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Gaut D, Sasine J, Schiller G. Secondary clonal hematologic neoplasia following successful therapy for acute promyelocytic leukemia (APL): A report of two cases and review of the literature. Leuk Res Rep 2018; 9:65-71. [PMID: 29892552 PMCID: PMC5993360 DOI: 10.1016/j.lrr.2018.04.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 03/16/2018] [Accepted: 04/07/2018] [Indexed: 11/27/2022] Open
Abstract
Although rare, secondary clonal hematologic neoplasia may occur after successful therapy for acute promyelocytic leukemia (APL). These secondary clonal events may be considered therapy-related, but may also be due to an underlying background of clonal hematopoiesis from which both malignancies may develop. In this manuscript, we describe two patients with secondary clones after APL therapy characterized in one patient by deletion of chromosome 11q23 and, in the other, by monosomy of chromosome 7, and also provide a review of all secondary clonal disorders described after APL therapy. We suggest that since most reports identify karyotypic abnormalities not typically associated with chemotherapy, there may be another mechanism underlying secondary clonal development after complete response to initial APL therapy.
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Key Words
- 6-MP, 6-mercaptopurine
- AML, acute myelocytic leukemia
- APL, acute promyelocytic leukemia
- ATG, antithymyocyte globulin
- ATO, arsenic trioxide
- ATRA, all-trans retinoic acid
- Acute myelocytic leukemia (AML)
- CR, complete remission
- FISH, fluorescence in situ hybridization
- MDS, myelodysplastic syndrome
- Myelodysplastic syndrome (MDS)
- PML-RARalpha, promyelocytic leukemia/Retinoic acid receptor alpha
- Secondary clone
- Therapy-related acute myelocytic leukemia (t-AML)
- Therapy-related myelodysplastic syndrome (t-MDS)
- t- MDS, therapy-related myelodysplastic syndrome
- t-AML, therapy-related acute myelocytic leukemia
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Affiliation(s)
- Daria Gaut
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, LA, California, USA
| | - Joshua Sasine
- Division of Hematology/Oncology, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, LA, California, USA
| | - Gary Schiller
- Division of Hematology/Oncology, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, LA, California, USA
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Flow cytometric analysis of CD64 expression pattern and density in the diagnosis of acute promyelocytic leukemia: a multi-center study in Shanghai, China. Oncotarget 2017; 8:80625-80637. [PMID: 29113330 PMCID: PMC5655225 DOI: 10.18632/oncotarget.20814] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 08/23/2017] [Indexed: 12/19/2022] Open
Abstract
No unified immunophenotypic profiles and corresponding analytic strategies have been established for the rapid diagnosis of acute promyelocytic leukemia (APL) using flow cytometry (FCM). Here we describe a characteristic immunophenotypic panel that can rapidly and accurately distinguish APL from other types of adult acute myeloid leukemia (AML) using only FCM. By comparing APL cells and non-APL AML cells that share APL common immunophenotypes (CD34−CD117+HLA−DR−) we found that CD64 was a significant factor that differentiated APL from other AMLs. Further retrospective analyses of 205 APL and 629 non-APL AML patients from different hematology centers showed that either the CD64dim and homoCD13+homo CD33+homoMPO+ (myeloperoxidase) CD11c− panel or the CD64dim and homoCD13+homo CD33+homoMPO+ CD11c+CD10−CD117+ SSChigh (high side scatter signal) panel could distinguish APL from non-APL AML patients with nearly 100% sensitivity, specificity and accuracy. Moreover, relative quantification of CD64 expression enhanced the applicability of our APL diagnostic immunophenotypic panels (ADI-panels) in different hematology centers. Application of the ADI-panels will decrease diagnosis time and improve personalized treatment for APL, a life-threatening disease with very rapid progression.
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Azevedo IDF, Magalhães MG, Souto FR, Neves WBD, Melo FCDBC, Rego EM, Melo RAM. Molecular and hematologic relapses in adult patients with acute promyelocytic leukemia: a cohort study. Rev Bras Hematol Hemoter 2017; 39:46-51. [PMID: 28270346 PMCID: PMC5339418 DOI: 10.1016/j.bjhh.2016.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Revised: 07/25/2016] [Accepted: 09/09/2016] [Indexed: 10/25/2022] Open
Abstract
OBJECTIVE To evaluate factors predictive for relapse in a cohort of adult patients with acute promyelocytic leukemia monitored by molecular methods during consolidation and during at least one month of maintenance therapy. METHODS The charts and laboratory data of 65 adult patients with acute promyelocytic leukemia treated according to the International Consortium on Acute Promyelocytic Leukemia 2006 protocol were reviewed. The identification of the promyelocytic leukemia-retinoic acid receptor-alpha gene rearrangement at diagnosis, post-induction, post-consolidation and during maintenance treatment was performed by qualitative and quantitative reverse transcription polymerase chain reaction. RESULTS Eighty-nine patients were diagnosed with acute promyelocytic leukemia over a seven-year period and of these 65 were eligible for treatment with the protocol. Among the 45 patients who received consolidation and maintenance treatment, six (13%) relapsed, three of whom presented hematologic and three presented molecular relapse. The first relapses occurred at a median of 39 months. Relapsed patients were from all risk groups (low, intermediate and high) and both morphological types (M3 and M3variant) were found. Three of these patients are alive and in molecular remission after salvage treatment. There were no statistically significant differences regarding gender, age, risk group, morphology, promyelocytic leukemia breakpoint cluster region, use of all-trans retinoic acid, development of differentiation syndrome and number of days to complete remission between the patients who relapsed and those who did not. CONCLUSION Our results reinforce the importance of prolonged monitoring of acute promyelocytic leukemia patients using molecular methods to detect relapse early.
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Affiliation(s)
| | | | | | | | | | - Eduardo Magalhães Rego
- Universidade de São Paulo (USP), Faculdade de Medicina de Ribeirão Preto (FMRP), Ribeirão Preto, SP, Brazil
| | - Raul Antônio Morais Melo
- Universidade de Pernambuco (UPE), Recife, PE, Brazil; Fundação de Hematologia e Hemoterapia de Pernambuco (HEMOPE), Recife, PE, Brazil.
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Dayton VJ, McKenna RW, Yohe SL, Dolan MM, Courville E, Alvarez H, Linden MA. Relapsed Acute Promyelocytic Leukemia Lacks "Classic" Leukemic Promyelocyte Morphology and Can Create Diagnostic Challenges. Am J Clin Pathol 2017; 147:69-76. [PMID: 28108472 DOI: 10.1093/ajcp/aqw202] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Although current therapies for acute promyelocytic leukemia (APL), such as all- trans retinoic acid and arsenic trioxide, usually result in remission, some patients relapse. Early recognition of relapse is critical for prompt intervention. In this study, we systematically reviewed morphologic, immunophenotypic, and cytogenetic findings in paired diagnostic and relapsed APL cases and describe and quantify the changes in blast morphology at relapse. METHODS By electronic database search, we identified eight paired diagnostic and relapsed APL cases for which peripheral blood or bone marrow smears were available for review. For two cases, diagnostic material was available for relapse after hematopoietic cell transplantation. RESULTS Neoplastic hypergranular or microgranular promyelocytes with indented or bivalve nuclei predominated at diagnosis in all patients. Most patients had undifferentiated blasts at relapse and/or hypergranular blast equivalents with round to oval nuclei. Classic acute promyelocytic leukemia cells with bivalve nuclei and bundles of cytoplasmic Auer rods were easily identifiable in fewer than half of cases at diagnosis and rare to absent in all relapsed cases. CONCLUSIONS Morphologic features of relapsed APL overlap with other types of acute myeloid leukemia, creating diagnostic challenges, especially if no history is available when relapsing patients seek treatment for care.
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Affiliation(s)
- Vanessa J Dayton
- From the Department of Laboratory Medicine and Pathology, University of Minnesota Medical School, Minneapolis
| | - Robert W McKenna
- From the Department of Laboratory Medicine and Pathology, University of Minnesota Medical School, Minneapolis
| | - Sophia L Yohe
- From the Department of Laboratory Medicine and Pathology, University of Minnesota Medical School, Minneapolis
| | - Michelle M Dolan
- From the Department of Laboratory Medicine and Pathology, University of Minnesota Medical School, Minneapolis
| | - Elizabeth Courville
- From the Department of Laboratory Medicine and Pathology, University of Minnesota Medical School, Minneapolis
| | | | - Michael A Linden
- From the Department of Laboratory Medicine and Pathology, University of Minnesota Medical School, Minneapolis
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Abstract
Dismal outcomes of acute myeloid leukemia (AML), especially in the elderly, are mainly associated with leukemia relapse and primary no response to initial therapy. This review will focus on AML relapse, and how a better understanding of the evolutionary stages that lead to relapse might help us improve disease outcome. The fact that the relapse rate for some AMLs is so high indicates that we do not truly understand the biology of relapse or possibly that we are not implementing our current understanding into, clinical practice. Therefore, this review will also aim to explore some of the current understanding of AML relapse biology in order to identify the gaps in our knowledge and translation. Accumulating evidence suggests that the root of relapse evolves even before the time of diagnosis, meaning that the complex clonal structure of AML is created before patients present to the clinic. Some of the clones that exist at diagnosis can survive chemotherapy and give rise to relapse. Accordingly, in order to better understand the mechanisms of relapse, we must consider both early and late steps in AML evolution.
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Outcomes and prognostic factors of first relapsed acute promyelocytic leukemia patients undergoing salvage therapy with intravenous arsenic trioxide and chemotherapy. Ann Hematol 2014; 93:941-8. [DOI: 10.1007/s00277-013-2000-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Accepted: 12/23/2013] [Indexed: 12/20/2022]
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Zeijlemaker W, Gratama JW, Schuurhuis GJ. Tumor heterogeneity makes AML a "moving target" for detection of residual disease. CYTOMETRY PART B-CLINICAL CYTOMETRY 2013; 86:3-14. [PMID: 24151248 DOI: 10.1002/cyto.b.21134] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Revised: 08/26/2013] [Accepted: 09/17/2013] [Indexed: 12/24/2022]
Abstract
Detection of minimal residual disease is recognized as an important post-therapy risk factor in acute myeloid leukemia patients. Two most commonly used methods for residual disease monitoring are real-time quantitative polymerase chain reaction and multiparameter flow cytometry. The results so far are very promising, whereby it is likely that minimal residual disease results will enable to guide future post-remission treatment strategies. However, the leukemic clone may change between diagnosis and relapse due to the instability of the tumor cells. This instability may already be evident at diagnosis if different subpopulations of tumor cells coexist. Such tumor heterogeneity, which may be reflected by immunophenotypic, molecular, and/or cytogenetic changes, can have important consequences for minimal residual disease detection, since false-negative results can be expected to be the result of losses of aberrancies used as minimal residual disease markers. In this review the role of such changes in minimal residual disease monitoring is explored. Furthermore, possible causes of tumor instability are discussed, whereby the concept of clonal selection and expansion of a chemotherapy-resistant subpopulation is highlighted. Accordingly, detailed knowledge of the process of clonal evolution is required to improve both minimal residual disease risk stratification and patient outcome.
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MESH Headings
- Adult
- Biomarkers, Tumor
- Clonal Evolution
- Drug Resistance, Neoplasm/genetics
- Flow Cytometry
- Genetic Variation
- Humans
- Immunophenotyping
- Leukemia, Myeloid, Acute/drug therapy
- Leukemia, Myeloid, Acute/pathology
- Neoplasm Recurrence, Local/diagnosis
- Neoplasm Recurrence, Local/prevention & control
- Neoplasm, Residual/diagnosis
- Neoplasm, Residual/prevention & control
- Real-Time Polymerase Chain Reaction
- Treatment Outcome
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Affiliation(s)
- W Zeijlemaker
- Department of Hematology, VU Institute for Cancer and Immunology (V-ICI), VU University Medical Center, Amsterdam, The Netherlands
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Acute promyelocytic leukemia: an experience on 95 greek patients treated in the all-trans-retinoic Acid era. Mediterr J Hematol Infect Dis 2011; 3:e2011053. [PMID: 22220250 PMCID: PMC3248330 DOI: 10.4084/mjhid.2011.053] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2011] [Accepted: 10/04/2011] [Indexed: 11/08/2022] Open
Abstract
Acute promyelocytic leukemia (APL) is highly curable with the combination of all-transretinoic acid (ATRA) and anthracycline based chemotherapy, but the percentage of early deaths remains high. In the present study, we report the clinical, immunophenotypic, cytogenetic and molecular characteristics and outcome of APL patients diagnosed and treated in various Hospitals of Greece and Cyprus.We describe the data of ninety-five APL patients who were diagnosed during the last 15 years. Seven (7.4%) newly diagnosed APL patients died due to intracranial hemorrhage within 72 hours of presentation. All but two patients were induced with ATRA alone or ATRA plus chemotherapy. The early death rate was 14.9%. After induction all 80 evaluable patients achieved complete hematologic remission. The cumulative incidence of relapse was 18.3%. Eight of the ten relapsed patients were successfully salvaged, while both patients with molecularly resistant disease died during salvage treatment. Overall survival (OS) at 5 years was 78.4% and disease free survival (DFS) 73.6%. In multivariate analysis of OS age over 60 years, DIC at diagnosis and marginally major hemorrhage at presentation were identified as adverse prognostic factors. In the subgroup of patients with available data on FLT3 mutation status (49 out of 94), ITD positivity also remained as an independent prognostic factor in the final model of OS, together with major hemorrhage and marginally high Sanz score. We found a close correlation between the CD2 expression and the development of the differentiation syndrome (DS). In conclusion, the main problem in managing patients with APL is still the high early death rate.
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Hart MK, Conway AB, Cioc AM, McKenna RW, Pambuccian SE. Butterfly-shaped nuclei in cerebrospinal fluid relapse of acute promyelocytic leukemia. Diagn Cytopathol 2011; 40:987-90. [PMID: 22102334 DOI: 10.1002/dc.21789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2011] [Accepted: 06/23/2011] [Indexed: 11/10/2022]
Affiliation(s)
- Melissa K Hart
- Department of Laboratory Medicine and Pathology, University of Minnesota Medical School, Minneapolis, Minnesota 55455, USA
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Targeting siglecs--a novel pharmacological strategy for immuno- and glycotherapy. Biochem Pharmacol 2011; 82:323-32. [PMID: 21658374 DOI: 10.1016/j.bcp.2011.05.018] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2011] [Accepted: 05/17/2011] [Indexed: 01/13/2023]
Abstract
The immune system must be tightly held in check to avoid bystander tissue damage as well as autoreactivity caused by overwhelming immune reactions. A novel family of immunoregulatory, carbohydrate-binding receptors, the Siglecs (sialic acid binding immunoglobulin-like lectins), has received particular attention in light of their capacity to mediate cell death, anti-proliferative effects and to regulate a variety of cellular activities. Siglec receptors are mainly expressed on leukocytes in a cell type-specific and differentiation-dependent manner. Siglecs might potentially be exploited as targets of novel immune- and glycotherapeutics for cell-directed therapies in autoimmune and allergic diseases, as well as in haematologic malignancies. Here we present novel insights on structural and functional characteristics, expression patterns and evolutionary aspects of Siglecs and their ligands. Pharmacological strategies using Siglec agonistic cross-linking therapeutics, such as monoclonal or engineered antibodies, intravenous immunoglobulin (IVIG), or glycomimetics are discussed. Modulation of immune responses by targeting Siglecs using agonistic or antagonistic therapeutics may have important clinical implications and may pave the way for novel pharmacological avenues for the treatment of autoimmune and allergic diseases or for tumor immunotherapy.
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Chetverina EV, Chetverin AB. Nanocolonies and diagnostics of oncological diseases associated with chromosomal translocations. BIOCHEMISTRY (MOSCOW) 2011; 75:1667-91. [DOI: 10.1134/s0006297910130109] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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