Association of monosomy 7 with myelodysplasia following chemotherapy for Hodgkin's disease: serial observations

Secondary malignancies in a child with Hodgkin's disease: T-cell lymphoma and myelodysplastic syndrome evolving into acute nonlymphoblastic leukaemia

Hodgkin's disease (HD) has been linked to an increase risk of second malignant neoplasms (SMN), especially non-Hodgkin's lymphoma (NHL) and acute nonlymphoblastic leukaemia (ANLL). The mutagenic property of cytotoxic therapy as well as defective immunity have been implicated as playing a major role in the development of SMN in patients previously treated for HD. We report a case of a 14-year-old girl with HD who developed two different second malignancies within a latent period of 28 months following HD diagnosis. The patient presented initially with bilateral cervical and supraclavicular as well as mediastinal and paraaortic lymphadenopathy. She was staged as IIIA, nodular sclerosing type HD, and was given eight alternative cycles of MOPP-ABVD followed by "mantle" field radiotherapy to a total dose of 3.3 Gy plus 0.4 Gy to the upper mediastinum. Within 8 months following the completion of therapy, a period of myelodysplasia and progressive severe immune deficiency, considered as a result of initial treatment, occurred. Eighteen months after HD diagnosis while the patient was continuously neutropenic and heavily immunocompromised, a peripheral T-cell lymphoma of the angiocentric immunoproliferative lesion type (AIL) Grade III, appeared in both lungs within and beyond the radiation field, with no evidence of HD in biopsy specimens. After institution of a new chemotherapy regimen (L17M), a satisfactory response regarding NHL lesions was noted. However, 10 months later the myelodysplastic syndrome (MDS) accompanied by complex chromosomal abnormalities evoluted to frank ANLL with a rapid fatal course. This case supports the hypothesis that combined modality treatment accompanied by severe immunodeficiency may result in the development of multiple second malignancies even within a very short latent period, especially in a subgroup of HD patients who may be particularly increased risk of second cancers.

Secondary acute non-lymphocytic leukemia with monosomy 7 arising 9 years after acute lymphoblastic leukemia in childhood

We report a case of pediatric acute non-lymphocytic leukemia (ANLL) with monosomy 7 occurring in a child successfully treated for acute lymphoblastic leukemia (ALL) nine years earlier. Acquired monosomy 7 is currently recognized as a distinct therapy-related cytogenetic abnormality which nonrandomly occurs as a late complication of cytotoxic therapy used in the treatment of both malignant and nonmalignant disease. Most commonly, this occurs as a disorder of bone marrow morphology and function characterized as a myelodysplastic syndrome (MDS) or ANLL. This case report emphasizes the need for continued evaluation of long-term survivors of childhood cancer to identify and minimize therapy-related side effects without compromising successful management.

Translocations and deletions with breakpoint on 21q are nonrandomly associated with treatment-related acute nonlymphocytic leukemia and preleukemia

Six of 70 (8.6%) consecutive cases with therapy-related acute nonlymphocytic leukemia (ANLL) or preleukemia had a translocation or deletion with a breakpoint on 21q. Such aberrations were seen in only one of 200 (0.5%) consecutive cases of de novo ANLL examined at our laboratory. The figures reflect a 17.1-fold increased incidence of 21q aberrations in therapy-related ANLL or preleukemia, compared with ANLL de novo. The difference is highly significant (p = 0.003). The increased incidence of 21q aberrations in therapy-related myelodysplastic syndromes was confirmed by literature studies. Band 21q22 was most often involved. Cases with t(8;21), which is strongly associated with the M2 variant of ANLL, or cases with i(21q), which is supposedly due to a centromeric misdivision, were not included in the count. It is concluded that the 21q aberrations are associated with treatment-related ANLL or preleukemia with at least the same degree of specificity as aberrations of #5 and #7.

Cytogenetic investigations in Hodgkin's disease: I. Involvement of specific chromosomes in marker formation

Cytogenetic studies were performed in five Hodgkin-derived permanently growing cell lines, as well as in bone marrow cells from two Hodgkin patients, one of which suffering from acute myeloid leukemia after Hodgkin's disease. No consistent and common marker chromosome was found, but certain chromosome regions seemed to be nonrandomly involved in marker formation. These are chromosome bands 7q22, 7q32, 7q36, 2q33, 1p22, 11q21/23, 14q32, 15p12, and 21q21. The importance and significance of these chromosomal findings are discussed in reference to data from the literature.

Carcinogenicity of antineoplastic agents in man

Review of the literature shows that: Anticancer drugs are in all probability mostly also carcinogenic. Alkylating agents such as melphalan, chlorambucil and cyclophosphamide seem to lead to the highest rate of second malignancies. Second malignancies after antitumour drugs are mostly acute leukaemias. Conditions which could influence the carcinogenicity of an antitumour drug are (a) its carcinogenic potency; (b) long-term administration; (c) the total dose used and (d) long-term survival of the patient. Irradiation and chemotherapy seem to have the greatest carcinogenic potential, e.g. in malignant lymphomas. The role of immunosuppression as a co-carcinogenic factor is difficult to estimate. Although transplant patients on anticancer drugs for immunosuppression have a higher risk of reticulosarcomas, but not of solid tumours, there is no evidence to suppose that in general immunosuppression and carcinogenicity are directly related. There is no reason to abandon intensive chemotherapy regimes if they lead to significant therapeutic results on the grounds of possible carcinogenicity of these drugs.

Chromosomes and causation of human cancer and leukemia. L. Cytogenetics of leukemias complicating other diseases

Complicating (secondary) leukemias in 20 patients, 18 of whom had various forms of neoplasia treated with chemotherapy and/or radiation, have been examined in regard to the karyotypic findings present in the leukemic cells of the marrow. In addition, the published cases of complicating leukemia have been tabulated. Based on the results of the present study and those in the literature it appears that chromosomes #3 and #17 should be stressed as being nonrandomly involved in complicating leukemia in addition to the previously stressed chromosomes #5 and #7. The results of the present study are discussed in relation to those reported in the literature, and stress put on the significance of cytogenetic changes in relation to possible causative factors of the complicating leukemia. The hypothesis is advanced that these nonrandom chromosome changes may reflect causative specificity of the complicating leukemia and that a concerted effort must be made to obtain more cogent information on the role of noxious agents in the causation of complicating leukemia.

Pathogenetic significance of "pure" monosomy 7 in myeloproliferative disorders. Analysis of 14 cases

Monosomy 7 is frequent in acute myeloid leukaemia (AML) and in preleukaemic dysmyelopoietic syndromes but often it is not the only chromosome anomaly associated with these conditions. We report 14 patients with "pure" monosomy 7 and their clinical and haematological data are analysed in order to clarify the possible implications of this chromosome anomaly. The following points are considered: 1) In spite of the apparent variability of clinical forms in which monosomy 7 is found, several characteristics are common to all monosomy 7 patients, i.e. the presence of a preleukaemic phase and blood and marrow features suggesting the early involvement in the disease of all marrow cell lines. The different diagnoses associated with monosomy 7 are correlated with different steps of a unique myeloproliferative disease whose typical course can be reconstructed. 2) Monosomy 7 has a negative prognostic value. When it is found in a preleukaemic disorder it indicates a high risk of progression to AML, while in AML it implies recurrent infections, poor response to therapy and short survival. 3) The significance of the lack of Colton blood group antigens in monosomy 7 patients is discussed, with particular regard to the fact that the patients in whom this lack was found are the only ones who had not received transfusions in the months before the tests were done. 4) The finding of defective neutrophil chemotaxis in monosomy 7 patients is confirmed and the clinical importance of this fact is emphasized. 5) The data on the 14 patients support the opinion that AML, in general, is heterogeneous in origin. It is postulated that monosomy 7 is a marker of a specific pathogenetic pathway of AML, which implies the beginning of the malignancy in a pluripotent stem cell.