The concept of preleukemia: clinical and laboratory studies

Hydroquinone, a benzene metabolite, and leukemia: a case report and review of the literature

Hydroquinone is a phenolic metabolite of benzene, a known human carcinogen. Hydroquinone is widely used in the industry. We report a case of a 43-year-old male diagnosed with antecedent myelodysplastic syndrome and acute myeloid leukemia following 16 years of occupational exposure to hydroquinone in radiographic developer solution. Cytogenetic studies revealed aberrations in chromosome 5 and chromosome 7. We review the literature on hydroquinone as a potential cause of hematolymphatic cancers and discuss the role of hydroquinone as a genotoxic and leukemogenic agent.

Enhanced growth of myelodysplastic colonies in hypoxic conditions

OBJECTIVE

To determine the response of bone marrow progenitor cells from patients with myelodysplastic syndromes (MDS) to culture in physiologic oxygen tension.

METHODS

Methylcellulose progenitor assays using both unfractionated bone marrow mononuclear cells (MNCs) and purified CD34(+) progenitors were performed in atmospheric oxygen (18.6% O(2)) or one of two levels of hypoxia (1% and 3% O(2)). Assays were performed using normal donor marrow, MDS patient marrow, acute myelogenous leukemia marrow or peripheral blood blasts, chronic phase chronic myelogenous leukemia (CML) marrow MNCs, and blast crisis CML peripheral blood.

RESULTS

The majority of MDS samples showed decreased colony-forming units (CFU) in 18.6% O(2) compared to normal controls, as expected. However, in either 1% or 3% O(2), 9 of 13 MDS samples demonstrated augmentation of CFUs beyond that observed in normal controls, with 6 of 13 demonstrating a greater than ninefold augmentation. This effect is cell autonomous, as it persisted after purification of CD34(+) progenitor cells. Additionally, the augmented response to physiologic oxygen tension is specific to MDS, as it was not observed in either acute or chronic myelogenous leukemia samples.

CONCLUSION

These results suggest that the reported decrease in MDS CFUs reflects greater sensitivity of MDS progenitors or their progeny to the nonphysiologic oxygen tensions routinely used in vitro, rather than a true decrease in progenitor frequency. Importantly, these experiments for the first time describe an experimental system that can be used to study the growth of primary cells from patients with MDS.

The myelodysplastic syndrome(s): a perspective and review highlighting current controversies

The myelodysplastic syndrome (MDS) includes a diverse group of clonal and potentially malignant bone marrow disorders characterized by ineffective and inadequate hematopoiesis. The presumed source of MDS is a genetically injured early marrow progenitor cell or pluripotential hematopoietic stem cell. The blood dyscrasias that fall under the broad diagnostic rubric of MDS appear to be quite heterogeneous, which has made it very difficult to construct a coherent, universally applicable MDS classification scheme. A recent re-classification proposal sponsored by the World Health Organization (WHO) has engendered considerable controversy. Although the precise incidence of MDS is uncertain, it has become clear that MDS is at least as common as acute myelogenous leukemia (AML). There is considerable overlap between these two conditions, and the former often segues into the latter; indeed, the distinction between AML and MDS can be murky, and some have argued that the current definitions are arbitrary. Despite the discovery of several tantalizing pathophysiological clues, the basic biology of MDS is incompletely understood. Treatment at present is generally frustrating and ineffective, and except for the small subset of patients who exhibit mild marrow dysfunction and low-risk cytogenetic lesions, the overall prognosis remains rather grim. In this narrative review, we highlight recent developments and controversies within the context of current knowledge about this mysterious and fascinating cluster of bone marrow failure states.

The cytogenetics of myelodysplastic syndromes

The myelodysplastic syndromes are a collection of five clinico-pathological entities with a wide spectrum of clinical behaviours and survival outcomes. Cytogenetic analysis has been instrumental in refining the prognosis, predicting the likelihood of progression to acute myeloid leukaemia and median survival, and in establishing clonality of these diseases. This review highlights the most frequent abnormalities and summarizes their clinical and genetic features.

Scientific update on benzene

The mechanism of benzene toxicity has been extremely difficult to fully characterize. Much progress has been made in assessing the relative potency of benzene metabolites but specific pathways to leukemia remain to be determined. Metabolite and mechanistic studies will have to focus on aplastic anemia and MDS and separate endpoints. This may serve to clarify the array of metabolite effects and consequent disparate effects. Biomarker research can contribute to the understanding of the toxicity process. The significance of understanding benzene toxicity will also lead to better clinical treatment of aplastic anemia and therapy-related MDS and AML, detection of populations particularly susceptible to benzene toxicity, screening of populations with suspected or unknown exposures, and determination of meaningful values for occupational and individual health risk while effectively monitoring ongoing exposures for early signs of toxicity.

A perspective on benzene leukemogenesis

Although benzene is best known as a compound that causes bone marrow depression leading to aplastic anemia in animals and humans, it also induces acute myelogenous leukemia in humans. The epidemiological evidence for leukemogenesis in humans is contrasted with the results of animal bioassays. This review focuses on several of the problems that face those investigators attempting to unravel the mechanism of benzene-induced leukemogenesis. Benzene metabolism is reviewed with the aim of suggesting metabolites that may play a role in the etiology of the disease. The data relating to the formation of DNA adducts and their potential significance are analyzed. The clastogenic activity of benzene is discussed both in terms of biomarkers of exposure and as a potential indication of leukemogenesis. In addition to chromosome aberrations, sister chromatid exchange, and micronucleus formation, the significance of chromosomal translocations is discussed. The mutagenic activity of benzene metabolites is reviewed and benzene is placed in perspective as a leukemogen with other carcinogens and the lack of leukemogenic activity by compounds of related structure is noted. Finally, a pathway from exposure to benzene to eventual leukemia is discussed in terms of biochemical mechanisms, the role of cytokines and related factors, latency, and expression of leukemia.

Induction of micronuclei and aneuploidy by the quinone-forming agents benzene and o-phenylphenol

A number of carcinogens appear to exert their tumorigenic effects through the formation of quinone metabolites. These quinone-forming carcinogens are generally inactive or weakly active in standard gene mutation assays. Accumulating evidence indicates that this class of compounds may exert their genotoxic and carcinogenic effects through the induction of large-scale gene alterations. This article presents an overview of work that has been performed using recently developed molecular cytogenic techniques to investigate the aneuploidy-inducing and clastogenic properties of the major quinone-forming metabolites of benzene, a widely used industrial chemical, and o-phenylphenol, a fungicide and disinfectant. These metabolites of benzene (hydroquinone, catechol, and benzenetriol) and o-phenylphenol (phenylhydroquinone) have each been shown to be capable of interfering with chromosome segregation and inducing chromosomal breakage. These results indicate that both numerical and structural chromosomal aberrations induced by the quinone metabolites of benzene and o-phenylphenol may play a role in the carcinogenic effects of these two agents.

Low dose cytosine arabinoside in refractory anemia with excess of blasts in transformation

Myelodysplastic syndromes (MDS) are heterogeneous diseases. Patients with blast counts of more than 20% of nucleated bone marrow cells have a high risk of short survival. We treated six patients with refractory anemia with excess of blast in transformation (RAEBiT) with low dose cytosine arabinoside (LD Ara-C). We had one partial remission (PR), surviving 16 weeks and two complete remissions (CR), surviving 22 and 55+ months. Myelosuppression was dominant in all patients, but was not as serious as with conventional remission-induction treatments for leukemias. Bone marrow aplasia occurred in all responding patients, but a differentiation effect is possible too. Maintenance therapy with LD Ara-C may be important for the two long-lasting CR.

KRAS2 oncogene overexpression in myelodysplastic syndrome with translocation 5;12

The factors that initiate and maintain the abnormal hematopoietic clone in the myelo-dysplastic syndromes (MDS) remain largely unknown. We describe a patient with MDS associated with an abnormal karyotype, 46,XY,t(5;12)(q31;p12). According to the FAB cooperative group classification, the patient was classified as chronic myelomonocytic leukemia. Because of the particular chromosomal translocation, the structure-function relationship of three genes relevant to the translocation breakpoints, CSF2, FMS, and KRAS2, was studied in bone marrow and peripheral blood lymphocytes in this patient. No major structural alterations were observed at these three genetic loci. Although the levels of expression of the CSF2 and FMS genes remained unaltered, the KRAS2 oncogene was overexpressed approximately six-fold in bone marrow cells from the MDS patient compared with normal donors. We postulate that the RAS oncogene activation may be instrumental in the genesis of MDS.

The preleukemic syndrome (hematopoietic dysplasia)

It has been recognized for many decades that epithelial dysplasia can represent an early histological sign of epithelial neoplasia. So it is with hematopoietic tissue wherein dysplasia of bone marrow cells can be an early sign of impending acute myeloid leukemia. Although this 'preleukemic syndrome' of hematopoietic dysplasia can often be identified well in advance of the classic histological signs of acute leukemia, a wide variety of basic studies on bone marrow cells, from patients and from experimental animals with induced preleukemia, clearly indicate that the preleukemic marrow cells are members of a fully established neoplastic clone. Consequently, it is likely that the preleukemic syndrome is merely acute leukemia diagnosed earlier than usual and which, in some patients, can be very slowly progressive, and in others may not progress at all. This article reviews the evidence in support of the notion that the preleukemic syndrome is an 'early leukemia', places the preleukemic syndrome in the context of a larger group of myelodysplastic disorders, reviews the laboratory studies of value for both diagnosis and for use in the assessment of prognosis, and summarizes the therapeutic options available for the management of patients with this disorder.

Cytogenetic findings in siblings with a myelodysplastic syndrome

A brother and sister, both in their third decade, presented 6 months apart with severe pancytopenia. Bone marrow examination demonstrated morphologic changes, characteristic of the myelodysplastic syndromes, subtype refractory anemia with excess of blasts; cytogenetic studies revealed complex but different karyotypic abnormalities in both siblings. No history of exposure to mutagenic agents was obtained; there was no evidence of congenital anomalies in the family. Both siblings died within 18 months of diagnosis from complications related to their disease. This report describes the clinical course and discusses the cytogenetic findings for both siblings.