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Ivanov S, Sharma P, Jobanputra Y, Zhang Y. Transformation of Chronic Myeloid Leukemia to Acute Biphenotypic Leukemia. J Med Cases 2021; 11:239-242. [PMID: 34434403 PMCID: PMC8383682 DOI: 10.14740/jmc3511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 06/17/2020] [Indexed: 11/11/2022] Open
Abstract
Chronic myeloid leukemia (CML) is a myeloproliferative disorder with clonal proliferation of all myeloid cell lines. The disease typically manifests in three phases: chronic course followed by an accelerated phase and finally a terminal blast crisis. A blast crisis is defined as the presence of > 20% blasts in the peripheral blood or bone marrow. The blasts could be characterized as either myeloid (60-80% of cases) resulting in acute myeloblastic leukemia or lymphoid (20-30% of cases) resulting in acute lymphoblastic leukemia. In rare instances, a blast crisis could present with biphenotypic expression for both myeloid and lymphoid blasts. In such cases, about 6-10% of the time, the course of the disease is more aggressive and renders a poorer prognosis especially if there is evidence of extramedullary involvement. We present a case of a 41-year-old woman with history of CML who presented with acute biphenotypic blast crisis with extramedullary involvement in the context of aggressive chemotherapy. Literature review reveals < 10 reported cases of CML with biphasic transformation and only three cases of CML with acute leukemia on presentation. Most cases described are in pediatric patients with varied presentations and none involving extramedullary sites. Mortality rates in such cases are near 100% despite aggressive chemotherapy.
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Affiliation(s)
- Stanislav Ivanov
- University of Miami/JFK Medical Center GME Consortium Internal Medicine Residency Program, Atlantis, FL 33467, USA
| | - Purva Sharma
- University of Miami/JFK Medical Center GME Consortium Internal Medicine Residency Program, Atlantis, FL 33467, USA
| | - Yash Jobanputra
- University of Miami/JFK Medical Center GME Consortium Internal Medicine Residency Program, Atlantis, FL 33467, USA
| | - Yuanming Zhang
- University of Miami/JFK Medical Center GME Consortium Internal Medicine Residency Program, Atlantis, FL 33467, USA
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Liu J, Zhou Y, Yuan Q, Xiao M. Myeloid Blast Crisis of Chronic Myeloid Leukemia Followed by Lineage Switch to B-Lymphoblastic Leukemia: A Case Report. Onco Targets Ther 2020; 13:3259-3264. [PMID: 32368084 PMCID: PMC7173800 DOI: 10.2147/ott.s251214] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 04/02/2020] [Indexed: 11/23/2022] Open
Abstract
Lineage switch is very rare in blastic crisis of chronic myeloid leukemia (CML-BC). Here, we report a case of CML-BC in which the blast lineage switched from myeloid to B-lymphoid. A 35-year-old male was initially admitted to our hospital because of abdominal distention for over a year and dizziness for one week. Prior to presentation at our hospital, he visited a local hospital because of abdominal distention where his white blood cell count and bone marrow (BM) smear indicated CML. Results from peripheral blood (PB) counts, bone marrow analysis, immunophenotyping by flow cytometry, and the detection of the Philadelphia chromosome were consistent with a diagnosis of myeloid blast crisis from CML. The patient received chemotherapy with imatinib for induction, which diminished the number of blasts. However, after three months, the blasts were increased in the PB and BM. The BM study and immunophenotyping by flow cytometry revealed B-lymphoblastic leukemia. In accordance with his first admission, a chromosome study revealed a karyotype of 46, XY, t(9; 22)(q34; q11) in all 20 cells analyzed, and B-lymphoblastic transformation from CML was diagnosed. Despite three months of treatment with DVCP (daunorubicin, vincristine, cyclophosphamide and prednisone) chemotherapy in combination with dasatinib, the patient did not achieve complete remission. The patient decided to stop treatment and was discharged from the hospital for financial reasons. This case implicates the Philadelphia chromosome with p210 BCR-ABL1 fusion proteins as a key molecule in CML-BC. Further research is needed to assess the frequency, treatment, and prognosis of CML-BC patients with lineage switch.
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Affiliation(s)
- Jiduo Liu
- Department of Clinical Laboratory, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510405, People's Republic of China
| | - Yingchun Zhou
- Department of Clinical Laboratory, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510405, People's Republic of China
| | - Qing Yuan
- Department of Clinical Laboratory, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510405, People's Republic of China
| | - Mingfeng Xiao
- Department of Clinical Laboratory, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong 510405, People's Republic of China
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Wu B, Jug R, Luedke C, Su P, Rehder C, McCall C, Lagoo AS, Wang E. Lineage Switch Between B-Lymphoblastic Leukemia and Acute Myeloid Leukemia Intermediated by "Occult" Myelodysplastic Neoplasm: Two Cases of Adult Patients With Evidence of Genomic Instability and Clonal Selection by Chemotherapy. Am J Clin Pathol 2017; 148:136-147. [PMID: 28898985 DOI: 10.1093/ajcp/aqx055] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES Lineage switch occurs in rare leukemias, and the mechanism is unclear. We report two cases of B-lymphoblastic leukemia (B-ALL) relapsed as acute myeloid leukemia (AML). METHODS Retrospective review of clinical and laboratory data. RESULTS Complex cytogenetic abnormalities were detected in B-ALL for both cases with subclone heterogeneity. Postchemotherapy marrow biopsies showed trilineage hematopoiesis without detectable B-ALL. Cytogenetics in both showed stemline abnormalities. The cases were considered "occult" myelodysplastic syndrome (MDS) preceding B-ALL. The patients relapsed 6.5 and 9 months following induction, respectively. Case 1 relapsed as AML-M5 initially, was treated as such, and then relapsed again as B-ALL. Case 2 relapsed as AML-M6. Cytogenetics demonstrated persistent abnormalities. Both patients died soon after relapse. CONCLUSIONS Lineage switch between B-ALL and AML could be intermediated by occult MDS. A pluripotent progenitor likely undergoes neoplastic transformation, resulting in a genomically unstable clone. This leads to a repertoire of heterogeneous subclones that may be selected by chemotherapy. Lineage switch heralds a dismal clinical outcome.
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MESH Headings
- Aged
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Cell Transformation, Neoplastic/drug effects
- Cell Transformation, Neoplastic/genetics
- Chromosome Aberrations
- Genomic Instability
- Humans
- Leukemia, B-Cell/genetics
- Leukemia, B-Cell/pathology
- Leukemia, Myeloid, Acute/drug therapy
- Leukemia, Myeloid, Acute/genetics
- Leukemia, Myeloid, Acute/pathology
- Male
- Myelodysplastic Syndromes/genetics
- Myelodysplastic Syndromes/pathology
- Neoplasms, Second Primary/genetics
- Neoplasms, Second Primary/pathology
- Young Adult
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Affiliation(s)
- Bin Wu
- Division of Hematology, Department of Medicine, Shengjing Hospital affiliated with China Medical University, Shenyang, People's Republic of China
- Department of Pathology, Duke University Medical Center, Durham, NC
| | - Rachel Jug
- Department of Pathology, Duke University Medical Center, Durham, NC
| | - Catherine Luedke
- Department of Pathology, Duke University Medical Center, Durham, NC
| | - Pu Su
- Department of Pathology, Duke University Medical Center, Durham, NC
| | - Catherine Rehder
- Department of Pathology, Duke University Medical Center, Durham, NC
| | - Chad McCall
- Department of Pathology, Duke University Medical Center, Durham, NC
| | - Anand S Lagoo
- Department of Pathology, Duke University Medical Center, Durham, NC
| | - Endi Wang
- Department of Pathology, Duke University Medical Center, Durham, NC
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Schulenburg A, Blatt K, Cerny-Reiterer S, Sadovnik I, Herrmann H, Marian B, Grunt TW, Zielinski CC, Valent P. Cancer stem cells in basic science and in translational oncology: can we translate into clinical application? J Hematol Oncol 2015; 8:16. [PMID: 25886184 PMCID: PMC4345016 DOI: 10.1186/s13045-015-0113-9] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 01/14/2015] [Indexed: 02/08/2023] Open
Abstract
Since their description and identification in leukemias and solid tumors, cancer stem cells (CSC) have been the subject of intensive research in translational oncology. Indeed, recent advances have led to the identification of CSC markers, CSC targets, and the preclinical and clinical evaluation of the CSC-eradicating (curative) potential of various drugs. However, although diverse CSC markers and targets have been identified, several questions remain, such as the origin and evolution of CSC, mechanisms underlying resistance of CSC against various targeted drugs, and the biochemical basis and function of stroma cell-CSC interactions in the so-called ‘stem cell niche.’ Additional aspects that have to be taken into account when considering CSC elimination as primary treatment-goal are the genomic plasticity and extensive subclone formation of CSC. Notably, various cell fractions with different combinations of molecular aberrations and varying proliferative potential may display CSC function in a given neoplasm, and the related molecular complexity of the genome in CSC subsets is considered to contribute essentially to disease evolution and acquired drug resistance. In the current article, we discuss new developments in the field of CSC research and whether these new concepts can be exploited in clinical practice in the future.
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Affiliation(s)
- Axel Schulenburg
- Bone Marrow Transplantation Unit, Department of Internal Medicine I, Medical University of Vienna, Währinger Gürtel 18-20, Vienna, A-1090, Wien, Austria. .,Ludwig Boltzmann Cluster Oncology, Medical University of Vienna, Spitalgasse 23, Vienna, 1090, Wien, Austria. .,Department of Medicine I, Stem Cell Transplantation Unit, Medical University of Vienna, Waehringer Guertel 18-20, A-1090, Wien, Austria.
| | - Katharina Blatt
- Department of Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Währinger Gürtel 18-20, Vienna, 1090, Wien, Austria.
| | - Sabine Cerny-Reiterer
- Ludwig Boltzmann Cluster Oncology, Medical University of Vienna, Spitalgasse 23, Vienna, 1090, Wien, Austria. .,Department of Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Währinger Gürtel 18-20, Vienna, 1090, Wien, Austria.
| | - Irina Sadovnik
- Department of Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Währinger Gürtel 18-20, Vienna, 1090, Wien, Austria.
| | - Harald Herrmann
- Ludwig Boltzmann Cluster Oncology, Medical University of Vienna, Spitalgasse 23, Vienna, 1090, Wien, Austria. .,Department of Radiation Therapy, Medical University of Vienna, Spitalgasse 23, Vienna, 1090, Wien, Austria.
| | - Brigitte Marian
- Ludwig Boltzmann Cluster Oncology, Medical University of Vienna, Spitalgasse 23, Vienna, 1090, Wien, Austria. .,Department of Medicine I, Institute for Cancer Research, Medical University of Vienna, Währinger Gürtel 18-20, Vienna, 1090, Wien, Austria.
| | - Thomas W Grunt
- Ludwig Boltzmann Cluster Oncology, Medical University of Vienna, Spitalgasse 23, Vienna, 1090, Wien, Austria. .,Department of Medicine I, Division of Clinical Oncology, Medical University of Vienna, Währinger Gürtel 18-20, Vienna, 1090, Wien, Austria.
| | - Christoph C Zielinski
- Ludwig Boltzmann Cluster Oncology, Medical University of Vienna, Spitalgasse 23, Vienna, 1090, Wien, Austria. .,Department of Medicine I, Division of Clinical Oncology, Medical University of Vienna, Währinger Gürtel 18-20, Vienna, 1090, Wien, Austria.
| | - Peter Valent
- Ludwig Boltzmann Cluster Oncology, Medical University of Vienna, Spitalgasse 23, Vienna, 1090, Wien, Austria. .,Department of Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Währinger Gürtel 18-20, Vienna, 1090, Wien, Austria.
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Shi Y, Rand AJ, Crow JH, Moore JO, Lagoo AS. Blast phase in chronic myelogenous leukemia is skewed toward unusual blast types in patients treated with tyrosine kinase inhibitors: a comparative study of 67 cases. Am J Clin Pathol 2015; 143:105-19. [PMID: 25511149 DOI: 10.1309/ajcpwex5yy4phscn] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVES To compare the features of the blast phase of chronic myelogenous leukemia (CML) in patients treated with tyrosine kinase inhibitors (TKIs) with those in the pre-TKI era. METHODS Sixty-seven patients with blast phase CML were identified in the Duke Pathology database from 1991 to 2011. The morphology and immunophenotype of blasts were evaluated, along with cytogenetic studies and associated findings in the peripheral blood and bone marrow. RESULTS In the TKI era, the blasts were more frequently of a type other than the usual myeloid or lymphoid types when compared with the pre-TKI era. Blast phase in TKI-treated patients was associated with a higher peripheral WBC count and a lower blast percentage in the bone marrow. Of the 23 patients with cytogenetic studies during blast phase, additional cytogenetic changes more frequently occurred in patients with an unusual blast type, and some patients showed these changes months before the onset of blast phase. CONCLUSIONS Blast phase CML in TKI- and non-TKI-treated patients differs in the morphology and immunophenotype of blasts, cytogenetic findings, and associated findings in the peripheral blood and bone marrow.
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Affiliation(s)
- Yang Shi
- Department of Pathology, Duke University Medical Center, Durham, NC
| | - Andrew J. Rand
- Department of Pathology, Duke University Medical Center, Durham, NC
| | - Jennifer H. Crow
- Department of Pathology, Duke University Medical Center, Durham, NC
| | - Joseph O. Moore
- Department of Medicine, Duke University Medical Center, Durham, NC
| | - Anand S. Lagoo
- Department of Pathology, Duke University Medical Center, Durham, NC
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CD2-positive B-cell precursor acute lymphoblastic leukemia with an early switch to the monocytic lineage. Leukemia 2013; 28:609-20. [PMID: 24270736 DOI: 10.1038/leu.2013.354] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Revised: 11/10/2013] [Accepted: 11/14/2013] [Indexed: 12/20/2022]
Abstract
Switches from the lymphoid to myeloid lineage during B-cell precursor acute lymphoblastic leukemia (BCP-ALL) treatment are considered rare and thus far have been detected in MLL-rearranged leukemia. Here, we describe a novel BCP-ALL subset, switching BCP-ALL or swALL, which demonstrated monocytosis early during treatment. Despite their monocytic phenotype, 'monocytoids' share immunoreceptor gene rearrangements with leukemic B lymphoblasts. All swALLs demonstrated BCP-ALL with CD2 positivity and no MLL alterations, and the proportion of swALLs cases among BCP-ALLs was unexpectedly high (4%). The upregulation of CEBPα and demethylation of the CEBPA gene were significant in blasts at diagnosis, prior to the time when most of the switching occurs. Intermediate stages between CD14(neg)CD19(pos)CD34(pos) B lymphoblasts and CD14(pos)CD19(neg)CD34(neg) 'monocytoids' were detected, and changes in the expression of PAX5, PU1, M-CSFR, GM-CSFR and other genes accompanied the switch. Alterations in the Ikaros and ERG genes were more frequent in swALL patients; however, both were altered in only a minority of swALLs. Moreover, switching could be recapitulated in vitro and in mouse xenografts. Although children with swALL respond slowly to initial therapy, risk-based ALL therapy appears the treatment of choice for swALL. SwALL shows that transdifferentiating into monocytic lineage is specifically associated with CEBPα changes and CD2 expression.
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Chen X, Rutledge JC, Wu D, Fang M, Opheim KE, Xu M. Chronic myelogenous leukemia presenting in blast phase with nodal, bilineal myeloid sarcoma and T-lymphoblastic lymphoma in a child. Pediatr Dev Pathol 2013; 16:91-6. [PMID: 23171293 DOI: 10.2350/12-07-1230-cr.1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
A 14-year-old boy presented with chronic myelogenous leukemia (CML) in blast phase with segregated extramedullary (nodal) myeloid sarcoma and T-lymphoblastic lymphoma. Immunohistochemical stains performed on the lymphadenectomy sample demonstrated T lymphoblasts in the lymph nodes and myeloblasts in the adjacent soft tissue. Fluorescence in situ hybridization performed on paraffin sections confirmed that both T-lymphoblast and myeloblast populations were positive for the t(9;22) BCR/ABL1 translocation. Subsequent flow cytometry analysis of the bone marrow showed expanded populations of abnormal myeloblasts and T lymphoblasts diagnostic of blast phase CML. To the best of our knowledge, bilineal blast phase of CML with segregated extramedullary T lymphoblasts and myeloblasts has not been reported.
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Affiliation(s)
- Xueyan Chen
- Department of Laboratory Medicine, University of Washington, Seattle, WA, USA
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Calderón-Cabrera C, Montero I, Morales R, Sánchez J, Carrillo E, Caballero-Velázquez T, Prats C, Bernal R, De Blas J, Pérez-Simón J. Differential cytogenetic profile in advanced chronic myeloid leukemia with sequential lymphoblastic and myeloblastic blast crisis. Leuk Res Rep 2013; 2:79-81. [PMID: 24371788 PMCID: PMC3850375 DOI: 10.1016/j.lrr.2013.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2013] [Revised: 08/09/2013] [Accepted: 08/16/2013] [Indexed: 11/10/2022] Open
Abstract
Frequency of additional chromosomal abnormalities in chronic myeloid leukemia (CML) is estimated to be 7% in chronic phase and increases to 40–70% in advanced disease. Progression of CML from chronic phase to accelerated phase or blast crisis is often associated with secondary chromosomal aberrations. We report an exceptional case of CML as debut in lymphoblastic blast crisis and a subsequent progression in myeloblastic blast crisis with rare cytogenetic abnormalities.
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Park SH, Chi HS, Cho YU, Jang S, Park CJ, Im HJ. A case with coexistence of major and minor BCR/ABL fusion transcript at lymphoblastic crisis of chronic myelogenous leukemia in patients with major BCR/ABL positivity during chronic phase. Ann Lab Med 2012; 33:80-3. [PMID: 23301228 PMCID: PMC3535203 DOI: 10.3343/alm.2013.33.1.80] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Revised: 09/14/2012] [Accepted: 11/13/2012] [Indexed: 11/19/2022] Open
MESH Headings
- Adolescent
- Antineoplastic Agents/therapeutic use
- Benzamides/therapeutic use
- Chromosome Deletion
- Chromosomes, Human, Pair 7
- Drug Resistance, Neoplasm
- Fusion Proteins, bcr-abl/genetics
- Fusion Proteins, bcr-abl/metabolism
- Humans
- Imatinib Mesylate
- Immunophenotyping
- Karyotyping
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/diagnosis
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/metabolism
- Male
- Piperazines/therapeutic use
- Pyrimidines/therapeutic use
- Real-Time Polymerase Chain Reaction
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Affiliation(s)
- Sang Hyuk Park
- Department of Laboratory Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea
| | - Hyun-Sook Chi
- Department of Laboratory Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea
| | - Young-Uk Cho
- Department of Laboratory Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea
| | - Seongsoo Jang
- Department of Laboratory Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea
| | - Chan-Jeoung Park
- Department of Laboratory Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea
| | - Ho-Joon Im
- Department of Pediatrics, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea
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Sachs RK, Johnsson K, Hahnfeldt P, Luo J, Chen A, Hlatky L. A multicellular basis for the origination of blast crisis in chronic myeloid leukemia. Cancer Res 2011; 71:2838-47. [PMID: 21487044 DOI: 10.1158/0008-5472.can-10-4600] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Chronic myeloid leukemia (CML) is characterized by a specific chromosome translocation, and its pathobiology is considered comparatively well understood. Thus, quantitative analysis of CML and its progression to blast crisis may help elucidate general mechanisms of carcinogenesis and cancer progression. Hitherto, it has been widely postulated that CML blast crisis originates mainly via cell-autonomous mechanisms such as secondary mutations or genomic instability. However, recent results suggest that carcinogenic transformation may be an inherently multicellular event, in departure from the classic unicellular paradigm. We investigate this possibility in the case of blast crisis origination in CML. A quantitative, mechanistic cell population dynamics model was employed. This model used recent data on imatinib-treated CML; it also used earlier clinical data, not previously incorporated into current mathematical CML/imatinib models. With the pre-imatinib data, which include results on many more blast crises, we obtained evidence that the driving mechanism for blast crisis origination is a cooperation between specific cell types. Assuming leukemic-normal interactions resulted in a statistically significant improvement over assuming either cell-autonomous mechanisms or interactions between leukemic cells. This conclusion was robust with regard to changes in the model's adjustable parameters. Application of the results to patients treated with imatinib suggests that imatinib may act not only on malignant blast precursors, but also, to a limited degree, on the malignant blasts themselves.
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Affiliation(s)
- Rainer K Sachs
- Department of Mathematics, University of California, Berkeley, California 94720, USA.
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