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Zhang X, Yang C, Peng X, Chen X, Feng Y. Acute WT1-positive promyelocytic leukemia with hypogranular variant morphology, bcr-3 isoform of PML-RARα and Flt3-ITD mutation: a rare case report. SAO PAULO MED J 2017; 135:179-184. [PMID: 28125133 PMCID: PMC9977332 DOI: 10.1590/1516-3180.2016.020104102016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2016] [Accepted: 10/04/2016] [Indexed: 12/18/2022] Open
Abstract
CONTEXT: Acute promyelocytic leukemia (APL) accounts for 8% to 10% of cases of acute myeloid leukemia (AML). Remission in cases of high-risk APL is still difficult to achieve, and relapses occur readily. CASE REPORT: Here, we describe a case of APL with high white blood cell counts in blood tests and hypogranular variant morphology in bone marrow, together with fms-like tyrosine kinase-3 with internal tandem duplication mutations (FLT3-ITD), and bcr-3 isoform of PML-RARα. Most importantly, we detected high level of Wilms' tumor gene (WT1) in marrow blasts, through the reverse transcription polymerase chain reaction (RT-PCR). To date, no clear conclusions about an association between WT1 expression levels and APL have been reached. This patient successively received a combined treatment regimen consisting of hydroxycarbamide, arsenic trioxide and idarubicin plus cytarabine, which ultimately enabled complete remission. Unfortunately, he subsequently died of sudden massive hemoptysis because of pulmonary infection. CONCLUSION: Based on our findings and a review of the literature, abnormal functioning of WT1 may be a high-risk factor in cases of APL. Further studies aimed towards evaluating the impact of WT1 expression on the prognosis for APL patients are of interest.
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Affiliation(s)
- Xi Zhang
- MD, PhD. Professor, Department of Hematology, Xinqiao Hospital, Third Military Medical University, Chongqing, China.
| | - Cheng Yang
- MD. Attending Physician, Department of Hematology, Xinqiao Hospital, Third Military Medical University, Chongqing, China.
| | - Xiangui Peng
- MD. Affiliated Professor, Department of Hematology, Xinqiao Hospital, Third Military Medical University, Chongqing, China.
| | - Xinghua Chen
- MD, PhD. Full Professor, Department of Hematology, Xinqiao Hospital, Third Military Medical University, Chongqing, China.
| | - Yimei Feng
- MD, PhD. Assistant Professor, Department of Hematology, Xinqiao Hospital, Third Military Medical University, Chongqing, China.
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Bochtler T, Fröhling S, Weichert W, Endris V, Thiede C, Hutter B, Hundemer M, Ho AD, Krämer A. Evolution of a FLT3-TKD mutated subclone at meningeal relapse in acute promyelocytic leukemia. Cold Spring Harb Mol Case Stud 2016; 2:a001123. [PMID: 27626069 PMCID: PMC5002926 DOI: 10.1101/mcs.a001123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Here, we report the case of an acute promyelocytic leukemia (APL) patient who—although negative for FLT3 mutations at diagnosis—developed isolated FLT3 tyrosine kinase II domain (FLT3-TKD)-positive meningeal relapse, which, in retrospect, could be traced back to a minute bone marrow subclone present at first diagnosis. Initially, the 48-yr-old female diagnosed with high-risk APL had achieved complete molecular remission after standard treatment with all-trans retinoic acid (ATRA) and chemotherapy according to the AIDA (ATRA plus idarubicin) protocol. Thirteen months after the start of ATRA maintenance, the patient suffered clinically overt meningeal relapse along with minute molecular traces of PML/RARA (promyelocytic leukemia/retinoic acid receptor alpha) in the bone marrow. Following treatment with arsenic trioxide and ATRA in combination with intrathecal cytarabine and methotrexate, the patient achieved a complete molecular remission in both cerebrospinal fluid (CSF) and bone marrow, which currently lasts for 2 yr after completion of therapy. Whole-exome sequencing and subsequent ultradeep targeted resequencing revealed a heterozygous FLT3-TKD mutation in CSF leukemic cells (p.D835Y, c.2503G>T, 1000/1961 reads [51%]), which was undetectable in the concurrent bone marrow sample. Interestingly, the FLT3-TKD mutated meningeal clone originated from a small bone marrow subclone present in a variant allele frequency of 0.4% (6/1553 reads) at initial diagnosis. This case highlights the concept of clonal evolution with a subclone harboring an additional mutation being selected as the “fittest” and leading to meningeal relapse. It also further supports earlier suggestions that FLT3 mutations may play a role for migration and clonal expansion in the CSF sanctuary site.
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Affiliation(s)
- Tilmann Bochtler
- Department of Internal Medicine V, University of Heidelberg, 69120 Heidelberg, Germany;; Clinical Cooperation Unit Molecular Hematology/Oncology, German Cancer Research Center (DKFZ) and Department of Internal Medicine V, University of Heidelberg, 69120 Heidelberg, Germany
| | - Stefan Fröhling
- Department of Translational Oncology, National Center for Tumor Diseases and German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany;; Section for Personalized Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany;; DKFZ-Heidelberg Center for Personalized Oncology (HIPO), 69120 Heidelberg, Germany
| | - Wilko Weichert
- Institute of Pathology, Technical University of Munich, 81675 Munich, Germany;; Institute of Pathology, University of Heidelberg, 69120 Heidelberg, Germany
| | - Volker Endris
- Institute of Pathology, University of Heidelberg, 69120 Heidelberg, Germany
| | - Christian Thiede
- Department of Internal Medicine I, University of Dresden, 01307 Dresden, Germany
| | - Barbara Hutter
- Division of Applied Bioinformatics, National Center for Tumor Diseases and German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | - Michael Hundemer
- Department of Internal Medicine V, University of Heidelberg, 69120 Heidelberg, Germany
| | - Anthony D Ho
- Department of Internal Medicine V, University of Heidelberg, 69120 Heidelberg, Germany
| | - Alwin Krämer
- Department of Internal Medicine V, University of Heidelberg, 69120 Heidelberg, Germany;; Clinical Cooperation Unit Molecular Hematology/Oncology, German Cancer Research Center (DKFZ) and Department of Internal Medicine V, University of Heidelberg, 69120 Heidelberg, Germany
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