Terminal deoxynucleotidyl transferase in acute myeloid leukaemia

Extramedullary presentation of the blast crisis of chronic myelogenous leukaemia

We report the clinical histories and a multiparameter pathological study of the extramedullary lesions of seven patients with chronic myelogenous leukaemia in whom the initial clinical presentation of blast crisis (BC) was in an extramedullary site (lymph nodes in six, mandibular mass in one). Bone marrow BC was demonstrated simultaneously or within a few months in four patients. Three patients received chemotherapy only, four underwent bone marrow transplant. Six patients died within 1 year from diagnosis of extramedullary BC, one is alive without disease. The longest survivals (12+, 12, 11 months) were those of patients who never developed bone marrow BC and were recipients of bone marrow transplant. Studies of extramedullary disease included: histology; histochemistry for chloracetate esterase (CAE) and lysozyme; assays for TdT; electron microscopy; immunofluorescence for Fc-receptors, immunoglobulins and lymphoid and myeloid antigens by a panel of monoclonal antibodies; and cytogenetics. Three cases were classified as myeloid BC based on histochemistry and/or ultrastructure and immunology (OKM1+, MCS2+, IG10+); two as lymphoid BC (CAE-, lysozyme-, TdT+), one of them expressing a T-cell phenotype. Cytogenetic analysis of extramedullary lesions and simultaneous or subsequent bone marrows demonstrated identical karyotypes in three patients and significantly different karyotypes in one.

Phenotypic conversion of TdT+ adult AML to CALLA+ ALL

A case of acute leukaemia is described in which the blast cells showed Sudan Black and terminal deoxynucleotidyl transferase (TdT) positivity at presentation and did not react with the monoclonal antibodies (McAb) My9 (anti-myeloid) and J5 (anti-CALL antigen). The myeloid lineage of these cells was confirmed by the myeloperoxidase (MPO) reaction at electron microscopic level. The patient entered complete remission but relapsed one year later with blasts showing negative Sudan Black and MPO reactions. These cells were still TdT+ but J5 was now positive. This case points to the existence of a clonogenic leukaemic cell with potential for evolution in both myeloid and lymphoid lineages. This is also suggested by the reactivity of both types of blast cells with the McAb 3C5 which recognises an antigen present both on early myeloid and lymphoid precursors. It is possible that patients with such leukaemias may benefit from combined therapy directed against cells of both myeloid and lymphoid lineages.

Acute leukemia of hybrid phenotype: T lymphoid and myelomonocytic markers

Several unique phenotypical and functional characteristics were found together in a patient with acute poorly differentiated leukemia. The blast cells showed an unusual T-cell phenotype, forming spontaneous rosettes with sheep red blood cells and expressing the T11 antigen, but were negative for the other immature or mature T markers tested--Leu-1, 3A1, T3, T4, T8, T9, T10, T6, and TdT--and reacted with the monoclonal antibody OKM1 expressed by myeloid lineage cells and which is also present in natural killer (NK) cells. Furthermore, these cells were able to produce interleukin-2 (IL-2) after mitogenic stimulation and showed cytotoxic activity against K-562 target cells after incubation with an IL-2 supernatant. These features do not correspond to any known stage of the T-cell differentiation pathway and may represent the expansion of a pre-NK cell which may be poorly represented in normal tissues.

Low dose cytarabine in acute non-lymphoblastic leukemia or myelodysplastic syndrome: report of six cases and review of the literature

Low dose cytarabine (10 mg m-2, 12 hourly by subcutaneous injection) was used to treat four patients with acute non-lymphoblastic leukemia, two of whom had failed standard induction chemotherapy, and two patients with refractory anemia with excess blasts in transformation. Following treatment two patients entered complete remission (CR) and two patients had survivals of ten and 18 months in stable partial remission. All patients have died, four of progressive or recurrent leukemia, one of a treatment-related intracerebral hemorrhage, and one of lung carcinoma while in CR. Our experience, and a review of the literature, suggest that in general low dose cytarabine is well tolerated, although myelosuppression is common and thrombocytopenia can be a major problem. This form of treatment appears to offer a useful alternative to intensive induction chemotherapy in those patients in whom such treatment is usually poorly tolerated, and has the advantage of being able to be given to an outpatient.

Biochemical enzyme analysis in acute leukaemia

This report summarises the current knowledge regarding the clinical utility of biochemical enzyme markers for both diagnostic and therapeutic purposes in acute leukaemia. The enzymes studied most extensively in this field are terminal deoxynucleotidyl transferase, adenosine deaminase, 5'-nucleotidase, purine nucleoside phosphorylase, and acid phosphatase, esterase, hexosaminidase isoenzymes. For each enzyme, the quantitative and qualitative characteristics in various immunologically defined subclasses of acute leukaemia are described. The quantitative evaluation of enzyme activities represents an adjunctive classification technique which should be incorporated into the multivariate analysis, the "multiple marker analysis." By qualitative characterisation pronounced heterogeneity of leukaemia subsets is uncovered. The application of 2'-deoxycoformycin, a specific inhibitor of adenosine deaminase, and the potential usefulness of two other enzymes as targets for treatment with selective agents is discussed. The concept that gene products expressed at certain developmental stages of normal cells can similarly be detected in leukaemic cells (which therefore seem to be "frozen" or "arrested" at this particular maturation/differentiation stage) is supported by the results obtained in enzyme studies. Besides their practical clinical importance for classification and treatment of acute leukaemias, biochemical enzyme markers constitute a valuable research tool to disclose biological properties of leukaemic cells.

The human leucocyte-common (LC) molecule: dissection of leukaemias using monoclonal antibodies directed against framework and restricted antigenic determinants

Monoclonal antibodies have previously been raised against two separate antigenic determinants on the human LC molecule. One, F10.89.4, recognizes a 'framework' epitope on all LC molecules; these are found on the majority of leucocytes. The other, F8.11.13, recognizes only a 'restricted' epitope present on a subset of these molecules; this subset is found on B lymphocytes and a subpopulation of T lymphocytes. LC molecules on myeloid cells do not carry the 'restricted' antigenic determinant. We have investigated the differential expression of these LC epitopes on human leukaemias, using immunofluorescence on fresh leukaemic blasts and established cell lines. Our study shows that, as on normal haemopoietic cells, LC molecules on B leukaemias bear both 'framework' and 'restricted' epitopes, while the majority of T leukaemias bear only the 'framework' determinant. The small proportion of T cells that are F8.11.13+ ('restricted' epitope) are relatively mature, being of either OKT4+ or OKT8+ phenotype, and may be in an activated state (HLA-DR+). However, in contrast to normal haemopoietic cells, some myeloid leukaemias carry both 'framework' and 'restricted' epitopes (30% AML and AMML samples are F10.89.4+, F8.11.13+), and it is within this group that all TdT+ AML and AMML cases lie. Thus, these monoclonal antibodies should be useful for studying haemopoiesis in man and for analyzing human haemopoietic malignancies.

Response to hydrocortisone of blast progenitors in acute myeloblastic leukemia: an aspect of lineage infidelity

The blast population in acute myeloblastic leukemia (AML) contains cells capable of forming blast-cell colonies in culture. The purpose of this study was to measure the effects of hydrocortisone on this process, using two end-points. First, we measured the effects of increasing concentrations of hydrocortisone on the primary plating efficiency of T-lymphocyte-depleted blast cell preparations from AML peripheral blood. Second, colonies forming in the presence or absence of the hormone were pooled and replated; changes in the plating efficiencies (secondary plating efficiency or PE2) of these suspensions reflected the effect of the hormone on blast progenitor self-renewal. For comparison, we measured the hydrocortisone dose response curves for normal granulopoietic and T-lymphocyte colony-formation. The latter showed little individual variation; T-lymphocyte colony-formation was regularly sensitive to the hormone while granulopoietic colony-formation was resistant. In contrast, wide variations were found in the hydrocortisone dose response curve for blast from 24 patients with AML (FAB 1-6). A significant association was found between successful remission induction and resistance to hydrocortisone in 24 treated patients. The association was maintained when the data was stratified by other risk factors, including PE2 and the presence of blasts bearing immunologically-defined markers of more than one differentiation lineage (lineage infidelity). We propose that sensitivity to hydrocortisone may reflect the passage of blast cells through lymphopoiesis-associated components of differentiation programs. From this point of view, the poor prognosis associated with sensitivity of blast progenitors to hydrocortisone may be similar to the response-failure of patients whose blasts exhibit lineaged infidelity when tested with immunological procedures.

DNA ligases in human leukemia

Following partial purification on sucrose gradient and/or phosphocellulose chromatography, DNA ligase was tested in peripheral white blood and bone marrow cells of nearly 100 patients with various kinds of leukemias, mainly acute leukemias. Terminal deoxynucleotidyl transferase (TdT) was tested in parallel. DNA ligase of acute myeloblastic leukemia (AML) was extracted with the same sedimentation coefficient (5.5S) on sucrose gradient, and eluted with the same KCl molarity (0.3 M) than the one extracted from normal lymphocytes. Acute lymphoblastic leukemias (ALL) were characterized by no detectable DNA ligase activity--in most T or non T-non B-ALL, or a low activity in pre-B and B (Burkitt type) ALL, with levels similar to the one observed in chronic lymphocytic leukemia (CLL). An inverse relationship was observed between DNA-ligase and TdT in ALL, ligase being undetectable in cells positive for TdT and being present in some T or non T-non B, and in all pre-B and B-ALL negative for TdT. AML and chronic myelocytic leukemia (CML) were characterized by a markedly higher DNA-ligase activity. This activity was higher in the most differentiated subtypes--M2, M3 and M4 subtypes of FAB classification--and in CML. Moreover a high degree of correlation was observed in AML between the DNA ligase activity and the S phase fraction measured by 3 H-thymidine autoradiography or flow cytophotometry on the total cell sampling. Besides their clinical interest, these results are discussed in relation with the role of DNA-ligase in DNA replication and repair.

Immunodiagnosis of childhood ALL with monoclonal antibodies to myeloid and lymphoid associated antigens

Sixty-five cryopreserved leukemic samples from children diagnosed and treated as having acute lymphocytic leukemia (ALL) were retrospectively examined for the presence of lymphoid and myeloid associated antigens by indirect immunofluorescence using monoclonal antibodies. Expectedly, the majority of these specimens expressed antigens known to be expressed on lymphoid, and not myeloid malignancies. These included the common acute lymphoblastic leukemia antigen (CALLA), the p32 B-cell associated antigen, and T-cell associated antigens. Leukemic cells from the 8 remaining patients expressed antigens known to be present on both myeloid and lymphoid leukemias. These included HLA/DR, and the antigens identified by BA-1 and BA-2. Cells from 2 of these 8 patients reacted with antibodies that define antigens present on normal and malignant myeloid cells. Both specimens reacted with 1G10, an anti-granulocyte antibody, and one reacted with 5F1 which reacts with monocytes, nucleated red blood cells, megakaryocytes and platelets. One of these patients relapsed while receiving ALL therapy, and the morphology of her leukemic cells became characteristic of acute monocytic leukemia (AMoL). The second patient failed ALL therapy but responded to standard acute nonlymphocytic leukemia (ANLL) therapy, clearing her peripheral blasts. Thus these studies confirm that cell surface phenotyping with monoclonal antibodies can recognize ALL cells that express myeloid rather than lymphoid associated antigens and demonstrate that the malignant cells display a clinical behavior consistent with the diagnosis of ANLL.

Phenotype of the terminal transferase-positive cells in human foetal liver and bone-marrow: analysis with monoclonal antibodies

Liver and bone-marrow of 20 human foetuses between 15th and 20th week of gestational age were examined. Mononuclear cells were labelled with murine monoclonal antibodies to reveal surface antigens and with a rabbit antiserum to TdT for the detection of the nuclear enzyme, using a double colour indirect immunofluorescence technique. The results have revealed that TdT+ cells express the phenotype of B cell precursors HLA-DR+, CALLA+, FMC8+, LEU-1-, LEU-5-, LEU-9-. It suggests that foetal liver and bone-marrow have an active function in B-lymphopoiesis in humans. The involvement of TdT in the process of B-cell immunological acquisition is uncertain because only humans and Xenopus embryos, among the species examined, express TdT outside the thymus during ontogenesis.

Demonstration of terminal deoxynucleotidyl transferase in single cells by indirect immunofluorescence. II. An examination of specificity

Advantages in the use of indirect immunofluorescence for the identification of terminal transferase (TdT) in single cells may be offset by lack of specificity, as compared to the biochemical assay of the enzyme, especially in analyses of lymphocyte populations. False positive results were obtained in 15/15 tonsillectomy samples and in 9/27 specimens from children with acute lymphoblastic leukemia in remission, perhaps due to antihuman lymphocyte activity in the rabbit heteroantisera which are used in the indirect immunofluorescence technique. This phenomenon may be more pronounced in 'activated' normal lymphocytes. Such reactions are not due to antibodies directed against adenovirus, papovavirus or EB virus antigens, although these are common constitutents of human tonsillar cells. Additional problems with TdT heteroantisera may result from immunization with non-TdT determinants in calf thymus extracts, as was manifest in human non-lymphoid (KB) cells cultured in fetal bovine serum. These difficulties will be overcome only by production of a monoclonal antibody using human TdT as the antigen.

Terminal deoxynucleotidyl transferase (TdT) in human foetuses. An immunofluorescent and biochemical study

The liver, bone marrow and cord blood of 30 human foetuses between the 15th and 21st weeks of gestational age were examined. Liver suspensions were investigated both by immunofluorescent and biochemical assay; cord blood suspensions and bone marrow touches with immunofluorescent assay. The results indicate the existence of a few TdT+ cells in the liver, cord blood and bone marrow of human foetuses in the ages studied. The peaks for each organ were: 15 +/- 1.60 (mean +/- SD) TdT+ cells in the liver, 12 +/- 2 in the bone marrow and 18 +/- 2.83 in the cord blood. In all the organs TdT+ cells decrease in the later weeks. In the liver, the results of the immunofluorescent assay were confirmed by the biochemical activity.