-phosphate dehydrogenase deficiency. Although blasts were absent from the peripheral smear and represented less than 10% of the bone marrow myeloid precursors, multiple organs including the heart, liver, lungs, and spleen were infiltrated with blasts at autopsy.

Monoclonal antibody M195: a diagnostic marker for acute myelogenous leukemia

Monoclonal antibody (mAb) M195 is a mouse IgG2a reactive with a myelomonocytic differentiation antigen found on early myeloid cells and monocytes. The reactivity of M195 with fresh hematopoietic neoplasms in the blood or bone marrow from 227 patients at Memorial Hospital was determined by flow cytometry. M195 was positive on 67% of 61 myeloblastic leukemias. Seventy percent of Tdt-negative ANLL and 30% of Tdt-positive ANLL were positive; 100% of CMMOL and 100% of CML in myeloblastic crisis or accelerated phase were positive. In contrast, M195 was positive on only 8% of 51 lymphoblastic leukemias and 1% of 70 other nonmyeloid samples. M195 binding did not correlate well with FAB classification of ANLL. The pattern of reactivity of M195 was similar but not identical to that of MY9 (CD33) on the same cases (83% concordance). Cross-blocking of M195 binding by MY9 and L4F3 (CD33) was demonstrated. M195 may bind to a different epitope on the same protein antigen. The presence of both MY9 and M195 positivity on a leukemia sample had a 98% specificity of diagnosing ANLL, which was greater than MY9 alone (88%) or M195 alone (92%). Assays of granulocytic-monocytic and erythroid colony-forming units showed M195 to be present on these hematopoietic progenitors. This pattern of reactivity of M195, together with its lack of reactivity with mature granulocytic elements or with adult tissues, make it a candidate for therapy of ANLL in vivo.

[Megakaryoblastic crisis of chronic myelogenous leukemia cytological and clinical studies in three cases]

Diagnostic significance of the megakaryocyte markers and clinical findings were evaluated in three cases with chronic myelogenous leukemia in megakaryoblastic crisis. Platelet peroxidase (PPO), glycoprotein IIb/IIIa, Ib, von Willebrand factor antigen (vWF: Ag) and demarcation membrane system (DMS) were examined as the megakaryocyte markers. Blast phenotypes were as follows: PPO- IIb/IIIa+ vWF: Ag+ DMS+ in Case 1, PPO+ IIb/IIIa +/- Ib- vWF: Ag +/- in Case 2 and PPO+ IIb/IIIa+ vWF: Ag +/- DMS +/- in Case 3 (-: 0% +/-: less than 10% +: greater than or equal to 10%). In Cases 1 and 3, no markers other than those for the megakaryocyte lineage were detected, but myeloperoxidase-positive blasts coexisted with PPO-positive megakaryoblasts in Case 2. Megakaryoblast phenotypes and involvement of other lineages were much different in each case. Therefore, marker study for cytological diagnosis should be performed in consideration of lineage heterogeneity. As to the clinical findings, no clear features common to the three cases were present. However, multiple osteolytic lesions were demonstrated on bone survey in Case 1 and considered to be caused by the proliferation of megakaryoblasts.

Expression of the myeloperoxidase gene in acute and chronic myeloid leukemias: relationship to the expression of cell cycle-related genes

The expression of the myeloperoxidase (MPO) gene was studied, by means of Northern blot analysis in 14 cases of acute myeloid leukemia (AML), 11 cases of chronic myeloid leukemia (CML), and 6 cases of CML blast crisis, and in HL60 cells before and after induction of terminal differentiation with retinoic acid (RA), phorbol esters (TPA), or vitamin D. The expression of a panel of cell cycle-related genes, namely C-MYC, histone H3, ornithine decarboxylase, P53, vimentin, and calcyclin, was also studied in the same cell populations. Our results indicate that: (a) MPO gene expression (steady state mRNA levels) is strictly confined to the first stages of myeloid differentiation, reaching its peak at the promyelocyte stage and becoming undetectable in mature granulocytes and monocytes; (b) cells devoid of any detectable MPO enzymatic activity such as leukemic basophils have a high content of MPO mRNA; and (c) MPO gene expression is not related to the growth activity of the cell population. Finally, our results show that the pattern of expression of growth-regulated genes in the neoplastic myeloid disorders AML, CML, and CML blast crisis is remarkably different.

Differentiation-inducing effect of recombinant human tumor necrosis factor alpha and gamma-interferon in vitro on blast cells from patients with acute myeloid leukemia and myeloid blast crisis of chronic myeloid leukemia

Tumor necrosis factor alpha (TNF-alpha) and gamma-interferon (IFN-gamma) have been shown to suppress clonogenic growth in cultures containing blast cells obtained from patients with acute myeloid leukemia. We report that recombinant human TNF-alpha and IFN-gamma are also able to induce functional and morphological maturation in fresh myeloid leukemic cells in vitro. Assessing suspension cultures containing cells from patients with acute myeloid leukemia (11 patients) or myeloid blast crisis of chronic myeloid leukemia (5 patients), it was found that recombinant human TNF-alpha and IFN-gamma significantly enhanced the number of cells reducing nitroblue tetrazolium, as compared to control cultures containing no cytokine (P less than 0.001 and P less than 0.001, respectively). Cells from responders showed alterations characteristic of monocyte/macrophage differentiation, adherence to plastic surfaces, development of positive staining for alpha-naphthyl acetate esterase, typical morphology, and expression of cell surface antigens detected by the monoclonal antibodies Mo-1, Mo-2, and My-4. Both cytokines decreased the number of viable cells, the number of blast cells, and the number of cluster-forming units in suspension culture, suggesting inhibitory actions on the growth capacity of leukemic cells. Compared to the maximum effects of either factor alone, the combination of recombinant human TNF-alpha and IFN-gamma significantly increased the extent of growth inhibition and cell adherence but did not result in further increases in nitroblue tetrazolium reduction. The presence of Auer rods in IFN-gamma or TNF-alpha differentiation-induced macrophages with cells from a patient with M5 acute myeloid leukemia demonstrates that these cytokines can induce differentiation of a leukemic clone in primary cells from patients with leukemia.

Identification of blast cells in the peripheral blood of patients with acute leukaemia using the Technicon H-1

The Technicon H-1 counter represents a refinement of the cytochemistry-based technology of its predecessors, the H6000 and the Hemalog-D. It also has a new channel, the basophil-lobularity channel, which is said to enhance the sensitivity of leukaemic blast detection in comparison with previous instruments. To evaluate this facility, 35 adult patients with acute leukaemia at different phases of their disease were monitored for the presence of circulating leukaemic blasts during a 4-week period. The ability of the H-1 to detect blasts was compared to a careful manual review of a blood and bone marrow smear. Using the latter review as the standard, the sensitivity was 83.8% with a specificity of 78%. Exclusion of patients with severe leucopenia (less than 1.0 x 10(9)/l) increased the specificity to 89%, with little alteration in the sensitivity. We were unable to confirm the high degree of sensitivity claimed in previous reports. The H-1 blast flag, however, would appear useful for screening patients who are off therapy or on maintenance regimens.

Philadelphia chromosome negative acute lymphoblastic leukemia preceding Philadelphia positive chronic myelogenous leukemia

A patient with Philadelphia chromosome (Ph) negative acute lymphoblastic leukemia (ALL, FAB type L1) developed Ph-positive chronic myelogenous leukemia (CML) after more than 2 years in complete remission. Subsequently, Ph-positive lymphoblastic transformation occurred, which was again successfully treated. Thereafter, the CML state was interrupted twice more by blast crisis. The additional chromosomal abnormalities were atypical for Ph-positive CML. The course is interpreted as a possible example of the multistep development of CML. Blastic transformation occurring prior to the Ph chromosome has been reported in only two cases previously.

Influence of cigarette smoking on the presentation and course of chronic myelogenous leukemia

It is known that cigarette smoking induces leukocytosis and increased genetic instability in normal individuals. Therefore, a retrospective review was conducted of 173 patients with chronic myelogenous leukemia to detect a possible influence of cigarette smoking on initial characteristics at the time of presentation and on the course of this disease. Thirty-nine patients (23%) were smoking 5 cigarettes/d or more at time of diagnosis. Cigarette smoking was significantly related to male sex (P = 0.0005) and younger age at diagnosis (P = 0.02) and smokers tended to have lower leukocyte counts (P = 0.07) than nonsmokers. Cigarette smoking was significantly associated with early blast crisis (P less than 0.0001) and short survival (P less than 0.0001). Other characteristics associated with a poor prognosis included hepatomegaly, anemia, and a high percentage of peripheral blast cells at time of diagnosis. When studied in a multivariate analysis, cigarette smoking remained the strongest prognostic factor for both occurrence of blast crisis (P = 0.0003) and overall survival (P = 0.0001). Other poor prognosis factors found in the multivariate analysis included a high percentage of blasts in the peripheral blood at time of diagnosis and high platelet count. It is possible that cigarette smoke may act as a promoter or cocarcinogen in the transformation of chronic myelogenous leukemia.

Near-haploid cell line in megakaryoblastic transformation of Philadelphia-positive chronic myeloid leukemia

A case of near haploidy in a patient with an acute megakaryoblastic transformation of Philadelphia (Ph)-positive chronic myeloid leukemia (CML) was studied. Cytogenetic studies revealed persistence of a Ph-positive pseudodiploid cell line and the emergence of a Ph-positive near-haploid cell line, i.e., 46,XX,t(9;22)(q34;q11)/28,XX,t(9;22),+8,+14,+18,+29. The near-haploid cell line is a rare cytogenetic finding. The patient rapidly deteriorated and died.

[The changes of mRNAs of both c-myc and MDR1 in CML-bc tumor cells during the clinical course: a case report]

We examined the expressions of both c-myc and MDR1 in four samples isolated from a CML-bc patient in series during the clinical course. A 46-year-old man was diagnosed as chronic phase of CML in june 1985. In February 1987, the diagnosis of blastic transformation was made because of marked increase of blastic cells. He was initially treated with vincristine (V) and prednisolone (P) successfully. However, the effect of VP therapy was gradually attenuated, so that combined chemotherapies including anthracyclines were started. After the treatments of several courses, tumor cells acquired the refractory to both vincristine and adriamycin . He died in January, 1988. Northern blot hybridization studies revealed no expression of MDR1 mRNAs. However, the expression of c-myc was increased in the latest sample. These findings suggest that the expression of c-myc mRNA in tumor cells of this case reflects one characteristic of clinically refractory states to chemotherapies.

[Chronic myelogenous leukemia characterized by successive lymphoid and myelomonocytic blast crises]

We report a 25 year-old male of CML, who repeated lymphoid blast crises twice and finally experienced a myelomonocytic blast crisis. In the first and the second crises, after 2 years of chronic phase, the blasts were only weakly positive or negative for terminal deoxynucleotidyl transferase. Based on other morphological features of the blasts, however, lymphoid blast crisis was strongly suspected. Actually, he responded well to the vincristine and prednisolone therapy. In the third crisis, the blasts showed myelomonocytic features. He did not respond to the same regimen, and died of intracranial infiltration during daunorubicin and cytosine arabinoside therapy after one year from the first crisis. Chromosomal analysis showed the karyotypes of 46, XY, t(9:22) (q34:q11) in the chronic phase, 45, XY, -7, -9, +der(9) t(7;9) (q11;p11), t(9:22) (q34:q11) in the lymphoid blast crisis, and 46, XY, t(9:22) (q34:q11), t(11:17) (q23:q25) in the myelomonocytic blast crisis.

Granulocyte-macrophage colony-stimulating factor enhances the cytotoxic effects of cytosine arabinoside in acute myeloblastic leukemia and in the myeloid blast crisis phase of chronic myeloid leukemia

A strategy designed to stimulate myeloid leukemic blasts into active cell cycle may increase the effectiveness of S phase-specific agents such as cytosine arabinoside (ARA-C). Since recombinant human granulocyte-macrophage colony stimulating factor (GM-CSF) is known to stimulate the growth of myeloid leukemic cells in vitro, we have evaluated the ability of this growth factor to enhance leukemic clonogenic cell kill in the presence of ARA-C. In seven patients studied, GM-CSF increased the fraction of myeloid leukemic blasts in S phase as measured by propidium iodide DNA staining, bromodeoxyuridine incorporation, or ARA-C suicide techniques. Six of these seven patients demonstrated clonogenic cell growth in agar in response to GM-CSF. In five of these six patients, the combination of GM-CSF and ARA-C treatment in vitro resulted in a significant increase in leukemic clonogenic cell kill when compared to treatment with ARA-C in the absence of GM-CSF. Similar results were observed with the combination of GM-CSF and hydroxyurea, another S phase specific agent, further suggesting that the observed enhancement of cytotoxicity was due to the ability of GM-CSF to increase the number of leukemic cells in S phase. These data provide a rationale for investigating the toxicity and efficacy of combined GM-CSF and ARA-C therapy in patients with high-risk myeloid leukemia.

Chromosomal characteristics of Ph-positive chronic myelogenous leukemia in transformation. A study of 23 Chinese patients in Taiwan

Cytogenetic study was performed in the past 3 years on 23 Chinese patients with Philadelphia chromosome (Ph) positive chronic myelogenous leukemia (CML) in transformation; seven were in accelerated phase and 16 in acute blast crisis. Chromosomal abnormalities in addition to Ph were found in three (43%) of the patients at accelerated phase and 14 (88%) of the patients at blast crisis. The common nonrandom chromosomal aberrations were double Ph, trisomy 8, trisomy 19, and trisomy 21, which occurred in 47%, 41%, 35%, and 29%, respectively, of the total patients with extra chromosomal abnormalities. Isochromosome for the long arm of chromosome 17 was found in only one patient. In patients with blast crisis, the type of blast cell was characterized through morphologic, cytochemical, and immunocytochemical studies. Eleven cases were classified as myeloid and five as lymphoid transformation. Trisomy 8, 19, and 21 were detected only in patients with myeloid blast crisis. This study also revealed a high incidence of trisomy 21 and a low incidence of i(17q) in Chinese patients with transformation of CML.

Prethymic phenotype and genotype of pre-T (CD7+/ER-)-cell leukemia and its clinical significance within adult acute lymphoblastic leukemia

Pretreatment blast cells from 739 adults with acute lymphoblastic leukemia (ALL) were immunophenotyped as part of a prospective treatment protocol study. Among 192 patients (26%) with T lineage ALL, 47 (6%; 24% of T lineage ALL) had lymphoblasts without sheep erythrocyte rosette formation, but with pan-T antigen CD7 on the membrane and intracellular CD3 proteins mostly in perinuclear accumulation. The T-cell surface antigens CD5 and/or CD2 and focal acid phosphatase were additional markers of this subgroup traditionally called pre-T ALL, whereas thymocyte antigen CD1 as well as CD4 and CD8 antigens were not expressed. Hematopoietic progenitor cell markers, namely terminal deoxynucleotidyl transferase (TdT), and in part common ALL antigen (CD10), HLA-DR antigens, and/or My-10 (CD34), a unique antigen of marrow cells absent in thymus cells, further characterized this immature T-ALL form of putative prothymocytic phenotype (CD7+/intracellular CD3+/TdT+/My-10+/-/HLA-DR+/-/CD10+/-). The prethymic T cell character was supported by germ-line T-cell receptor beta genes found in 21 of 36 patients analyzed. In five cases only T gamma-chain genes were rearranged. Fifteen patients, however, had rearrangements of both T beta and T gamma genes. Immunoglobulin heavy chain genes were rearranged only in two cases. Pre-T ALL differed significantly from E-rosette+ T-ALL in some presenting clinical features, namely mediastinal mass, lymphoadenopathy, and platelet count, and independently of clinical factors in prognosis (P = .02, median remission duration: 15.7 v 33.5 months, and P = .02, median survival time: 24.6 v 50.7 months). We conclude that ALL classification based solely on T- or B-cell lineage affiliation is not sufficient but needs further subdivision according to relevant maturation stages as exemplified here within the T-cell axis. The putative prethymic T cell progenitor phenotype described might help elucidate the sequence of genetic events that commit normal hematopoietic cells to the T-cell lineage.

[Extramedullary blast crisis in chronic myeloid leukemia]

Out of 113 cases of blastic crisis (BC) of Ph'-positive chronic myeloid leukaemia (CML), 13 had extramedullary involvement, this being the first BC manifestation in 5 instances. The median interval between extramedullary BC and bone marrow BC in these last was 2 months. Lymph nodes were the commonest extramedullary site of BC (8 cases), followed by osteoperiosteal and central nervous system (CNS). Lymph node BC occurred as generalised lymphadenopathy in most cases. Osteoperiosteal BC was seen as severe bone pain on osteolytic areas, whereas CNS blast crisis occurred as meningeal leukaemia in one case and chloroma in another. Lymphoid phenotype of blast cells was found in only 2 instances. The median survival of the patients after the onset of extramedullary involvement was 3 months.

[Monocytic crisis in chronic myeloid leukemia: a case report]

We report a 17-year-old female with chronic myeloid leukemia (CML) who developed monocytic crisis. She was diagnosed as chronic phase of Ph1-chromosome positive CML at 14 years old. Three years after the diagnosis of the disease, she was admitted to the hospital because of low grade fever, lethargy and marked splenomegaly. Small dose of Ara-C relieved her symptoms and splenomegaly. Six months later, however, a marked leukocytosis over 70,000/microliters were observed, and the peripheral blood smear disclosed that about 80% of the leukocytes were relatively mature monocytoid cells. Chromosomal analysis revealed additional abnormalities (double Ph1, +8, +9, +19). Lysozyme levels in serum and urine were high and NAP score was elevated. These monocytoid cells expressed receptors for IgG-Fc and C3, phagocytic activity, and monocytoid antigens which were determined by monoclonal antibodies (MY4, Mo2, OKM5). Cytochemically, almost all of monocytoid cells were positive for peroxidase and naphthol-ASD-chloroacetate esterase (CAE), but the monocytoid cells positive for non-specific esterase were limited. These data suggested that this case was monocytic crisis in CML with proliferation of CAE positive monocytoid cells. Among several types of blast crisis, monocytic crisis is extremely rare condition. The definite monocytic crisis demonstrated by this case may support the hypothesis that target cells of CML are pluripotent hematopoietic precursors.

Interferon is able to reduce tumor cell susceptibility to human lymphokine-activated killer (LAK) cells

It is known that IL-2 induces lymphocytes to produce interferon-gamma (IFN-gamma) and this IFN type is particularly efficient in inducing tumor cell resistance to natural killer (NK) cell-mediated lysis. We have investigated the effect of IFN on tumor cell sensitivity to LAK cell-mediated cytotoxicity. Pretreatment of the human K562 leukemia and HHMS melanoma with IFN-gamma and the Daudi lymphoma with IFN-alpha caused a significant reduction in sensitivity to lysis by human LAK cells generated in vitro in the presence of human recombinant IL-2 (100 U/ml). The LAK activity was mediated by cells expressing NK cell markers (CD16,NKH1) as well as by cells with T cell markers (CD3, CD5). IFN-treated K562 cells were protected from lysis mediated by all these populations. Supernatants from LAK cultures containing IFN-gamma were able to induce NK and LAK resistance when used to pretreat K562 overnight. Antibodies to IFN-gamma but not to IFN-alpha were able to neutralize this activity. Taken together, these results indicate that the production of IFN-gamma by LAK cells may be of importance in induction of tumor cell resistance to LAK cell-mediated lysis.