An acute myeloid leukemia case with concurrent 11q23 anomaly and D13S319 deficiency diagnosed by combined inter- and metaphase fluorescence in situ hybridization / 中华医学遗传学杂志

Objective@#To carry out multipath cytogenetic analysis of a rare case of acute myeloid leukemia (AML) with 11q23 aberration and D13S319 deletion.@*Methods@#G+ R banding technique was used to analyze the chromosomal karyotype of the patient after 24 h of cell culture. Combined interphase and metaphase fluorescence in situ hybridization (FISH) was used to detect specific chromosomal sites for complex translocations and minor missing fragments.@*Results@#The patient was found to harbor MLL-AF10 fusion gene due to rearrangement of the mixed lineage leukemia (MLL) gene in conjunct with deletion of the D13S319 locus on chromosome 13.@*Conclusion@#Whether MLL gene rearrangement and absence of D13S319 locus has a double impact on AML should attract more attention. For AML patient with clonal abnormalities such as 13q-, del (13)(q14), -13 or der (13), FISH assay should be proof and considered to determine the size of missing fragment so as targeted therapy may be implemented.

Application of multiple MLL gene rearrangement detection techniques for children with acute mononuclear leukemia / 中华医学遗传学杂志

Objective@#To assess the value of detecting multiple rearrangements of MLL gene in children with acute mononuclear leukemia (AML).@*Methods@#Eighty six children with AML were analyzed by fluorescence in situ hybridization (FISH), chromosomal karyotyping and multiplex reverse transcription-PCR (RT-PCR).@*Results@#Cross signals were detected by FISH in 26 cases, and 30.2% were detected with MLL gene rearrangements. R-band karyotyping analysis revealed 14 translocations with breakages involving 11q23 and 5 other aberrations, which yielded an overall detection rate of 22.1%. Multiple RT-PCR has detected 12 fusion genes produced by the MLL translocation, which yielded a detection rate of 14.0%. A significant difference was found in the detection rate of the three methods (P<0.05).@*Conclusion@#Combined use of FISH, chromosomal karyotyping and multiplex RT-PCR can improve the detection of MLL gene rearrangements and provide important clues for clinical diagnosis, treatment and prognosis of AML.

Clinical characteristics and prognosis of 34 cases of acute myeloid leukemia with FLT3 internal tandem duplication and MLL gene rearrangement / 中华血液学杂志

Objective@#To analyze the clinical characteristics and prognosis of 34 cases of acute myeloid leukemia (AML) with FLT3 internal tandem duplication (FLT3-ITD) and MLL gene rearrangement.@*Methods@#The clinical data of 34 AML patients with FLT3-ITD and MLL gene rearrangement was compared and analyzed for the therapeutic efficacy, prognostic factors when treated with chemotherapy, chemotherapy combined with targeted therapy or allogenic hematopoietic stem cell transplantation (allo-HSCT).@*Results@#Of the thirty-four cases with median age 41 (4-71) years old, 63.6% presented with white blood cells (WBC) greater than 30×109/L, 39.4% greater than 50 × 109/L respectively on admission. M5 (35.3%) made up the highest proportion. The cytogenetic abnormality reached 61.8%, of which the complex cytogenetic abnormality accounted for 11.8%. Eleven patients (32.35%) had both FLT3-ITD and MLL gene abnormalities. In addition to FLT3 and MLL abnormalities, 23 patients (67.6%) had one or more other gene abnormalities (multiple gene abnormalities). Of the 34 cases, 29.4% patients went into complete remission (CR) after two courses of chemotherapy. 20.6% (7 patients) went into CR after 3 or more courses of chemotherapy. The rate of early relapse in the CR group was 52.9%. Patients with WBC>50×109/L or multiple gene abnormalities had a lower remission rate (7.7%, 5.4%) after two courses of chemotherapy. CR rate for the patients with more than three gene abnormalities was 0. The total 2-year overall survival (OS) in the 34 patients was 28.8% (95% CI 13.5%-46.0%) and the disease-free survival (DFS) was 27.1% (95% CI 12.5%-44.0%). Of the 18 patients treated with chemotherapy alone or chemotherapy combined with targeted therapy, 17 cases died within 2 years and 1 lost follow-up after giving up treatment. For the 16 patients received allo-HSCT, the 3-year OS was 43.4% (95% CI 13.7%-70.4%) and DFS 42.7% (95% CI 13.4%-69.7%).@*Conclusion@#AML patients with FLT3-ITD and MLL gene rearrangement often presented with M5, accompanied by hyperleukocytosis, cytogenetic or multiple gene abnormalities. Those patients were observed to have low response rate and high early relapse when treated with chemotherapy without allo-HSCT. Patients had multiple gene abnormalities may be an important poor prognostic factor. Allo-HSCT is an effective treatment which could significantly improve the prognosis and survival of AML patients with FLT3-ITD and MLL gene abnormalities.

Clinical characteristics and prognosis of 34 cases of acute myeloid leukemia with FLT3 internal tandem duplication and MLL gene rearrangement / 中华血液学杂志

Objective: To analyze the clinical characteristics and prognosis of 34 cases of acute myeloid leukemia (AML) with FLT3 internal tandem duplication (FLT3-ITD) and MLL gene rearrangement. Methods: The clinical data of 34 AML patients with FLT3-ITD and MLL gene rearrangement was compared and analyzed for the therapeutic efficacy, prognostic factors when treated with chemotherapy, chemotherapy combined with targeted therapy or allogenic hematopoietic stem cell transplantation (allo-HSCT). Results: Of the thirty-four cases with median age 41 (4-71) years old, 63.6% presented with white blood cells (WBC) greater than 30×10(9)/L, 39.4% greater than 50 × 10(9)/L respectively on admission. M(5) (35.3%) made up the highest proportion. The cytogenetic abnormality reached 61.8%, of which the complex cytogenetic abnormality accounted for 11.8%. Eleven patients (32.35%) had both FLT3-ITD and MLL gene abnormalities. In addition to FLT3 and MLL abnormalities, 23 patients (67.6%) had one or more other gene abnormalities (multiple gene abnormalities). Of the 34 cases, 29.4% patients went into complete remission (CR) after two courses of chemotherapy. 20.6% (7 patients) went into CR after 3 or more courses of chemotherapy. The rate of early relapse in the CR group was 52.9%. Patients with WBC>50×10(9)/L or multiple gene abnormalities had a lower remission rate (7.7%, 5.4%) after two courses of chemotherapy. CR rate for the patients with more than three gene abnormalities was 0. The total 2-year overall survival (OS) in the 34 patients was 28.8% (95% CI 13.5%-46.0%) and the disease-free survival (DFS) was 27.1% (95% CI 12.5%-44.0%). Of the 18 patients treated with chemotherapy alone or chemotherapy combined with targeted therapy, 17 cases died within 2 years and 1 lost follow-up after giving up treatment. For the 16 patients received allo-HSCT, the 3-year OS was 43.4% (95% CI 13.7%-70.4%) and DFS 42.7% (95% CI 13.4%-69.7%). Conclusion: AML patients with FLT3-ITD and MLL gene rearrangement often presented with M(5), accompanied by hyperleukocytosis, cytogenetic or multiple gene abnormalities. Those patients were observed to have low response rate and high early relapse when treated with chemotherapy without allo-HSCT. Patients had multiple gene abnormalities may be an important poor prognostic factor. Allo-HSCT is an effective treatment which could significantly improve the prognosis and survival of AML patients with FLT3-ITD and MLL gene abnormalities.

Rare Cytogenetic Abnormalities Showing both MLL Rearrangement and Philadelphia Chromosome Positive in Pediatric Acute Lymphoblastic Leukemia Patients.

Objective: To evaluate the cytogenetics abnormalities in pediatric ALL cases and to correlate the cytogenetics Philadelphia chromosome - positive with the Fluorescence In - Situ Hybridization results. Methods: Retrospective cytogenetics and FISH analysis of the Bone marrow samples of both adult and pediatric patientswere done. However, since the inclusion criteria for this study was pediatric ALL, only the data of the pediatric patients were taken for this study. For the prospective samples, the cytogenetic analyses and Fluorescence in - Situ Hybridization were performed on the procured samples. The cytogenetics and FISH test were performed as per the standard protocol of our lab and were analysed as per the standard guideline. The cytogenetics Philadelphia chromosome - positive were correlated with the Fluorescence In - Situ Hybridization results and vice versa. Results: In our study of 50 pediatric ALLB patients, two patients showed low Ph+ by FISH. A confirmatory test by conventional cytogenetics revealed a rare association of Philadelphia chromosome positive along with the cytogenetics abnormality involving the MLL gene as well. One of the patient showed a karyotype of 46,XY,del(9) (p21),t((10;11)(p12;q21)[7]/46,XY,del(9)(p21)[9]/46,XYdel(22)(q11.2)[3] and the other patient showed 46, XX, t(9;11) (p13;q23)),?del(22)(q11.2)[6]/46,XX,del (11) (q23) [8]/46, XX[5] which were confirmed by cytogenetics and Fluorescence In - Situ Hybridization (FISH). Two patients showed complete Ph+ve and one patient showed normal karyotype along with tetraploidy. The rest of the cases showed either a normal karyotype or an insignificant abnormality. Conclusion: In our study of 50 pediatric ALL patients, two cases showed a rare association of Philadelphia chromosome positive along with a cytogenetics abnormality involving the MLL gene. Apart from the rare findings in our study, emphases is also made on the confirmatory test by cytogenetics incidence of low Ph+ve by FISH and vice versa and a need for larger collaborative studies and intense follow up of the treatment and the prognosis of this subset of patients to determine the prognostic pattern to improve the treatment options for these kind of rare patients.

Your dilemma, my identity: Unusual immunogenetic profiles of pediatric B cell acute lymphoblastic leukemia.

B-cell acute lymphoblastic leukemia (B-ALL) is characterized by CD19 expression, which is one of the most important prerequisites, along with expression of CD10, CD22 and/or CD79a. Rearrangements involving MLL gene are seen in CD10− B-ALL (pro-B cell origin) and t(9;11)(p21;q23) is most commonly reported in acute myeloid leukemia (AML), where it is known to carry very good prognosis in pediatric AMLs and rarely in acute lymphoblastic leukemia (ALL). We report a case of CD10+, CD19− pediatric ALL with rearrangements of MLL gene as a result of t(9;11)(p21;q23), thus conferring a very poor prognosis. The case emphasizes use of comprehensive panel of antibodies for fl ow cytometric immunophenotyping and cytogenetic correlation for correct diagnosis and prognostication. KEY WORDS: Acute lymphoblastic leukemia, CD19, MLL gene, t(9;11)(p21;q23)

Detection of rearrangements of mixed lineage leukemia gene in acute leukemia patients / 白血病·淋巴瘤

Objective To explore the value of fluorescence in situ hybridization (FISH) and multiplex RT-PCR in the detection of mixed lineage leukemia (MLL) gene rearrangement in acute leukemia (AL) patients. Methods Dual-color MLL probe, multiplex RT-PCR and R or G banding techniques were used to detect the MLL gene rearrangement in 189 cases of AL.Results MLL gene rearrangements were detected in 9 cases (5.03 ％) by FISH,and 16 cases (8.47 ％) by multiplex RT-PCR,including MLL/AF9,MLL/AF10,MLL/AF6, MLL/AF7, MLL/ELL, MLL/PTD. R or G banding techniques could find 11q23 in 5 out of 189 patients (2.65 ％). There was no statistic difference in the incidence of 6 common MLL gene rearrangements between ALL (73 cases) and AML patients (116 cases) (P ＞ 0.05).Conclusion Multiplex RT-PCR is a powerful technique in the detection of MLL gene rearrangement for tentatively diagnosed AL.It could not only confirm translocation detected by conventional cytogenetic method, but also detect MLL partial tandem duplication which could not been detected by cytogenetic examination or FISH. It plays an important role in guiding therapy and predicting prognosis for AL.

Survival Benefit of Hematopoietic Stem Cell Transplantation in Infant Acute Lymphoblastic Leukemia, According to Classification of High Risk Group / 임상소아혈액종양

BACKGROUND: In comparison to older children, acute leukemia in infants has a dismal outcome, despite introduction of intensive multi-agent chemotherapy. Patients with age under 1 year and mixed-lineage leukemia (MLL) gene rearrangements are the most high risk group. In this study, we investigate the outcome of more intensive chemotherapy and the role of hematopoietic stem cell transplantation (HSCT) in high risk group of infant leukemia.METHODS: This study analyzed on 9 infants with acute lymphoblastic leukemia (ALL) who were diagnosed and treated between 1998 and 2008 at Severance hospital. We classified high risk group with age at diagnosis is under 6 months or white blood cell at diagnosis are over 50,000/microL or presence of MLL gene rearrangements. Patients in high risk group were treated on a protocol of intensive chemotherapy followed by HSCT.RESULTS: In this study, the 3-years EFS rate for 9 infant ALL patients was 66.7+/-15.7%. Both of 2 patients younger than 6 months of age at diagnosis did not survive. 3yr-EFS rate for the 7 patients categorized in high risk group out of 9 infant ALL patients was 57.1+/-18.7%, and 3 yr EFS of the 6 patients in the high risk group who received HSCT was 60+/-21.9%. We did not experience relapse in 6 patients treated with HSCT.CONCLUSION: This study showed promising results and lesser risks in high risk group infant ALL treated with intensive chemotherapy and HSCT. We suggest early HSCT with intensive chemotherapy for infant leukemia patients in high risk group.

A Case of Therapy-related Acute Lymphoblastic Leukemia with t(11;19)(q23;p13.3) and MLL/MLLT1 Gene Rearrangement / 대한진단검사의학회지

Therapy-related ALL (t-ALL) is a rare secondary leukemia that develops after chemotherapy and/or radiotherapy for primary malignancies. Chromosomal 11q23 abnormalities are the most common karyotypic alterations in t-ALL. The t(11;19)(q23;p13) aberration is extremely rare and has not been confirmed at the molecular genetic level. Here, we report a case of t-ALL with t(11;19)(q23;p13.3) and MLL-MLLT1 (alias ENL) gene rearrangement confirmed by cytogenetic analysis, multiplex reverse transcription-PCR (multiplex RT-PCR), and DNA sequencing in a patient who had undergone treatment for breast cancer. A 40-yr-old woman developed acute leukemia 15 months after undergoing 6 cycles of adjuvant chemotherapy (doxorubicin 60 mg/m2 and cyclophosphamide 600 mg/m2), radiation therapy (dose, 5,900 cGy), and anticancer endocrine therapy with tamoxifen. The complete blood cell counts and bone marrow examination showed increased blasts and the blasts showed B lineage immunophenotype (positive for CD19, CD34, and cytoplasmic CD79a). Cytogenetic analysis revealed the karyotype 47,XX,+X,t(11;19)(q23;p13.3)[4]/46,XX[16]. FISH analyses, multiplex RT-PCR, and DNA sequencing confirmed the MLL-MLLT1 gene rearrangement. The patient underwent induction chemotherapy with fractionated cyclophosphamide, vincristine, doxorubicin, and dexamethasone (Hyper-CVAD) and achieved complete remission. Subsequently, she underwent consolidation chemotherapy, but died of brain ischemia in the pons and the region of the middle cerebral artery. To our knowledge, this is the first case report of t-ALL with t(11;19)(q23;p13.3) and the MLL-MLLT1 gene rearrangement.

Survival Benefit of Hematopoietic Stem Cell Transplantation in Infant Acute Lymphoblastic Leukemia, According to Classification of High Risk Group / 임상소아혈액종양

BACKGROUND: In comparison to older children, acute leukemia in infants has a dismal outcome, despite introduction of intensive multi-agent chemotherapy. Patients with age under 1 year and mixed-lineage leukemia (MLL) gene rearrangements are the most high risk group. In this study, we investigate the outcome of more intensive chemotherapy and the role of hematopoietic stem cell transplantation (HSCT) in high risk group of infant leukemia. METHODS: This study analyzed on 9 infants with acute lymphoblastic leukemia (ALL) who were diagnosed and treated between 1998 and 2008 at Severance hospital. We classified high risk group with age at diagnosis is under 6 months or white blood cell at diagnosis are over 50,000/microL or presence of MLL gene rearrangements. Patients in high risk group were treated on a protocol of intensive chemotherapy followed by HSCT. RESULTS: In this study, the 3-years EFS rate for 9 infant ALL patients was 66.7+/-15.7%. Both of 2 patients younger than 6 months of age at diagnosis did not survive. 3yr-EFS rate for the 7 patients categorized in high risk group out of 9 infant ALL patients was 57.1+/-18.7%, and 3 yr EFS of the 6 patients in the high risk group who received HSCT was 60+/-21.9%. We did not experience relapse in 6 patients treated with HSCT. CONCLUSION: This study showed promising results and lesser risks in high risk group infant ALL treated with intensive chemotherapy and HSCT. We suggest early HSCT with intensive chemotherapy for infant leukemia patients in high risk group.

A Case of Therapy-related ALL with MLL Gene Rearrangement Following Treatment of Breast Cancer / 대한진단검사의학회지

ALL with MLL gene rearrangement secondary to chemotherapy has been rarely reported. We report a case of therapy-related ALL (t-ALL) with MLL gene rearrangement in a patient who had undergone treatment for breast cancer. A 60-yr-old woman with breast cancer underwent breast-conserving surgery followed by 6 cycles of adjuvant chemotherapy (cyclophosphamide, epirubicin, and fluorouracil) and radiation therapy (dose, 5,040 cGy to the left breast and a 1,000 cGy boost to the tumor bed). A follow-up examination performed 14 months after the chemotherapy revealed no evidence of breast malignancy. However, the patient's complete blood cell count indicated acute leukemia: white blood cell count, 174.1x10(9)/L with 88% blasts; Hb level, 12.5 g/dL; and platelet count, 103.0x10(9)/L. Examination of the bone marrow aspirate smear revealed a high percentage of blasts (85.1% of all nucleated cells); the blasts showed a pro-B immunophenotype and were positive for CD19, CD79a, HLA-DR, CD34, and terminal deoxynucleotidyl transferase (TdT). Cytogenetic and FISH analyses revealed t(4;11)(q21;q23) and MLL gene rearrangement, respectively. The patient received induction chemotherapy with cyclophosphamide, vincristine, doxorubicin, and dexamethasone and achieved complete remission. Following consolidation chemotherapy, she underwent allogenic peripheral blood stem cell transplantation and has been clinically stable. To our knowledge, this is the first reported case of t-ALL with MLL gene rearrangement following treatment of breast cancer in Korea.

Detection of MLL gene rearrangement in acute leukemia and its clinical significance / 白血病·淋巴瘤

Objective To study the frequency of mixed-lineage leukemia(MEL)gene rearrangement and frequent types of fusion genes and the clinical characteristics in acute leukemia(AL)with MLL gene rearrangement.Methods MLL gene rearrangement was detected by multiplex nested RT-PCR in 109 cases of AL.Immunophenotypes were screened by flow cytometry and the chnical features of MLL gene rearranged were analyzed.Results MLL gene rearrangement were identified in 6.4%(7/109)of the patients,4 cases of AML,1 case of M2,1 case of M4,2 cases of M5,3 cases of.B-ALL.MLL-AF4,MLL-AF6,MLL-AF9,MLL-AF10.MLL-ENL were deleted by multiplex nested RT-PCR.Patients with MLL gene rearrangement presented higher initial white blood cell count(WBC)(P=0.019).Conclusion Multiplex nested RT-PCR is a fast and effective method to detect gene rearrangement of MLL in AL Patients with MLL gene rearrangement presented higher WBC and poor prognosis.

Chromosomal Abnormalities at 11q23 after Topoisomerase II Inhibitor Treatment: A Report of Three Cases / 대한임상병리학회지

It has become apparent that the MLL (myeloid-lymphoid leukemia or mixed-lineage leukemia) gene is frequently rearranged in patients with secondary leukemias or myelodysplasias associated with chemotherapeutic regimens including topoisomerase II inhibitors (topo II inhibitors). Few studies have been reported on hematological or chromosomal abnormalities associated with topo II inhibitor therapy in Korea. We report three cases with 11q23 abnormalities associated with topo II inhibitor therapy. The first case was a 10-year-old female patient with t(11;16)(q23;p13.3) but without abnor-mal bone marrow findings. The second patient was a 67-year old male with therapy-related myelodys-plastic syndrome (MDS) with add(11)(q23), which evolved into acute myeloid leukemia with t(2;11) (p23;q23) after one year. The other patient was a 42-year-old male with a therapy-related acute myeloid leukemia with rearranged 11q23 demonstrated by fluorescence in situ hybridization (FISH) analysis using an MLL gene probe, which subsequently proved to be t(9;11)(p22;q23) by cytoge-netic analysis. The chemotherapeutic agents for the primary malignancies in the three patients (ovarian primitive neuroectodermal tumor, PNET; lung squamous cell carcinoma; and Ewing's sar-coma/ PNET, respectively) included topo II inhibitiors as well as alkylating agents. The periods from the primary therapy to the identification of 11q23 abnormalities were relatively short; 9 months, 35 months, and 22 months, respectively. Patients treated with topo II inhibitors are at risk for develop-ing secondary MDS and leukemia that have distinct features from those associated with alkylating agents. Although the genetic basis and optimal treatment for the clonal changes induced by topo II inhibitor therapy remain to be determined, a close follow-up with cytogenetic and/or MLL FISH study in patients with a history of topo II inhibitor treatment would be very useful for diagnosis and prediction of secondary hematologic malignancies.