Huanping Wang

CD19-positive acute myeloblastic leukemia with trisomy 21 as a sole acquired karyotypic abnormality

We report that a 63-year-old Chinese female had acute myeloblastic leukemia (AML) in which trisomy 21 (+21) was found as the sole acquired karyotypic abnormality. The blasts were positive for myeloperoxidase, and the immunophenotype was positive for cluster of differentiation 19 (CD19), CD33, CD34, and human leukocyte antigens (HLA)-DR. The chromosomal analysis of bone marrow showed 47,XX,+21[2]/46,XX[18]. Fluorescent in situ hybridization (FISH) showed that three copies of AML1 were situated in separate chromosomes, and that t(8;21) was negative. The patient did not have any features of Down syndrome. A diagnosis of CD19-positive AML-M5 was established with trisomy 21 as a sole acquired karyotypic abnormality. The patient did not respond well to chemotherapy and died three months after the diagnosis. This is the first reported case of CD19-positive AML with trisomy 21 as the sole cytogenetic abnormality. The possible prognostic significance of the finding in AML with +21 as the sole acquired karyotypic abnormality was discussed.

Arsenic trioxide may improve the prognosis of APL with ider(17)(q10): report of a rare adult case of acute promyelocytic leukemia with ider(17)(q10)t(15;17) showing poor response to all-trans retinoic acid

Dear Editor, Acute promyelocytic leukemia (APL) is now considered a curable leukemia that is particularly sensitive to alltrans retinoic acid (ATRA) [1–3]. ider(17)(q10)t(15;17) (q22;q21) is a rare variant cytogenetic abnormality among APL patients, and its prognostic significance is still controversial [4–10]. We describe here a 58-year-old female with APL carrying ider(17)(q10)t(15;17). This patient presented with 1 week of fever. The result of the physical examination was normal. Complete blood count analysis showed a hemoglobin level of 91 g/L, white cell count of 1.9×10/L, and platelet count of 51×10/L. Coagulation studies revealed normal parameters. In flow cytometric analysis, the cells were positive for CD13 (75.48%), CD117 (49.16%), CD56 (96.1%), CD64s (87.66%), but negative for HLA-DR. Bone marrow examination showed 61% hypergranular promyelocytic blasts. The cytochemical staining showed the cells were positive for Sudan black B, peroxidase and myeloperoxidase, but negative for nonspecific esterase and the sodium fluoride inhibition test. FISH analysis showed a variant fusion pattern with one PML signals (red), one RARA signals (green), and three fusion signal (yellow) in 60% of the cells examined (Fig. 1). The karyotype was interpreted as 46,XX,der(15)t(15;17)(q22;q21),ider(17) (q10)t(15;17). A diagnosis of APL was made, and therapy was initiated with ATRA. On day 14 post-admission, however, the hypergranular promyelocytic blasts in bone marrow increased to 80.5%. Then idarubicin was added at day 15–17. On day 34 posttreatment of ATRA, the patient still failed to achieve remission. Then she received another induction treatment of arsenic trioxide (As2O3) for 21 days. The patient showed good response to As2O3, and a complete remission was established. Then the patient received consolidation chemotherapy for three courses during the next 23 months and remained in clinical remission up to now. Almost all the adult patients with ider(17)(q10) and available clinical data who did not die during induction therapy had a favorable response to ATRA [4–10], but in the present case, treatment with ATRA did not achieve the expected response. Even worse, the hypergranular promyelocytic blasts in the patient’s bone marrow increased continuously during the treatment of ATRA and remission was not achieved until after a course of As2O3 was given. Although it is reported that some relapse patients take more than 30 days to achieve complete remission (CR) under the treatment of ATRA, the duration of initial hospitalization was very short for patients who achieved CR, 3 to 20 days (median 8 days) [1]. Therefore, we consider that it is a clear APL case with ider(17)(q10) which respond worse to ATRA. Moreover, according to the review of the literature by Manola et al., patients with ider(17)(q10) who were not H. Tong (*) :K. Li : C. Mei : J. Jin Department of Hematology, the First Affiliated Hospital, Zhejiang University, College of Medicine, #79 Qingchun Road, Hangzhou, Zhejiang Province 310003, People’s Republic of China e-mail: hongyantong@yahoo.com.cn

t(X;17) as the sole karyotypic anomaly in a case of M3r subtype of acute promyelocytic leukemia without RARα rearrangement

We describe here a unique chromosomal abnormality found in a patient with M(3r) subtype of APL. Neither t(15;17) nor rearrangement of RARalpha was detected by routine R-banded chromosome as well as fluorescence in situ hybridization (FISH) analysis using PML/RARalpha dual-color dual-fusion translocation probe and RARalpha dual-color break apart rearrangement probe. Instead of the typical rearrangement between chromosomes 15 and 17, all cells analyzed had a translocation between X and 17 as the sole karyotypic anomaly. The translocation was conformed by whole chromosome painting (WCP) with painting probes of chromosomes X and 17. To our knowledge, this is the first documented APL with a novel translocation involving chromosomes X and 17 without RARalpha gene rearrangement.

MiR-362-5p as a novel prognostic predictor of cytogenetically normal acute myeloid leukemia

BackgroundMicroRNAs are of special interest in cancer research and hold significant promise as diagnostic and prognostic biomarkers for malignant disease. MiR-362-5p have been found to exert both oncogenic and tumor suppressive effects depending highly on the cellular context. The aim of this study was to determine whether the expression of miR-362-5p can be served as a prognostic factor for patients with cytogentically normal acute myeloid leukemia (CN-AML).MethodsWe enrolled 224 patients with CN-AML and measured the expression of miR-362-5p by quantitative real time PCR analysis. We classified patients into high and low expression based on the median value. The Cox regression analyses were carried out to assess the prognostic significance of miR-362-5p expression in the context of the well-established predictors. Additionally, microRNA expression profiling were conducted to identify the biological insights between high and low group.ResultsHigh expressers had older age. High expressers obtained shorter overall survival in the univariate analysis. The independent prognostic value of miR-362-5p remained in the context of the well-established clinical and cytogenetic predictors. Moreover, the prognostic value of miR-362-5p was also validated in an independent cohort of CN-AML. Notably, numerous oncomiRs were also high expressed in high miR-362-5p group.ConclusionHigh miR-362-5p expression was associated with poorer overall survival implicating the oncogenic function in AML development.

Impact of Chemotherapy Delay on Overall Survival for AML with IDH1/2 Mutations: A Study in Adult Chinese Patients.

The effect of time from diagnosis to treatment (TDT) on overall survival of patients with acute myeloid leukemia (AML) remains obscure. Furthermore, whether chemotherapy delay impacts overall survival (OS) of patients with a special molecular subtype has not been investigated. Here, we enrolled 364 cases of AML to assess the effect of TDT on OS by fractional polynomial regression in the context of clinical parameters and genes of FLT3ITD, NPM1, CEBPA, DNMT3a, and IDH1/2 mutations. Results of the current study show IDH1/2 mutations are associated with older age, M0 morphology, an intermediate cytogenetic risk group, and NPM1 mutations. TDT associates with OS for AML patients in a nonlinear pattern with a J shape. Moreover, adverse effect of delayed treatment on OS was observed in patients with IDH1/2 mutations, but not in those with IDH1/2 wildtype. Therefore, initiating chemotherapy as soon as possible after diagnosis might be a potential strategy to improve OS in AML patients with IDH1/2 mutations.

A new complex translocation t(9;17;15)(q31;q21;q22) in acute promyelocytic leukemia

Department of Hematology, the First Affiliated Hospital, Zhejiang University, College of Medicine, Hangzhou, Zhejiang, People’s Republic of China, Institute of Hematology, Zhejiang University, Hangzhou, Zhejiang Province, People’s Republic of China, and The First Affiliated Hospital of Soochow University, Jiangsu Institute of Hematology, Key Laboratory of Thrombosis and Hemostasis, Suzhou, People’s Republic of China

Additional rearrangements affecting the derivative chromosome 9 involved in the standard Philadelphia translocation after imatinib therapy in a patient with chronic myeloid leukemia

Imatinib is a selective BCR-ABL tyrosine kinase inhibitor that has shown significant activity against Philadelphiapositive chronic myeloid leukemia (CML). Although the majority of CML patients in chronic phase have durable hematologic and cytogenetic responses to imatinib, a subset of CML patients lose their best response despite continued treatment. Some of these patients progress to accelerated phase or blast crisis, but some relapse [1]. Here, we describe the novel case of a patient with CML, in which a standard Ph translocation transformed into a second translocation between chromosomes der(9) and der(21) accompanied by relapse and resistance after a brief disappearance of Ph chromosome subsequent to imatinib therapy. A 25-year-old man was referred to our hospital because of suspected acute leukemia in August 2004. His full blood counts were as follows: hemoglobin 13.9 g/dL, platelets 671 10/L, and white blood cells 27.1 10/L. The bone marrow aspirate showed hypercellularity and granulocytic hyperplasia. No blasts were seen. Rbanded karyotype analysis revealed 46,XY,t(9;22) (q34;q11.2)[9]/46,XY[1] (Fig. 1a). Reverse transcriptase polymerase chain reaction (RT-PCR) showed the p210(b3a2) fusion transcript. Thus, he was diagnosed as having CML in chronic phase. Imatinib therapy (400 mg daily) was started. The patient was sensitive to imatinib and soon gained complete cytogenetic response. The Philadelphia chromosome and the b3a2 fusion transcript were no longer detected. In April 2006, however, when his disease relapsed and he showed resistance to imatinib, the karyotype was determined to be 46,XY,der(9)(9pter/ 9q34::21p11.2/21pter),der(22)t(9;22) (Fig. 1b). The RT-PCR showed the b3a2 transcript as before. Dualcolor, dual-fusion fluorescence in situ hybridization (D-FISH) using the LSI BCR-ABL probe (Abbott Molecular/Vysis, Des Plaines, IL) showed a yellow fusion signal, one red signal (ABL), and one green signal (BCR) in interphase nuclei (Fig. 2a). On metaphase spreads, this yellow fusion signal for the BCR-ABL fusion gene could be defined to the Ph chromosome, with a red signal (ABL) located on der(9q) and a green signal (BCR) on der(21p) (Fig. 2b).

Absence of miR-142 mutation in Chinese patients with acute myeloid leukemia

Recently, Ley and his colleagues reported a 4/200 (2.0%) mutation rate of miR-142 in patients with acute myeloid leukemia (AML). All four of these patients had one mutation site located in the seed region of miR-142-3p, which may aff ect the message RNA of its target genes [1]. MicroRNAs are a class of small non-coding RNAs that negatively regulate gene expression at the post-transcriptional level. miR-142 is a hematopoietic specifi c microRNA [2]. Th e validated targets of miR-142-3p include CD133, ADCY9, interleukin-6 (IL-6) and RAC1 [3 – 6]. BTG3 is a validated target of miR-142-5p [7]. Previously, Kwanhian and his colleagues found that miR-142 was mutated in 20% of patients diagnosed with diff use large B-cell lymphoma [8]. Moreover, aberrant expression of miR-142-5p and miR-142-3p has been observed in gastric mucosa-associated lymphoid tissue lymphoma and T-cell lymphoblastic leukemia, respectively [9,10]. Recent evidence suggests that low expression of miR-142 is involved in the development of AML. Patients with de novo AML show decreased expression of miR-142-3p [11]. High expression of miR-142 is associated with better overall survival in the intermediate cytogenetic risk group [12]. Nowadays, it has become more important to analyze the prognostic infl uence of mutations in groups of patients who have been treated similarly, such as patients who have participated in a clinical trial. Th e use of multivariate analysis has been recommended to explore the impact of a specifi c gene combined with other mutant genes and also within diff erent risk subgroups. Based on this suggestion, we analyzed the mutation status of miR-142 in 183 patients with de novo AML who participated in a phase 3 Chinese AML clinical trial (ChiCTR-TRC-06000054) [13]. Informed consent was obtained from all patients. Th e characteristics of these patients are listed in Table I. Th ere was no sample selection bias, as the distribution of patients ’ age, sex, French – American – British (FAB) subtype, cytogenetic profi le and mutation status in this study was comparable to that reported in our previous phase 3 Chinese AML clinical trial [13]. Total DNA was extracted from bone marrow mononuclear cells after Ficoll gradient centrifugation in 101 patients, using methanol – acetic acid-fi xed cells that had been prepared for cytogenetic analysis in 26 patients, and archived bone marrow slides in another 56 patients. miR-142 was amplifi ed by polymerase chain reaction (PCR) using the forward primer: 5 ′ -CATGCTGAGTCACCGCCCAC-3 ′ and reverse primer: 5 ′ TTCCCCTCCACGTACCATCCCT-3 ′ . Mutation was detected by direct Sanger sequencing of PCR products. In our study, we did not fi nd any miR-142 mutations in 183 patients with de novo AML. Th e mutation rate of other genes studied was similar between samples obtained from archived bone marrow slides and the other two resources (DNA extracted from bone marrow mononuclear cells after Table I. Characteristics of 183 patients. Characteristic Value Median age at diagnosis (range; years) 38 (14 – 59) Males, no. (%) 93 (50.1) Median bone marrow blasts (range; %) 67 (20 – 98) Median white cell count at diagnosis (range, 10 9 /L) 19.5 (1.0 – 487)

Prognostic utility of six mutated genes for older patients with acute myeloid leukemia

Approximately 50% of older patients with acute myeloid leukemia (AML) do not obtain chromosomal abnormalities as an effective risk‐stratification, and present cytogenetically normal AML (CN‐AML). To develop a reliable prediction model for stratifying the risk of these elderly patients, we conducted a study with a discovery and validation design. As a result, we found the top 6 mutated genes in the discovery cohort of 26 case by the whole exome sequencing, and verified as recurrent mutations in the large cohort of 329 patients by Sanger sequencing. The top 6 genes were NPM1, FLT3‐ITD, DNMT3A, CEBPA double allele, IDH1 and IDH2 mutations, and the frequency of each gene in the combining cohort was 36.8%, 19.8%, 20.1%, 5.8%, 14.9% and 22.5%, respectively. In addition, clinical variables such as age, white blood cell counts, genes of IDH1 and DNMT3A mutations, European LeukemiaNet genotype (NPM1 mutations and lacking FLT3‐ITD or CEBPA double allele mutations) and treatment protocols were independent factors for predicting the probabilities of overall and event‐free survival. The prediction nomograms based on these significant factors showed accurate discrimination. In conclusion, we developed a reliable prediction model for stratifying the risk of elderly patients with CN‐AML.