Cytogenetic Biclonality in Malignant Hematologic Disorders Takashi Furuya, Rodman Morgan, and Avery A. Sandberg
ABSTRACT: Generally, malignant hematologic disorders have been believed to be of monoclonal origin.
However, cytogenetically unrelated clones have been reported in some disorders including one case of acute leukemia (AL), one of acute lymphoblastic leukemia (ALL), one of acute myeloblastic leukemia (AMMoL), and five of myelodysplastic syndromes (MDS). The most frequent chromosome abnormality was trisomy 8 (75%), followed by trisomy 21 (37.5%, including tetrasomy 21) and trisomy 11 (25%). Two patients showed both trisomy 8 and 11, one also had trisomy 21 (triclonal). One patient showed two cytogenetically distinctive clones in which one was 47,XY,+8, related to myeloid cells, and the other had a del(6q) and del(9p), suggesting lymphoid cells. One patient we report and 5 from the literature had two unrelated clones with trisomy 8 and deletion of the long arm of chromosome 5 (5q-); all had MDS. Review of our records showed that 11 patients with both trisomy 8 and 5 q - in the same abnormal karyotype (not biclonal) had AL, i.e., 10 of acute nonlymphocytic leukemia (ANNL) and one of chronic myelogenous leukemia (CML) in blastic crisis. These findings suggest that cytogenetically unrelated clones may indicate hematopoietic biclonality.
INTRODUCTION
MATERIALS AND METHODS
Multiple abnormal karyotypes in bone marrow (BM) or peripheral blood (PB) cells from acute leukemia (AL) or myelodysplastic syndromes (MDS) are almost always cytogenetically related. Therefore, these diseases have been believed to be derived from one original cell. The monoclonality in malignant hematologic disorders has been supported by findings based on studies of glucose-6-phosphate dehydrogenase (G6PD), X-linked restriction fragment length polymorphisms (RFLP), immunoglobulin gene rearrangements, and T-cell receptor gene rearrangements
Biclonal and triclonal cytogenetic studies of hematologic disorders were selected from cases performed at our laboratory between January 1978 and December 1991. BM cells were cultured in a final volume of 10 ml RPMI 1640 medium supplemented with 20% calf serum, 1% glutamine, and 10% giant cell tumor-conditioned medium for 24 hours at 37°C. Colcemid was added 30 minutes before harvest at a final concentration of 0.017/~g/ml. Cells were treated with 0.075 M hypotonic KC1 solution for 10 minutes, fixed in 3 : 1 methanol:glacial acetic acid, and then spread on slides. Chromosomes were analyzed with a G-banding technique. Chromosome abnormalities were described according to the International System of Human Cytogenetic Nomenclature [8].
[1-5]. Recently, cytogenetically unrelated clones were reported in AL and MDS [6, 7]. Kobayashi et al. [6] reported 9 patients with unrelated clones who were divided into three groups; those with unrelated clones at diagnosis, those with unrelated clones at relapse, and those with unrelated clones at diagnosis (one clone) and at relapse (the other). Whether the latter is cytogenetically biclonal is not apparent. Therefore, in the present study, we dealt with patients who had concomitant unrelated clones, whether at diagnosis or relapse. We discuss differences in the karyotypes among patients with different leukemia subtypes and between patients with and without previous chemotherapy.
From the Cancer Center of Southwest Biomedical Research Institute and Genetrix, Scottsdale, Arizona. Address reprint requests to: Avery A. Sandberg, M.D., Southwest Biomedical Research Institute, 6401 East Thomas Road, Scottsdale, AZ 85251. Received February 14, 1992; accepted April 2, 1992.
RESULTS
We observed 8 patients with malignant hematologic disorders with unrelated clones. Their diagnoses were one AL, one acute lymphoblastic leukemia (ALL), one acute myeloblastic leukemia (AMMoL), and five MDS. Unfortunately, no further clinical information was supplied and the diagnoses were based on those diagnoses at referral. The karyotypes of the patients are shown in Table 1. The most frequent numerical abnormality was trisomy 8 (6 patients, 75%). In 5 patients, trisamy 8 was the sole abnormality and in the remaining patient trisomy 8 was associated with other changes. Two patients had trisomy 11 (25%); one also showed trisomy 8. One patient had three unrelated clones, trisomy 8, trisomy 11, and trisomy 21. Trisomy 21 was observed in 3 patients (37.5%, including 25
© 1992 Elsevier Science P u b l i s h i n g Co,, Inc. 655 A v e n u e of the Americas, N e w York, NY 10010
Cancer Genet Cytogenet 6 2 : 2 5 - 2 8 (1992) 0165-4608/92/$05.00
26
T. Furuva et al.
Table 1
Cases with unrelated clones
Case/age (yr)
Diagnosis
1/80
AML
2/83
MDS
3/40
MDS
4/42
MDS
5/66
MDS
6/76
MDS
7/10
ALL
8/63
AL
Karyotype
No. ~f cells
47,XY,+8 47,XY,+11 46,XY 47,XY,+8 47,XY,+11 47,XY,+21 46,XY 46,XY,del(9)(q13q22) 47,XY,+8 46,XX,del(5)(q13q34) 47,XX,+8 47,XX,+21
Io
5 12 5 2 2 8 3 ~} 14 4 3 17 3 18 2 10 4 2 4 5 2.
46,XX,d er( 6 p ),d el(12 ) (p12.2p13.2 ) , - 1 8 , + r
46,XY 46,XY,der(5)t(1;5)(q21 ;q35} 46,XY, + der(1)t(1;7)(p11;pl 1},- 7 46,XY 46,XY,t(3;12)(q25;q13) 57,XY,dup(1)(q25q44),+ 5,+5,+6,+8,+ 10,+ 14,+ 17,+ 18,+ 19,+21,+ 21 46,XY 45,X, Y 47,XY,+8 48,X.-Y,+der(3) x 2,del(6)(q23q25),dup(7q),del(9)(p121+ der(9q),del(10)(q22q25). 16p* ,19p+
4
Abbreviotiot~s: AML, acute myeloblastic leukemia; MDS, myelodysplastic syndrome: ALL, acute lymphoblastic leukemia; AL, acute leukemia.
tetrasomy 21). A b n o r m a l i t i e s of c h r o m o s o m e 6 were observed in 3 patients. DISCUSSION
A strong argument for the m o n o c l o n a l i t y of hematologic disorders is the existence of cytogenetically related clones in malignant hematologic disorders, but such unrelated clones are rarely observed. The frequency of patients with biclonality was 4.3-6.5% in MDS, 1.1 3.7% in acute nonl y m p h o c y t i c l e u k e m i a {ANLL), 0 - 0 . 6 % in acute l y m p h o blastic l e u k e m i a (ALL), and 7.3% in chronic l y m p h o c y t i c l e u k e m i a (CLL) [6, 9]. It is noteworthy that 6 (75.0%) of 8 patients in the present study (Table 1) and 46 (65.7%) of 70 patients (Fig. 1) described in the literature [2, 6, 7, 10-35] had clones of m y e l o i d origin and usually had some form of MDS or ANLL (Table 2). These 70 patients were grouped into leukemia subtypes and d i v i d e d into two groups, i.e., those who had and those who had not received previous c h e m o t h e r a p y (Fig. 1): Twenty-seven (38.6%) had not received previous chemot h e r a p y and 31 (44.3%) had had previous chemotherapy. The data suggest that the overall incidence of cytogenetically biclonal cases is not affected by previous chemotherapy. In the 46 m y e l o i d patients, some of the associated c h r o m o s o m a l abnormalities are a p p a r e n t l y different bet w e e n patients with and w i t h o u t previous chemotherapy. Patients with previous c h e m o t h e r a p y have been believed to show a high frequency of m o n o s o m y 5, m o n o s o m y 7, and deletion of the long arm of c h r o m o s o m e 5 ( 5 q - ) and c h r o m o s o m e 7 ( 7 q - ) [17, 36, 37]. The total frequency of
these abnormalities in patients with b i c l o n a l i t y was 70% (7 patients) in MDS (not i n c l u d i n g 5 q - ) and 42.9% (3 patients) in ANLL (Table 1). Therefore, these findings may indicate that at least one of the two u n r e l a t e d clones may be therapy induced. On the other hand, trisomy 8 in patients with biclonality witli MDS and ANLL was the most frequent c h r o m o s o m e change regardless of whether patients received previous
Figure 1 Number of cases from the literature with unrelated clones. "Others" includes unclassified leukemia, polycythemia vera, and idiopathic myelofibrosis. Symbols ( - , ?, and +) indicate no previous treatment, no information on previous treatment, and previous treatment, respectively. Biclonal 7O
cases
Myeloid 46 (65.7%)
Others 7
Lymphoid 17
//
/\
(io o%)
ALL 2
-
1
?
0
CLL 15
÷
1
7
6
i
o
+
8
1
+ 5
MDS 26 (37.1%)
ANLL 20 (28.6%)
/ \ /I\ ?+
I0
6
?+
I0
9
4
7
B i c l o n a l i t y in H e m a t o l o g i c D i s o r d e r s
Table 2
27
C h r o m o s o m a l a b n o r m a l i t i e s of 45 cases f r o m literature w i t h u n r e l a t e d c l o n e s ANLL
MDS
Previous chemotherapy
Previous chemotherapy Disease
(n - 10)
? (n = 6)
+ (n = 10)
Total (n - 26)
(n = 9)
? (n = 4)
+ (n - 7)
Total (n = 20)
Deletion of 5q Monosomy 5 Monosomy 7 Deletion of 7q Trisomy 8 Trisoiny 11 Trisomy 17 Trisomy 21
6 1 1 0 8 1 0 0
2 0 0 0 5 0 0 0
2 2 4 1 5 0 0 0
10 3 5 1 18 1 0 0
0 1 0 0 5 3
1 0 0 0 1 0
2 0 1 0 3 0
3 1 1 0 9 3
1
0
1
2
1
0
1
2
Abbreviations as in Table 1.
c h e m o t h e r a p y : 75% in the p r e s e n t s t u d y (Table 1) and 58.7% in the p a t i e n t s d e s c r i b e d in the literature (Table 2). T h e s e rates are v e r y h i g h as c o m p a r e d w i t h patients w i t h m o n o c l o n a l i t y w i t h t r i s o m y 8: 25% in MDS [22-25] and 16.6% in A N L L [11, 17, 36, 38]. Patient 8 was d i a g n o s e d w i t h AL (of u n k n o w n type) and s h o w e d t w o c y t o g e n e t i c a l l y d i s t i n c t i v e clones. C h r o m o s o m a l l y , the t r i s o m y 8 is c o n s i s t e n t w i t h a m y e l o i d cell, a n d the c l o n e w i t h d e l e t i o n s of the long arm of c h r o m o s o m e 6 and short arm of c h r o m o s o m e 9 has a high a s s o c i a t i o n w i t h l y m p h o i d d i s o r d e r s [37]. Jacobs et al. [22] r e p o r t e d a s i m i l a r p a t i e n t w i t h MDS. In a r e v i e w of all our p a t i e n t s s t u d i e d in a 10-year period, w e i d e n t i f i e d 11 w i t h 5 q - a n d t r i s o m y 8 in the s a m e abnormal k a r y o t y p e (R. Morgan, u n p u b l i s h e d observations), all w i t h AL, i.e., 10 w i t h A N L L and o n e w i t h c h r o n i c m y e l o g e n o u s l e u k e m i a (CML) in blastic crisis. O n the other hand, all p a t i e n t s w i t h b i c l o n a l i t y w h o had had no p r e v i o u s chem o t h e r a p y d e s c r i b e d in the literature and t h o s e in the present s t u d y w h o s h o w e d 5 q - and t r i s o m y 8 had MDS and not ANLL. If the t w o different c l o n e s in b i c l o n a l MDS (trisomy 8 / 5 q - ) w e r e u l t i m a t e l y related to p r o g r e s s i o n to ANLL, o n e m i g h t a n t i c i a p t e that s u c h MDS patients w i t h t r a n s f o r m a t i o n to A N L L w o u l d h a v e b o t h changes c o n c o m itantly, but w e f o u n d no s u c h r e p o r t e d cases. T h i s observation m a y s u p p o r t the a r g u m e n t that t h e s e patients w i t h b i c l o n a l i t y a n d MDS truly h a v e h e m a t o p o i e t i c biclonality. O n the o t h e r h a n d , R a s k i n d et al. [2] r e p o r t e d that an MDS p a t i e n t w i t h two c h r o m o s o m a l l y u n r e l a t e d c l o n e s e x h i b i t e d a h o m o g e n e o u s G-6-PD pattern. Kobayashi et al. [6] r e p o r t e d 5 p a t i e n t s w i t h t w o c o n c o m i t a n t c h r o m o s o m ally u n r e l a t e d c l o n e s w h i c h s h o w e d h o m o g e n e o u s morp h o l o g i c and p h e n o t y p i c h o m o g e n e o u s p o p u l a t i o n s of leuk e m i c cells. T h e s e findings suggest that t h e s e u n r e l a t e d c l o n e s m a y h a v e b e e n d e r i v e d f r o m a single cell (monoclonality) and that the p r i m a r y c h a n g e is too s m a l l to be detected microscopically. U n t i l n o w , h o w e v e r , the a n s w e r to w h e t h e r two cytogenetically unrelated clones indicate hematopoietic biclonality or m o n o c l o n a l i t y is not o b v i o u s . F u r t h e r c y t o g e n e t i c and m o l e c u l a r - b i o l o g i c s t u d i e s m u s t be p e r f o r m e d in pa-
tients w i t h u n r e l a t e d c l o n e s to a s c e r t a i n the n a t u r e of t h e s e c l o n e s and their c e l l u l a r e q u i v a l e n t s .
REFERENCES
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12. I)astugue N, Pris l, Colombies P (1990): Translocatiml l(3;21)(q26;q22) in acute myeloblastic leukemia secondarv t~ i~olycythemia vera. Cancer Genet Cytogenet 44:275-276. 13. Benitez J, Frejo CM, Toledo C, Fayos JS, Ranms C (1987]: l,enkemic transformation in patients with the 5q alteration: Analysis of the behavior of the 5 q - clones in preleukemic to leukemic phases. Cancer Genet Cytogenet 26:199-2(/7. 14. Groupe Frang, ais de Cytog6netique H6matologique (1988): Cytogenetics of acutely transformed chronic myeloproliferative syndrmnes without a Philadelphia chromosome. A multicenter study of 55 patients. Cancer Genet Cytogenet 32:157 168. 15. Dewald GW, Davis MP, Pierre RV, O'Fallon JR, Hoagland HC (1985): Clinical characteristics and prognosis of 50 patients with a myeloproliferative syndrome and deletion of part of the long arm of chromosome 5. Blood 66:189-197. 16. Hayashi Y, Raimondi SC, Behm FG, Santana VM, Kalwinsky DK, Pui CH, Mirro J, Williams DL (1989): Two karyotypically independent leukemic clones with the t(8;21) and 11q23 translocation in acute myeloblastic leukemia at relapse. Blood 73:1650 1655. 17. Groupe Frangais de Cytog6n6tique H6matologique {1984}: Chromosome analysis of 63 cases of secondary nonlymphoid blood disorders: A cooperative study. Cancer Genet Cytogenet 12:95-104. 18. Swirsky DM, Li YS, Matthews JG, Flemans RJ, Rees JKH, Hayhoe FGJ (1984): 8;21 Translocation in acute granulocytic leukemia: Cytological, cytochemical and clinical features. Br J Haematol 56:199-213. 19. Testa JR, Misawa S, Oguma N, Van Sloten K, Wiernik PH (1985): Chromosomal alterations in acute leukemia patients studied with improved culture methods. Cancer Res 45:430-434. 20. Swolin B, Weifeld A, Westin J (1986): Trisomy lq in polycythemia vera and its relation to disease transition. Am J Hematol 22:155-167. 21. Morrison-Delap SJ, Kuffel DG, Dewald GW, Letendre L (1986): Unbalanced 1;7 translocation and therapy-induced hematologic disorders: A possible relationship. Am J Hematol 21:39-47. 22. Jacobs RH, Cornbleet MA, Vardilnan JW, Larson RA, Le Beau MM, Rowley JD (1986): Prognostic implications of morphology and karyotype in primary myelodysplastic syndromes. Blood 67:1765-1772.
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25. Benftez ], Carbonell F, l"ayos ]S, Heimpel H (19851: Karvotypi{ evohltion in patimlts with myelodysplasti¢: syndromes. (',a nc~r (;enet Cytogenet lfi:157- 1fi7. 26. Castoldi GL, Lanza F, Cuneo A {1987): Cytogenetic: aspecls ol B-cell chronic lymphocytic leukemia: Their correlation with clinical stage and different potyclonal mitogens. Cancer Genel Cytogenet 26:27 84. 27. Jnliusson G, Rob6rt KH, ()st A, Friberg K, Biberfeld P, Nilsson B, Zech L, Gahrton G {1985): Prognostic information from cytogenetic analysis in chronic B-lymphocytic leukemia and leukemic immu nocytoma. Blood 65:134-141. 28. Raimondi SC, Behm FG, Roberson PK, Pui CH, Rivera GK, Murphy SB, Williams DL (1988}; Cytogenetics of childhood T-cell leukemia. Blood 72:1560-1566. 29. Anastasi J, Pettenati MI, Le Beau MM, Kwaan HC, Weil SC {1988): Acute lymphoblastic leukemia in a patient with longstanding polycythemia vera: Cytogenetic analysis reveals two distinct abnormal clones. Am J Hematol 29:33-37. 30. Bardi G, Pandis N, Arsenis P, Stamatellou M, Dermitzaki K, Papanastasiou C, Tsakanikas S, Kallinikou-Maniatis A (1989): Mixed lineage leukemia with cytogenetically unrelated abnormal clones. Cancer Genet Cytogenet 40:83-87. 31. Fitchett M, Griffiths MJ, Oscier DG, Johnson S, Seabright M (1987): Chronmsome abnormalities involving band 13q14 in hematologic malignancies. Cancer Genet Cytogenet 24:143-150. 32. Ohtaki K, Han T, Sandberg AA (1986): Sequential chromosome abnormalities in B cell lymphocytic leukemia. Cancer Genet Cytogenet 20:73-87. 33. Kerim S, Rege-Cambrin G, Scaravaglio P, Godio L, Saglio G, Aglietta M (1991): Trisomy 8 and an unbalanced t(5;17)(ql 1;p11) characterize two karyotypically independent clones in a case of idiopathic myelofibrosis evolving to acute nonlymphoid leukemia. Cancer Genet Cytogenet 52:63-69. 34. Mecucci C, Rege-Cambrin G, Michaux IL, Tricot G, Van den Berghe H (1986): Multiple chromosomally distinct cell populations in myelodysplastic syndromes and their possible significance in the evolution of the disease. Br J Haematol 64:699-706. 35. Berger R, Bernheim A, Le Coniat M, Vecchione D, Flandrin G, Dresch C, Najean Y (1984): Chromosome studies in polycythemia vera patients. Cancer Genet Cytogenet 12:217-223. 36. Arthur DC, Bloomfield CD (1984): Banded chromosome analysis in patients with treatment-associated acute nonlymphocytic leukemia. Cancer Genet Cytogenet 12:189-199. 37. Sandberg AA (19901: The Chromosomes in Human Cancer and Leukemia, 2nd Ed. Elsevier Science Publishing Company, New York. 38. Hagemeijer A, Hahlen K, Abels J (19811: Cytogenetic followup of patients with nonlymphocytic leukemia. II. Acute nonlymphocytic leukemia. Cancer Genet Cytogenet 3:109-124.
ABSTRACT: Generally, malignant hematologic disorders have been believed to be of monoclonal origin.
However, cytogenetically unrelated clones have been reported in some disorders including one case of acute leukemia (AL), one of acute lymphoblastic leukemia (ALL), one of acute myeloblastic leukemia (AMMoL), and five of myelodysplastic syndromes (MDS). The most frequent chromosome abnormality was trisomy 8 (75%), followed by trisomy 21 (37.5%, including tetrasomy 21) and trisomy 11 (25%). Two patients showed both trisomy 8 and 11, one also had trisomy 21 (triclonal). One patient showed two cytogenetically distinctive clones in which one was 47,XY,+8, related to myeloid cells, and the other had a del(6q) and del(9p), suggesting lymphoid cells. One patient we report and 5 from the literature had two unrelated clones with trisomy 8 and deletion of the long arm of chromosome 5 (5q-); all had MDS. Review of our records showed that 11 patients with both trisomy 8 and 5 q - in the same abnormal karyotype (not biclonal) had AL, i.e., 10 of acute nonlymphocytic leukemia (ANNL) and one of chronic myelogenous leukemia (CML) in blastic crisis. These findings suggest that cytogenetically unrelated clones may indicate hematopoietic biclonality.
INTRODUCTION
MATERIALS AND METHODS
Multiple abnormal karyotypes in bone marrow (BM) or peripheral blood (PB) cells from acute leukemia (AL) or myelodysplastic syndromes (MDS) are almost always cytogenetically related. Therefore, these diseases have been believed to be derived from one original cell. The monoclonality in malignant hematologic disorders has been supported by findings based on studies of glucose-6-phosphate dehydrogenase (G6PD), X-linked restriction fragment length polymorphisms (RFLP), immunoglobulin gene rearrangements, and T-cell receptor gene rearrangements
Biclonal and triclonal cytogenetic studies of hematologic disorders were selected from cases performed at our laboratory between January 1978 and December 1991. BM cells were cultured in a final volume of 10 ml RPMI 1640 medium supplemented with 20% calf serum, 1% glutamine, and 10% giant cell tumor-conditioned medium for 24 hours at 37°C. Colcemid was added 30 minutes before harvest at a final concentration of 0.017/~g/ml. Cells were treated with 0.075 M hypotonic KC1 solution for 10 minutes, fixed in 3 : 1 methanol:glacial acetic acid, and then spread on slides. Chromosomes were analyzed with a G-banding technique. Chromosome abnormalities were described according to the International System of Human Cytogenetic Nomenclature [8].
[1-5]. Recently, cytogenetically unrelated clones were reported in AL and MDS [6, 7]. Kobayashi et al. [6] reported 9 patients with unrelated clones who were divided into three groups; those with unrelated clones at diagnosis, those with unrelated clones at relapse, and those with unrelated clones at diagnosis (one clone) and at relapse (the other). Whether the latter is cytogenetically biclonal is not apparent. Therefore, in the present study, we dealt with patients who had concomitant unrelated clones, whether at diagnosis or relapse. We discuss differences in the karyotypes among patients with different leukemia subtypes and between patients with and without previous chemotherapy.
From the Cancer Center of Southwest Biomedical Research Institute and Genetrix, Scottsdale, Arizona. Address reprint requests to: Avery A. Sandberg, M.D., Southwest Biomedical Research Institute, 6401 East Thomas Road, Scottsdale, AZ 85251. Received February 14, 1992; accepted April 2, 1992.
RESULTS
We observed 8 patients with malignant hematologic disorders with unrelated clones. Their diagnoses were one AL, one acute lymphoblastic leukemia (ALL), one acute myeloblastic leukemia (AMMoL), and five MDS. Unfortunately, no further clinical information was supplied and the diagnoses were based on those diagnoses at referral. The karyotypes of the patients are shown in Table 1. The most frequent numerical abnormality was trisomy 8 (6 patients, 75%). In 5 patients, trisamy 8 was the sole abnormality and in the remaining patient trisomy 8 was associated with other changes. Two patients had trisomy 11 (25%); one also showed trisomy 8. One patient had three unrelated clones, trisomy 8, trisomy 11, and trisomy 21. Trisomy 21 was observed in 3 patients (37.5%, including 25
© 1992 Elsevier Science P u b l i s h i n g Co,, Inc. 655 A v e n u e of the Americas, N e w York, NY 10010
Cancer Genet Cytogenet 6 2 : 2 5 - 2 8 (1992) 0165-4608/92/$05.00
26
T. Furuva et al.
Table 1
Cases with unrelated clones
Case/age (yr)
Diagnosis
1/80
AML
2/83
MDS
3/40
MDS
4/42
MDS
5/66
MDS
6/76
MDS
7/10
ALL
8/63
AL
Karyotype
No. ~f cells
47,XY,+8 47,XY,+11 46,XY 47,XY,+8 47,XY,+11 47,XY,+21 46,XY 46,XY,del(9)(q13q22) 47,XY,+8 46,XX,del(5)(q13q34) 47,XX,+8 47,XX,+21
Io
5 12 5 2 2 8 3 ~} 14 4 3 17 3 18 2 10 4 2 4 5 2.
46,XX,d er( 6 p ),d el(12 ) (p12.2p13.2 ) , - 1 8 , + r
46,XY 46,XY,der(5)t(1;5)(q21 ;q35} 46,XY, + der(1)t(1;7)(p11;pl 1},- 7 46,XY 46,XY,t(3;12)(q25;q13) 57,XY,dup(1)(q25q44),+ 5,+5,+6,+8,+ 10,+ 14,+ 17,+ 18,+ 19,+21,+ 21 46,XY 45,X, Y 47,XY,+8 48,X.-Y,+der(3) x 2,del(6)(q23q25),dup(7q),del(9)(p121+ der(9q),del(10)(q22q25). 16p* ,19p+
4
Abbreviotiot~s: AML, acute myeloblastic leukemia; MDS, myelodysplastic syndrome: ALL, acute lymphoblastic leukemia; AL, acute leukemia.
tetrasomy 21). A b n o r m a l i t i e s of c h r o m o s o m e 6 were observed in 3 patients. DISCUSSION
A strong argument for the m o n o c l o n a l i t y of hematologic disorders is the existence of cytogenetically related clones in malignant hematologic disorders, but such unrelated clones are rarely observed. The frequency of patients with biclonality was 4.3-6.5% in MDS, 1.1 3.7% in acute nonl y m p h o c y t i c l e u k e m i a {ANLL), 0 - 0 . 6 % in acute l y m p h o blastic l e u k e m i a (ALL), and 7.3% in chronic l y m p h o c y t i c l e u k e m i a (CLL) [6, 9]. It is noteworthy that 6 (75.0%) of 8 patients in the present study (Table 1) and 46 (65.7%) of 70 patients (Fig. 1) described in the literature [2, 6, 7, 10-35] had clones of m y e l o i d origin and usually had some form of MDS or ANLL (Table 2). These 70 patients were grouped into leukemia subtypes and d i v i d e d into two groups, i.e., those who had and those who had not received previous c h e m o t h e r a p y (Fig. 1): Twenty-seven (38.6%) had not received previous chemot h e r a p y and 31 (44.3%) had had previous chemotherapy. The data suggest that the overall incidence of cytogenetically biclonal cases is not affected by previous chemotherapy. In the 46 m y e l o i d patients, some of the associated c h r o m o s o m a l abnormalities are a p p a r e n t l y different bet w e e n patients with and w i t h o u t previous chemotherapy. Patients with previous c h e m o t h e r a p y have been believed to show a high frequency of m o n o s o m y 5, m o n o s o m y 7, and deletion of the long arm of c h r o m o s o m e 5 ( 5 q - ) and c h r o m o s o m e 7 ( 7 q - ) [17, 36, 37]. The total frequency of
these abnormalities in patients with b i c l o n a l i t y was 70% (7 patients) in MDS (not i n c l u d i n g 5 q - ) and 42.9% (3 patients) in ANLL (Table 1). Therefore, these findings may indicate that at least one of the two u n r e l a t e d clones may be therapy induced. On the other hand, trisomy 8 in patients with biclonality witli MDS and ANLL was the most frequent c h r o m o s o m e change regardless of whether patients received previous
Figure 1 Number of cases from the literature with unrelated clones. "Others" includes unclassified leukemia, polycythemia vera, and idiopathic myelofibrosis. Symbols ( - , ?, and +) indicate no previous treatment, no information on previous treatment, and previous treatment, respectively. Biclonal 7O
cases
Myeloid 46 (65.7%)
Others 7
Lymphoid 17
//
/\
(io o%)
ALL 2
-
1
?
0
CLL 15
÷
1
7
6
i
o
+
8
1
+ 5
MDS 26 (37.1%)
ANLL 20 (28.6%)
/ \ /I\ ?+
I0
6
?+
I0
9
4
7
B i c l o n a l i t y in H e m a t o l o g i c D i s o r d e r s
Table 2
27
C h r o m o s o m a l a b n o r m a l i t i e s of 45 cases f r o m literature w i t h u n r e l a t e d c l o n e s ANLL
MDS
Previous chemotherapy
Previous chemotherapy Disease
(n - 10)
? (n = 6)
+ (n = 10)
Total (n - 26)
(n = 9)
? (n = 4)
+ (n - 7)
Total (n = 20)
Deletion of 5q Monosomy 5 Monosomy 7 Deletion of 7q Trisomy 8 Trisoiny 11 Trisomy 17 Trisomy 21
6 1 1 0 8 1 0 0
2 0 0 0 5 0 0 0
2 2 4 1 5 0 0 0
10 3 5 1 18 1 0 0
0 1 0 0 5 3
1 0 0 0 1 0
2 0 1 0 3 0
3 1 1 0 9 3
1
0
1
2
1
0
1
2
Abbreviations as in Table 1.
c h e m o t h e r a p y : 75% in the p r e s e n t s t u d y (Table 1) and 58.7% in the p a t i e n t s d e s c r i b e d in the literature (Table 2). T h e s e rates are v e r y h i g h as c o m p a r e d w i t h patients w i t h m o n o c l o n a l i t y w i t h t r i s o m y 8: 25% in MDS [22-25] and 16.6% in A N L L [11, 17, 36, 38]. Patient 8 was d i a g n o s e d w i t h AL (of u n k n o w n type) and s h o w e d t w o c y t o g e n e t i c a l l y d i s t i n c t i v e clones. C h r o m o s o m a l l y , the t r i s o m y 8 is c o n s i s t e n t w i t h a m y e l o i d cell, a n d the c l o n e w i t h d e l e t i o n s of the long arm of c h r o m o s o m e 6 and short arm of c h r o m o s o m e 9 has a high a s s o c i a t i o n w i t h l y m p h o i d d i s o r d e r s [37]. Jacobs et al. [22] r e p o r t e d a s i m i l a r p a t i e n t w i t h MDS. In a r e v i e w of all our p a t i e n t s s t u d i e d in a 10-year period, w e i d e n t i f i e d 11 w i t h 5 q - a n d t r i s o m y 8 in the s a m e abnormal k a r y o t y p e (R. Morgan, u n p u b l i s h e d observations), all w i t h AL, i.e., 10 w i t h A N L L and o n e w i t h c h r o n i c m y e l o g e n o u s l e u k e m i a (CML) in blastic crisis. O n the other hand, all p a t i e n t s w i t h b i c l o n a l i t y w h o had had no p r e v i o u s chem o t h e r a p y d e s c r i b e d in the literature and t h o s e in the present s t u d y w h o s h o w e d 5 q - and t r i s o m y 8 had MDS and not ANLL. If the t w o different c l o n e s in b i c l o n a l MDS (trisomy 8 / 5 q - ) w e r e u l t i m a t e l y related to p r o g r e s s i o n to ANLL, o n e m i g h t a n t i c i a p t e that s u c h MDS patients w i t h t r a n s f o r m a t i o n to A N L L w o u l d h a v e b o t h changes c o n c o m itantly, but w e f o u n d no s u c h r e p o r t e d cases. T h i s observation m a y s u p p o r t the a r g u m e n t that t h e s e patients w i t h b i c l o n a l i t y a n d MDS truly h a v e h e m a t o p o i e t i c biclonality. O n the o t h e r h a n d , R a s k i n d et al. [2] r e p o r t e d that an MDS p a t i e n t w i t h two c h r o m o s o m a l l y u n r e l a t e d c l o n e s e x h i b i t e d a h o m o g e n e o u s G-6-PD pattern. Kobayashi et al. [6] r e p o r t e d 5 p a t i e n t s w i t h t w o c o n c o m i t a n t c h r o m o s o m ally u n r e l a t e d c l o n e s w h i c h s h o w e d h o m o g e n e o u s morp h o l o g i c and p h e n o t y p i c h o m o g e n e o u s p o p u l a t i o n s of leuk e m i c cells. T h e s e findings suggest that t h e s e u n r e l a t e d c l o n e s m a y h a v e b e e n d e r i v e d f r o m a single cell (monoclonality) and that the p r i m a r y c h a n g e is too s m a l l to be detected microscopically. U n t i l n o w , h o w e v e r , the a n s w e r to w h e t h e r two cytogenetically unrelated clones indicate hematopoietic biclonality or m o n o c l o n a l i t y is not o b v i o u s . F u r t h e r c y t o g e n e t i c and m o l e c u l a r - b i o l o g i c s t u d i e s m u s t be p e r f o r m e d in pa-
tients w i t h u n r e l a t e d c l o n e s to a s c e r t a i n the n a t u r e of t h e s e c l o n e s and their c e l l u l a r e q u i v a l e n t s .
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