Paule-Marie Carli

Twenty-five years of epidemiological recording on myeloid malignancies: data from the specialized registry of hematologic malignancies of Côte d’Or (Burgundy, France)

Background Epidemiological data on myeloid malignancies are very rare in the literature due to a lack of registration by cancer registries until 2000. The Registry of Hematologic Malignancies of the Côte d’Or Department in France has, however, steadfastly registered data on cases occurring in the Department since 1980, resulting, to date, in a database of over 5,000 cases classified according to the ICD-O-3 classification, following the most recent World Health Organization classification criteria. Design and Methods Twenty-five years of data on myeloid malignancies, including acute myeloid leukemia, myeloproliferative neoplasms, myelodysplastic syndromes and myelodysplastic/myeloproliferative syndromes were analyzed. World population standardized incidence rates were calculated as were as observed and relative survival. Results Incidence rates per 100,000 inhabitants/year were 2.5 for acute myeloid leukemia, 1.3 for myelodysplastic syndromes, 3.2 for myeloproliferative neoplasms and 0.6 for myelodysplastic/myeloproliferative syndromes. It was found that the incidence rate of myelodysplastic syndromes increased significantly over the period. The median overall survival is 8.9 months for patients with acute myeloid leukemia, 33.8 months for patients with myelodysplastic syndromes, 91.7 months for those with myeloproliferative neoplasms and 26.6 months for patients with myelodysplastic/myeloproliferative syndromes. Observed and relative 20-year survival rates are, respectively, 12% and 13% in acute myeloid leukemia, 2% and 6% in myelodysplastic syndromes and 20% and 34% in myeloproliferative neoplasms. Conclusions These population-based data on myeloid malignancies are the first data collected over such a long period and provide interesting information for clinicians and public health authorities, particularly given the paucity of other long-term, population-based data from cancer registries.

AML transformation in 56 patients with Ph-MPD in two well defined populations

The Philadelphia chromosome‐negative (Ph−) chronic myeloproliferative disorders (MPD) have an inherent tendency for transformation into acute myelogenous leukaemia (AML). The long‐term rate of leukaemic transformation in unselected MPD patients was studied in well‐defined MPD populations in Gothenburg, Sweden and the Côte d′Or area, Burgundy, France, respectively. Over a median observation time of 15 yr, 56 subjects (7%) out of a total of 795 patients with Ph− MPD transformed to AML. The yearly incidence of AML transformation was 0.38% in polycythaemia vera (PV), 0.37% in essential thrombocythaemia (ET) and 1.09% in idiopathic myelofibrosis (IMF). The incidence of AML development was significantly higher in IMF as compared with both PV and ET (P = 0.002 and P = 0.02, respectively). Six of the patients who developed AML had never been treated with cytoreductive agents and two had only been exposed to interferon. In IMF, the average time from diagnosis to AML transformation was 42 ± 33 months, which was significantly shorter than for both PV and ET (88 ± 56 and 76 ± 57 months; P = 0.0075 and P = 0.027, respectively). The time from diagnosis to AML transformation appears to be a continuous event as regards all three MPD entities. It was shown that 17 out of the 18 patients with PV who developed AML were females; this was true despite the fact that the male/female ratio for the whole PV group was 146/171 (0.85). As regards ET and IMF patients who transformed to AML, the gender ratio showed slight male predominance (1.33 and 1.13, respectively). The average survival time for the 56 MPD patients who developed AML was 4.6 ± 5.5 (range 0–28) months and did not differ with respect to the three subtypes of pre‐AML MPD.

Immunophenotype of a transient myeloproliferative disorder in a newborn with trisomy 21.

Cytologic, immunologic, and cytogenetic studies were performed on the blast cells of a newborn with Down syndrome and transient myeloproliferative disease. This hematologic disorder is uncommon, and occurs primarily in infants with Down syndrome. This boy presented with a high white blood cell count and a high percentage of blast cells, without anemia or thrombocytopenia. Chromosome analysis showed a constitutional trisomy 21 without any other clonal abnormality. A three-color flow cytometric analysis was performed and revealed two different CD45 dim, CD34(+), CD117(+), CD56(+) immature subpopulations: the normal immature myeloid precursor and an immature blast cell population that expressed CD41, CD42, CD61, CD36, CD13, CD1a, and CD2. We postulate that this population could be the leukemic precursor involved in the acute megakaryoblastic leukemia frequently observed in children with Down syndrome.

Bone Marrow Necrosis and Human Parvovirus Associated Infection Preceding an Phl + Acute Lymphoblastic Leukemia

A case of bone marrow necrosis associated with a serologically documented recent Parvovirus B 19 infection which preceded the development of PH1+ acute lymphoblastic leukemia is reported. No conclusions can be drawn on the basis of a single case but the question of the role of human Parvovirus B19 in the pathogenesis of bone marrow necrosis is discussed. It is suggested that the virus may act as a co-factor for the induction of bone marrow necrosis, in some cases.

Hypereosinophilia in acute B-lineage lymphoblastic leukaemia.

A 14-year-old girl was hospitalized for fatigue and hypereosinophilia: the blood count showed haemoglobin 13Æ4 g/dl, WBC 41 · 10/l, with 76% eosinophils and 1% basophils, and platelet count 309 · 10/l. No blast cells were noted in the blood. No parasitic infection or allergic condition to explain the hypereosinophilia was found; serum immunoglobulin (Ig) E was 65 000 iu/l (normal level < 150 000). A bone marrow aspirate showed heavy eosinophil infiltration with hyperlobulated and hypogranular eosinophils and a blastic population (20%) with the following features: blast cells were of moderate size, with a variable nuclear/cytoplasmic ratio; the nuclei were frequently irregular with a non-homogeneous chromatin and a prominent nucleolus; remarkably, large azurophilic intracytoplasmic granules were observed (Figures). The peroxidase stain was negative. An immunophenotype performed on bone marrow CD45 dim cells revealed lymphoblastic B lineage cells, expressing CD19, CD10 bright, CD22, CD24, CD34, CD38, terminal deoxynucleotidyl transferase and the myeloid antigen CD33, confirming the diagnosis of acute pre-B lymphoblastic leukaemia (ALL). The other myeloid antigens (CD13, CD65, CD117, cytoplasmic myeloperoxidase) were all negative. Chromosomal analysis showed t(5;14)(q31;q32) in two cells, confirmed by fluorescence in situ hybridization (Whole Chromosome Paint DNA FISH Probes 5/14 Vysis). Very few cases (fewer than 50) of hypereosinophilia in acute lymphoblastic leukemia have been reported. In some cases, a t(5;14)(q31;q32) has been noted, joining the IL3 gene from chromosome 5 to the IGH gene from chromosome 14. Our case, where there was an association of granular B lineage ALL, hypereosinophilia and a t(5;14)(q31;q32), is unusual and emphasizes the fact that an unexplained hypereosinophilia, even in the absence of anaemia and thrombocytopenia, may be caused by ALL, and needs to be explored with a bone marrow aspirate.

Acute myeloid leukemia with hypergranular cytoplasm: a differential diagnosis of acute promyelocytic leukemia

We report here the case of a woman with acute myeloid leukemia with some blast cells exhibiting acute promyelocytic leukemia (APL)-like hypergranular cytoplasm. The cytologic and cytochemical aspects as well as the mature myeloid phenotype and hemostasis disorders were consistent with the diagnosis of APL. However, no t(15;17), or RARalpha gene, MLL gene or PML gene rearrangement was observed, or any other cytogenetic clonal abnormality. Coexpression on blast cells of CD33 and CD56 without CD34, CD16 or HLA-DR, suggested a myeloid/natural killer cell acute leukemia.

Heterogenous expression of CD15 in acute lymphoblastic leukemia: a study of ten anti-CD15 monoclonal antibodies in 158 patients.

Discrepancies in the literature on acute leukemia blast cell immunophenotypes are sometimes related to differences between the epitopes recognized by various monoclonal antibodies (MoAb) in the same cluster of differentiation. CD15 is one example of such a variation. CD15 expression has been reported in 1.6% to 39% of acute lymphoblastic leukemias (ALL). We studied the expression of CD15 using 10 different commercially available anti-CD15 MoAbs and we observed three different expression patterns using anti-CD15 MoAbs by flow cytometry in 158 cases of ALL: Smy15c was found in 70% of B lineage ALLs, Smy15a and FMC-13 in 30 to 40% of cases and all others in less than 9% of B-ALL cases (p < 0.0001). In T lineage ALLs, Smy15c, Smy15a and FMC-10 identified CD15 in 30% of the cases and all others in less than 8% of the cases. Logistic regression revealed that Smy15a, CD34 and CD14 correlated significantly with Smy15c expression. We conclude that CD15 MoAbs have to be chosen carefully when ALL immunophenotype and subsequent studies of prognostic significance are performed particularly in assessing multiphenotypic ALLs.

Philadelphia chromosome-positive thrombocythemia without features of chronic myeloid leukemia (CML) in peripheral blood.

We read with interest the recent paper of Michiels and colleagues who described biological and histopathological features of Philadelphia chromosome-positive thrombocythemia without features of chronic myeloid leukemia (CML) in peripheral blood [1]. They observed a large majority of women in this group of patients and the absence of splenomegaly. The major difference between essential thrombocythemia (ET) and the thrombocythemic form of CML was the presence of small megakaryocytes typically having hypolobulated round nuclei in the latter cases. Moreover, all of the patients were women. We recently diagnosed four cases of Philadelphia chromosome-positive thrombocythemia without features of chronic myeloid leukemia in peripheral blood: three of them were men; they had no splenomegaly and were referred to the hospital for exploration of thrombocythemia (Table 1). The blood cell count was first suggestive of thrombocythemia, primitive or secondary, and not of CML; however, examination of bone marrow smears revealed a hypercellular bone marrow and the absence of giant megakaryocytes, criteria which are more in favor of CML than ET. As usual in such cases, cytogenetic and molecular analyses were performed and revealed in all cases a Philadelphia chromosome and a BCR/ABL fusion gene. Unlike Michiels and colleagues, we observed a majority of men in our small series of patients, and we do not believe that the thrombocythemic form of CML is reserved to women. The morphological aspects of the megakaryocytes were of great interest, tending toward the diagnosis of CML rather than ET, which was confirmed using cytogenetic methods. In our cases, because of the presence of Philadelphia chromosome and a BCR/ABL fusion gene, all patients were considered as having CML and were treated using imatinib as first-line therapy. Our findings confirm the usefulness of morphological analysis of bone marrow megakaryocytes to distinguish between CML and ET. Moreover, we agree with Michiels and colleagues who consider BCR+ET to be a clinical variant of CML. F. Girodon (*) . F. Bailly . B. Favre . P.-M. Carli . M. Maynadié Hematology Laboratory, University Hospital, 21034 Dijon, France e-mail: francois.girodon@chu-dijon.fr Tel.: +33-380-293314 Fax: +33-380-293660

Endogenous erythroid colony growth in polycythaemia vera

A 67-year old woman presented with headaches, dyspnoea, lassitude and pruritus after bathing in hot water. She had a ruddy face without cyanosis and palpable spleen. No cause of secondary erythrocytosis was identified. A blood count showed haemoglobin 21.8 g/dl, haematocrit 0.67, white blood cells (WBC) 9.1 10/l (normal differential count without abnormal cells) and platelet count 575 10/l. The diagnosis of polycythaemia vera was considered probable, and further investigations revealed that the red cell mass related to the surface area was increased by 25% above the normal predicted value and the serum erythropoietin level was very low (,0.6 IU/l ; normal range 3.1±14.7). We observed endogenous erythroid colony growth in a serum-free medium based on collagen (Stemcell Technologies, France): on d 7, collagen gels were harvested onto glass slides, dried and stained with May±GruÈ nwald±Giemsa then observed microscopically ( 50). Erythroid colonies were easily recognized (see figure). This standardized collagen-based, serum-free, cytokine-free medium method allows both in situ colony staining and easier identification of erythroid colonies than in methylcellulose.