Analysis of peroxidase-negative acute unclassifiable leukemias by monoclonal antibodies. 1. Acute myelogenous leukemia and acute myelomonocytic leukemia

Acute myelogenous leukemia with PIG-A gene mutation evolved from aplastic anemia-paroxysmal nocturnal hemoglobinuria syndrome

We report a patient with aplastic anemia (AA)-paroxysmal nocturnal hemoglobinuria (PNH) syndrome who developed acute myelogenous leukemia (AML). Flow cytometric analysis showed that the leukemic cells in the bone marrow lacked CD59 antigen on their surface and were positive for P-glycoprotein. Heteroduplex and single-strand conformation polymorphism analysis followed by sequencing of the leukemic cells in the bone marrow disclosed 1 frameshift-type mutation in exon 2 of the phosphatidylinositol glycan-class A (PIG-A) gene, which deductively produces truncated PIG-A protein. These findings provide direct evidence that the leukemic cells evolved from the affected PNH clone. Cytogenetic analysis in the bone marrow in each stage of AA-PNH, AML, and at relapse of AML showed normal, -7, and -7 plus -20, respectively, showing evidence of a clonal evolution. Because complete remission of AML was not achieved by intensive chemotherapies, allogeneic peripheral blood stem cell transplantation (PBSCT) from the patient's HLA-matched sister was performed successfully with recovery of CD59 antigen on bone marrow hematopoietic cells; however, leukemia relapsed 4 months after PBSCT. Leukemia derived from PNH may be resistant to intensive chemotherapy, and a highly myeloablative regimen may be required for stem cell transplantation to eradicate the PNH-derived leukemia clone.

Effect of ubenimex (Bestatin) on the cell growth and phenotype of HL-60 and HL-60R cell lines: up-and down-regulation of CD13/aminopeptidase N

Ubenimex (Bestatin), a low-molecular-mass dipeptide, has been demonstrated to have anti-tumor activities and immunomodulating activities. We here report cell growth inhibition and phenotypic changes of HL-60 and HL-60R cell lines induced by Bestatin treatment. Bestatin (0.1 microg/ml) showed remarkable cell growth inhibition against HL-60 cells, whereas it was ineffective for HL 60R cells. Bestatin also showed growth inhibition in the concentration of 1 microg/ml against HL-60R cells which are resistant to differentiation induction by DMSO and TPA. In both cell types, the effect of growth inhibition by Bestatin treatment was dose dependent. We found a low level expression of CD13 and a low number of CD13 positive cells in HL-60R cells compared with that of HL-60. We also observed phenotypic changes of HL-60 and HL-60R cells following incubation with Bestatin (10 microg/ml) for 1 and 3 hrs, respectively. With HL-60 cells, the upregulation of CD13/aminopeptidase N was found after 1 hr, however, the downregulation was observed after 3 hrs incubation with Bestatin. On the other hand, the downregulation of CD15 and CD33 was observed after both one and 3 hrs incubation. Similarly, in HL-60R cells, the upregulation of CD13/aminopeptidase N was found temporarily (1hr), and then CD13 downregulation was observed after 3 hrs incubation with Bestatin. No notable change was observed for expression of other myeloid-related antigens, e.g. CD14 (My4, LeuM3), CD11b (OKM1), and CD34 (My10). On the basis of these observations of in vitro activity, we suggest that Bestatin may also be an effective anti-leukemic agent in vivo.

Sensitive detection technique of myeloperoxidase precursor protein by flow cytometry with monoclonal antibodies

This report describes the analysis of culture cells and blast cells separated from the heparinized bone marrow and whole blood of patients with acute leukemias by means of a density-gradient technique (Ficoll-sodium metrizoate d = 1.077 g/cm3). Cell-surface antigens were analyzed by a fluorescence-activated cell sorter using a panel of monoclonal antibodies (MAbs). The blast cells and culture cells were fixed by 3% paraformaldehyde in phosphate-buffered saline. A low level of expression of MPO precursor protein was found in THP-1. K-562 and HEL, MEG-01, erythro-megakaryocytic leukemia cell lines, Jurkat, MOLT-3, MOLT-4, RPM18402, ATL-5, T-cell leukemia cell lines, Raji, Daudi. BALL-1, B-cell leukemia cell lines, and AGNK1 showed negative reaction. The de novo MPO-negative acute leukemias, middle level of expression of MPO precursor protein, was found in the blasts of MPO-negative AML (AML, M0), which coexpressed CD13, CD33, CD34, and CD38. A high level of expression of MPO protein was found in all cases of AML, M1, and M2. The MPO expression was not found in all cases of acute lymphoblastic leukemia. The highest level of MPO expression was found in cases of AML, M3, and AML, M3v, suggesting the diagnostic value for this type of leukemia. The detection of MPO precursor protein by flow cytometric analysis with monoclonal antibodies is essential for the determination of lineage and precise diagnosis of acute unclassifiable leukemia, and should contribute substantially to the development of an effective form of therapy and cure.

Myeloperoxidase mRNA analysis in acute lymphoblastic leukemia

Expression of the myeloperoxidase (MPO) gene at the mRNA level is a better lineage marker than enzymatic activity in early myeloid precursors and their leukemic counterparts. Its diagnostic use depends on the specificity of expression for myeloblasts and its absence in blasts of lymphoid lineage. The present study investigates MPO mRNA expression in adult acute lymphoblastic leukemia (ALL), using reverse transcription-polymerase chain reaction. Of a total of 13 cases, six were found to have blasts positive for MPO mRNA; in all of these cases, the blasts were cytochemically negative for MPO. This unexpected finding of MPO mRNA positivity in six of 13 cases was further investigated at the molecular level. Bcr gene rearrangement analysis was positive in all six cases for the bcr breakpoint diagnostic of chronic myelogenous leukemia (CML). Only three of these six cases were cytogenetically positive for a Philadelphia (Ph) chromosome. Based on molecular analysis, these cases are considered as CML presenting in blast crisis of lymphoid lineage, as opposed to de novo ALL. The remaining seven cases were Ph negative at the cytogenetic and molecular levels; the leukemic blasts were MPO mRNA negative, confirming the lack of MPO gene expression in de novo ALL.

CD4+, CD45RA+, CD29- T-cell lymphocytic leukemia functioning as T suppressor inducer for B-cell immunoglobulin synthesis

We describe here a case of T-cell lymphocytic leukemia (T-CLL) which coexpressed CD4 and CD45RA cell-surface antigens and functioned as suppressor inducer cells. The patient, an 81 year-old man, had massive generalized lymphadenopathy. His hemoglobin was 9.4g/dl, the platelet count 94,000, and the WBC was 895,000/microliters with 98% abnormal lymphoid cells. He had massive hepatosplenomegaly. Serum LDH was elevated to 3,990 u/l. The T-CLL cells coexpressed antigens detected by MAbs CD2, CD3, CD4, CD5, Ti(TcR alpha/beta; WT31) CD45 and CD45RA, but did not express any other antigens including CD1, CD8, CD29, and TCR gamma/delta, Ti gamma A and TQ-1. The cell-surface phenotypes of the cultured cells established by utilizing recombinant interleukin 2 were basically the same as those of the uncultured peripheral blood lymphoid cells. Both the peripheral blood and cultured cells clearly showed gene rearrangement for T cell receptors, TcR beta and TcR gamma. No association with human T-cell leukemia virus-1 (HTLV-1) was found by means of electron microscopic studies or the application of MAbs to p19 and p24 of HTLV-1. No anti-HTLV-1 antibody was detected. By the means of two color fluorescence, it was clearly demonstrated that the leukemic cells possessing CD4 in the peripheral blood and cell cultures coexpressed CD45RA, but did not express either CD29 or TQ-1. In vitro immunoglobulin synthesis by normal T and B cells was remarkably reduced in the presence of CD8+ T and leukemic cells. This suggests suppressor inducer T cell activity for the leukemic cells.(ABSTRACT TRUNCATED AT 250 WORDS)

Detection of high incidence of H-RAS oncogene point mutations in acute myelogenous leukemia

We have been analyzing RAS p21 proteins and the DNA sequence of leukemic cells. We report here that these cells have high expression of H-RAS p21, which originates from point mutations of RAS oncogenes. The leukemic cells from six patients with acute myelogenous leukemia were separated from heparinized whole blood and bone marrow by a density gradient technique. The expression of RAS oncogenes was analyzed by a fluorescence-activated cell sorting with a panel of monoclonal antibodies. The high expression of DWP, which was reported to recognized activated RAS oncogene, was found in two patients and was associated with high levels of H-RAS expression. These facts prompted us to analyze the DNA sequence of RAS genes with an automated DNA sequencer. Unexpectedly, various kinds of H-RAS point mutations were found in all six cases, including two cases of hot-spot point mutation at codon 12, whereas K-RAS point mutation (no hot-spot point mutations) was found in six cases. The same H-RAS point mutations, at codons 10, 11, and 15, were found in all six cases. To our knowledge, there is no report on H-RAS point mutation in human leukemias. On the basis of these findings, we suggest that H-RAS point mutation together with p53 gene mutation may play an important role in leukemogenesis.

Association between ATL and non-hematopoietic neoplasms

A high incidence of multiple primary neoplasms has been observed in our patients with ATL in comparison to persons with other forms of hematologic malignancy who we have observed during the past 23 years (1963-1985). Five of 15 patients with ATL (33.3 per cent) have had at least one other associated neoplasm in comparison to only 44 of 1156 patients with other forms of hematological malignancy (3.8 per cent). The incidence figures for secondary neoplasms associated with the other hematologic malignancies were 4.3 per cent (16/370) for acute non-lymphocytic leukemia (ANLL), 2.2 per cent (2/90) for acute lymphocytic leukemia (ALL), 4.8 per cent (1/21) for acute unclassifiable leukemia, 2.2 per cent (5/225) for chronic myelogenous leukemia, 4.7 per cent (2/43) for chronic lymphocytic leukemia, 5.9 per cent (8/136) for malignant monoclonal gammopathy and 3.7 per cent (10/271) for malignant lymphoma. The incidence of multiple neoplasms in patients with ATL in comparison to those with other hematological malignancies was statistically significant (p < 0.01 or p < 0.001). The neoplasms associated with ATL have been adenocarcinoma of the thyroid or stomach, and squamous cell carcinoma of the larynx, lip or lung. We identified ATL-derived factor (ADF) in the cytoplasm of the secondary neoplasms of the ATL patients by means of indirect immunofluoroscopy and immunohistochemical techniques utilizing anti-ADF antibody. We also identified ras p21 products in these neoplasms by means of p21 ras monoclonal antibody studies. The possibility that HTLV-I was the cause of the secondary neoplasms thus was investigated. HTLV-I provirus genome was not found in all the six cases of non-ATL leukemic cells of the patients with anti-HTLV-I antibodies as determined by means of Southern blot analysis utilizing pX DNA probe. These findings suggest that there is some association between ATL cells and pre-malignant cells through ADF or other unknown factors in the activation of ras oncogenes. Subsequent suppression of host immune defence mechanisms in ATL patients permits evolution of the secondary neoplasms.

Immunological detection of myeloperoxidase in poorly differentiated acute leukemia

We performed immunocytochemical detection of myeloperoxidase (MPO), using monoclonal antibody MPO-7, in 15 consecutive cases of adult acute leukemia (AL) unclassified by conventional cytological and cytochemical criteria and 7 AML-M1 with less than 10% of cytochemically MPO-positive blasts. In AL with negative MPO cytochemistry the anti-MPO reaction was positive in 5 of the 15 patients with 3, 3, 7, 11 and 45% positive blasts respectively. In AML-M1, immunocytochemistry was positive in a larger percentage of blasts than cytochemistry in 2 cases. Immunological detection of myeloid surface markers was positive in all 15 cases of unclassified AL (including the 10 AL with negative anti-MPO reaction). Eleven of the 22 patients from this study had mixed lymphoid-myeloid phenotype. Discrepancy between immunological MPO detection and light cytochemistry was more frequent in patients with mixed immunophenotype than in patients without lymphoid markers. No relationship between MPO-antigen positivity and clinical or biological features was seen. These findings confirm immunological detection of MPO as useful for the diagnosis of poorly differentiated AL. The high incidence of inactive MPO detectable only by immunocytochemistry in mixed lineage AL needs to be confirmed.

Acute myeloid leukaemia with an unusual phenotype: myeloperoxidase (+), CD13 (-), CD14 (-) and CD33 (-)

We herein describe an unusual case of acute myeloid leukaemia (AML) showing strong cytochemical reactivity for myeloperoxidase (MPO) but surprisingly no reactivity using flow cytometry for any of the lineage-specific cell surface markers, i.e. myelomonocytic antigens CD13, CD14 and CD33; or B-lymphoid antigens CD19, CD20 and immunoglobulins; or T-lymphoid antigens CD2, CD3 and CD5. The strong reactivity for MPO and the complete absence of reactivity for CD13 and CD14 was verified by an independent assay involving alkaline phosphatase-anti-alkaline phosphatase (APAAP). Our case is of interest for at least two reasons: First, a poorly differentiated variant of AML (negative for MPO but positive for one or more of the myeloid-lineage CD antigens) has been designated FAB M0. In terms of the expression of phenotypic markers, our case may be considered as an 'MPO (+), CD antigen (-) AML'. The CD antigens are known to be expressed very early during myeloid differentiation whereas MPO (in its functional form) is viewed as being expressed relatively late in the process. It is therefore intriguing from a biological standpoint why the supposedly early antigens (CD33 and CD13) remain unexpressed; this may represent an example of 'asynchronous differentiation' in leukaemia. Second, from a practical standpoint, the use of immunophenotyping as a first-line diagnosis would fail to detect such cases. This case strengthens the notion that immunophenotyping by flow cytometry does not eliminate the necessity of performing peroxidase cytochemical staining.

Detection of minimal residual disease in acute lymphoblastic leukemia by flow cytometry with monoclonal antibodies

To detect more precisely the minimal residual disease in acute lymphoblastic leukemia (ALL), two-color flow cytometric analysis for the detection of cell-surface antigen (CD10; CALLA) and nuclear terminal deoxynucleotidyl transferase (TdT) was performed in the six patients with CALLA-positive ALL coexpressing TdT. In all patients, the leukemic blasts coexpressed Ia (HLA-DR), CD9, CD19, CD20, CD24, and CD10. Five of six patients achieved complete remission, but one has so far relapsed. No leukemic blasts (CD10+, TdT+) were detected at the time of complete remission. During maintenance chemotherapy, leukemic blasts coexpressed C10 and TdT were found 2.32% in the patient's peripheral blood by two-color analysis, whereas no obvious leukemic cells were recognized morphologically. The patient relapsed leukemia with the same phenotype 4 weeks after the examination. On the basis of our findings, we suggest that two-color flow cytometric analysis with the use of these antibodies is quite valuable to detect the minimal residual leukemic cells in a patient with ALL. The reduction of leukemic cells below the threshold of detection of methods currently available appears to be necessary to achieve a cure in ALL. Hence accurate diagnosis of ALLs with monoclonal antibodies (MAbs) should contribute substantially to the development of an effective form of therapy for their cure.

CD7 false-positive acute myelogenous leukemia and promyelocytic leukemia cell line HL-60: characterization of CD7 epitopes by four monoclonal antibodies

Phenotypes of cells from 12 patients with acute myelogenous leukemia (AML) were analysed by means of a fluorescence-activated cell sorter utilizing a panel of monoclonal antibodies (MAbs). A majority of the cells from peripheral blood coexpressed the antigens against MAbs CD11, CD13, and CD33 but did not express the antigens against CD1, CD3, CD4, CD5, CD8, CD19, CD20, CD21, CD41 and 42, and glycophorin A. Three out of the 12 cases expressed CD7 antigen. However, one of them showed no reaction with Tp40 MAb, whereas the others showed reaction with Leu9 and T55. The discrepancy of reactivities between Leu9 and Tp40 MAbs prompted us to study the promyelocytic leukemia cell line HL-60, which showed similar reactions against Leu9 and Tp40 MAbs. Leu9, OKT16, and T55 MAbs reacted strongly with HL60 cells, whereas Tp40 MAb, which reacted strongly with T-cell leukemia cell line Jurkat, showed no reaction. The reactivity of Leu9, OKT16, and T55 MAbs with HL-60 cells was completely inhibited after preincubation with aggregated human immunoglobulin G (AHIG), which clearly shows the existence of nonspecific binding between these 3 MAbs and HL-60 cells via Fc gamma R. On the basis of our experiments, we conclude that HL-60 cells bind nonspecifically with Leu9, OKT16, and T55 MAbs via FcRI, and this is suggestive that de novo AML cells probably behave in the same fashion. Hence, we recommend that the utilization of murine IgG2a and IgG3 MAbs should be avoided especially in cell surface analysis of myeloid leukemic cells.

FAB L3 type of B-cell acute lymphoblastic leukemia (B-ALL) without chromosome abnormalities

Acute lymphocytic leukemias (ALLs) are morphologically classified into L1, L2, and L3. The former two types are phenotypically constituted of quite heterogeneous ALLs. In the present study, phenotypes of cells from five L3 type ALL were analysed in FACS-IV using a panel of monoclonal antibodies (MAbs). The leukemic cells of all these patients coexpressed la (HLA-DR), CD19, CD20, CD21, CD24, CD38, and surface immunoglobulins, whereas a negative reaction with MAbs CD1, CD2, CD3, CD4, CD7, CD8, and Ti (WT31), Ti gamma A, delta TCS 1, and anti TCR-gamma/delta was observed. Neither myeloid-monocyte-erythroid nor megakaryocyte related cell surface antigens were detected in these cases with L3 type ALL. Chromosomal analysis of the ALL cells from two cases revealed a normoploid karyotype with specific translocation t(8;14)(q24;q32), whereas it was normal (46XY or 46XX) for the remaining three cases. Expression of myc oncogene was high in the former group, but low in the later one. Basing from our findings, we conclude that L3 type ALL is heterogeneous with respect to immunophenotypes, cytogenetics and oncogene analysis.

Discordance between phenotype and function of Japanese adult T cell leukemia cells

Phenotypes of cells from 12 patients with ATL were analysed by means of a fluorescence-activated cell sorter by utilizing a panel of monoclonal antibodies. A majority of the cells from peripheral blood coexpressed the antigens against MAbs CD2, CD3, CD4, CD5, Ti (WT31), CD25, CD38, CD45, and CD29, but did not express the antigens against CD1, CD13, CD14, CD33, CD36, CD10, CD19, CD20, CD21, CD24, CD41, CD42, CD45RA, CD56, and CD57. The expression of antigen for TQ-1 or Leu8 was variable. Surface immunoglobulins were not detected. Phenotypes of cultured cells established by utilizing recombinant interleukin II were similar to those of the uncultured peripheral blood lymphoid cells except for the lack of expression of CD8. By means of two-color fluorescence, the ATL cells possessing CD4 in peripheral blood and culture coexpressed CD29, but did not express CD45RA. The suppression of PWM-induced B-cell immunoglobulin synthesis by normal T and B cells was found in five cases in the presence of ATL cells. The ATL cells demonstrated helper T-cell phenotypes (CD4+, CD29+) with suppressor function, paradoxically. We conclude that the phenotype of the ATL cells was CD4+, CD29+, and CD45RA- but that the function of these cells was of suppressor T-cells. Our results inevitably suggest the possible existence of suppressor T-cells with CD4+, CD29+ phenotype in persons without evidence of any underlying hematologic disorder.

Distribution of cell surface glycoprotein CD9 (P24) antigen on megakaryocyte lineage leukemias and cell lines

We herein describe CD9 (p24) antigen as existing on the cell surface of megakaryocyte lineage leukemias as well as megakaryocytic leukemia cell line, MEG-01 and HEL, by means of fluorescence-activated cell sorter (FACS IV) with a panel of monoclonal antibodies (Mabs). We found CD9 antigen expression on the cell surface of megakaryoblastic leukemias as well as MEG-01 and HEL cells. Furthermore, CD9 antigen expression increased while culturing these cells with phorbol esters, and was also found in the cytoplasm by means of indirect immunofluorescence test. These findings clearly showed that CD9 antigen exists on the cell surface of megakaryocytic cells which are capable of synthesizing the CD9.

Varied expressions of receptors on the human megakaryoblastic cell line MEG-01 by monoclonal antibodies

We herein describe the regulation of specific receptors on the megakaryoblastic cell line MEG-01 by means of fluorescence-activated cell sorting (FACS IV) with a panel of monoclonal antibodies (MAbs). MEG-01 cells expressed GpIIb/IIIa (CD41a) and OKM5 (CD36) antigens on their cell surface, whereas they showed only a little expression of GPIb (CD42b), suggesting that these are megakaryoblastic cells. The up regulation of von Willebrand factor receptor (GPIb) and thrombospondin receptor (GPIV) and the down regulation of fibrinogen receptor (GPIIb/IIIa) and C3bi receptor (CD11b) were found by incubation with MAbs AN51 (CD42b), OKM5 (CD36), J15 (CD41a), and OKM1 (CD11b), respectively. This phenomenon was enhanced in the Ca2+ containing medium, except for the experiment with OKM5 (CD36) MAb. We thus suggest that several kinds of receptors on the surface of MEG-01 cells are dexterously regulated through stimulation from outside the cell.

Aggressive natural killer cell leukaemia/lymphoma: report of four cases and review of the literature. Possible existence of a new clinical entity originating from the third lineage of lymphoid cells

The morphologic, immunologic, genotypic and functional properties of peripheral blood and bone marrow cells or cultured cells from four patients with a clinically aggressive non-T, non-B natural killer cell leukaemia/lymphoma (ANKL/L) are described. The leukaemic cells possessed medium to large granules in the cytoplasm, antigens against CD38, CD2, OKIa 1 and NKH-1 CD56) monoclonal antibodies on their cell-surface, and also showed natural killer (NK) activity. In addition, these ANKL/L belonged to neither T- nor B-cell lineage, proved by studying clonal gene rearrangement for the T beta, T gamma and T delta receptors, and immunoglobulin. After comparing them with the seven cases of ANKL/L reported in other institutions, with regard to immunophenotype, genotype and function, we conclude that ANKL/L originating from a third lineage of lymphoid cells is a distinct clinical entity.

Analysis of peroxidase negative acute leukemias by monoclonal antibodies: III. Acute lymphoblastic leukemia

Peripheral-blood leukemic cells from 45 patients with peroxidase negative acute lymphoblastic leukemia (ALL), which did not express either myeloid or megakaryocyte-platelet-related cell surface antigens, were analyzed by using monoclonal antibodies capable of recognizing T- or B-cell-associated and/or T- or B-cell-restricted antigens. Numerous subclasses of ALL, including B-cell lineage leukemias and T-cell lineage leukemias, were identified phenotypically and immunophenotypically in an effort to more accurately characterize the heterogeneous ALLs, their states of differentiation, and their relationships to normal B- and T-lymphoid cells. Among the cases studied, only seven (15.6%) were found to have stem cell (undifferentiated) leukemia (Ia+, CD24+, CD9+, CD34+). It is concluded that the use of monoclonal antibodies for the characterization of heterogeneous ALLs improves the specificity of leukemia classification, which may contribute to the selection of more effective forms of therapy for the types of leukemia identified.