Complex Cytogenetic Abnormalities Research Articles

Myelodysplastic Syndrome in Fanconi Anemia: Morphologic and Cytogenetic Findings Are Strongly Correlated.

Predisposition to myelodysplastic syndrome (MDS) and acute leukemia is a hallmark of Fanconi anemia (FA). Morphologic criteria for MDS in FA are not well established. The presence of some degree of bone marrow (BM) dysplasia, especially dyserythropoiesis, as background in these patients can confound the diagnosis. Similarly, the significance of cytogenetic abnormalities in patients with the chromosomal instability syndrome of FA has been debated. To address both the morphologic diagnosis of MDS in FA and the relationship between morphologic and cytogenetic (CG) findings, we reviewed 169 BM biopsies and CG results from 118 FA patients referred to University of Minnesota from 1991-2006. Peripheral blood and BM smears, sections, iron and immunoperoxidase stains were reviewed by a single hematopathologist without knowledge of CG. MDS was diagnosed and classified according to WHO criteria. Dyserythropoiesis alone was considered diagnostic of MDS only if present in an arbitrarily determined level of at least 50% of cells, or if more than 15% ring sideroblasts (RS) were identified. A borderline MDS category was also defined. G-banding, FISH, and/or array based CGH were performed for detection and characterization of clonal chromosomal abnormalities. Twenty-two patients (18.6%) had morphologic evidence of MDS: RCMD and RCMD-RS were predominant, with RAEB-1 and 2, MDS-unclassifiable, RA and RARS accounting for the remainder. Of the 22 patients with MDS, 20 (91%) had clonal abnormalities; 2 patients, one with RA and one with RARS, showed normal cytogenetics. Of the abnormalities observed, 80% involved gain of 1q, gain of 3q, and/or loss of 7q, and most patients had more than one abnormality. Six patients had borderline MDS; all but one of these had clonal abnormalities. Eight patients with AML were identified, all of whom showed complex cytogenetic abnormalities. Eighty-six patients showed insufficient abnormalities for MDS, but most had some degree of dyserythropoiesis. Cytogenetics was normal in 75 of these patients (87.2%) and abnormal in 11 (12.8%). Most of these patients had clones with a single abnormality. In summary, 37.3% of all FA patients showed chromosomal abnormalities. The presence of MDS as diagnosed by WHO criteria is strongly correlated with the presence of a clonal chromosomal abnormality. With respect to morphologic findings, the diagnosis of MDS in FA is highly dependent upon the detection of myeloid dysplasia, megakaryocytic dysplasia and/or increased blasts. Dyserythropoiesis per se, even if present in excess of 50% of cells, does not correlate with a clonal cytogenetic abnormality. The finding that most patients with borderline MDS also had CG abnormalities suggests that the clonal abnormalities in such cases may herald evolution to MDS. Interpretation of the finding of a clonal abnormality in FA patients without morphologic evidence of MDS requires consideration of the particular chromosomal abnormality involved, the size of the clone, and the presence or absence of clonal evolution. The strong correlation between morphologic and CG findings has implications for monitoring patients with FA.

Syndromes myélodysplasiques de l'adulte

Myelodysplastic syndromes (MDS) are clonal hematological disorders characterized by ineffective hematopoiesis. Their increased prevalence is associated with the aging of the population. The aim of this article is to analyze the available literature about MDS - its classification, pathophysiology, prognosis and recent progress in treatment - and report our experience with it. Its diagnosis and classification are based on the morphological features of blood and bone marrow cells. The World Health Organization (WHO) working group has proposed a new classification to improve the homogeneity of the categories in the widely-used French-American-British classification in term of pathophysiology and prognosis. This new classification permits the consideration of clinical, etiologic, and cytogenetic data, including complex and heterogeneous cytogenetic abnormalities. The International Scoring System for evaluating Prognosis (IPSS), which has proven highly useful for this purpose, is a risk-based classification system for MDS, based on these cytogenetic abnormalities. It can be used to help guide therapeutic choices. For MDS with low IPSS scores (low-risk), appropriate treatment includes best supportive care, hematopoietic growth factors, and immunomodulatory drugs. For MDS with high IPSS scores, chemotherapy is appropriate at low or intense doses. For younger patients, allogeneic bone marrow transplantation, the only truly curative treatment, may be considered. Better understanding of the pathophysiology of MDS, including the role of oncogenes and various cytokines, is required to develop new treatments and treatment targets. The new classification and prognosis scoring system should lead to new therapeutic strategies that may modify the overall prognosis and quality of life of patients with MDS.

Acute myeloid leukaemia presenting with mediastinal myeloid sarcoma: Report of three cases and review of literature

Although myeloid sarcomas (MS) are frequently associated with acute myeloid leukaemia (AML), the occurrence of mediastinal MS is a much rarer event. The authors describe a distinct group of three AML patients with mediastinal MS and complex cytogenetics presenting at their centre over a 7-year period. Clinical features consistent with superior vena caval obstruction were noted at presentation in two of the three patients. Mediastinal mass was detected on routine chest radiography, and biopsies confirmed the diagnosis of MS. One patient relapsed after consolidation chemotherapy and died from progressive disease. Two patients underwent allogeneic haemopoietic stem cell transplant, but succumbed to transplant related complications. Review of mediastinal MS over the last 20 years shows that a significant proportion of patients have complex cytogenetic abnormalities and a poor long-term prognosis. Early and accurate diagnosis is essential and patients should be managed along the lines of high risk AML.

MK-0457, a Novel Multikinase Inhibitor, Has Activity in Refractory AML, Including Transformed JAK2 Positive Myeloproliferative Disease (MPD), and in Philadelphia-Positive ALL.

Background. MK-0457 (VX-680) is a small-molecule inhibitor of aurora kinases A, B, and C, FLT3, BCR-ABL, and JAK2. MK-0457 exhibits nanomolar level broad-spectrum preclinical anti-tumor activity. Specifically, MK-0457 inhibits proliferation of patient-derived AML cells in vitro, and improves survival of a Ba/F3 FLT3 ITD murine model of systemic AML. A Phase I study of MK-0457 is being conducted in patients with a broad range of hematological malignancies, including acute myeloid and lymphoid leukemias.Methods. After IRB approval, 15 consenting patients with relapsed/refractory AML and ALL, ECOG performance status ≤ 2, and adequate organ function were enrolled using a standard dose escalation scheme with 3 patients/dose level until dose-limiting toxicity (DLT), followed by 6 patients/level. MK-0457 was administered by continuous 5-day intravenous infusion every 2 to 3 weeks. DLT was defined as grade 3 or higher non-hematologic toxicity during cycle 1. Pharmacokinetics (PKs) were collected pre-dose through 168 h and analyzed for MK-0457 by HPLC/mass spec.Results. Thirteen patients with AML and 2 patients with ALL were enrolled at 8, 12, 20, 24, and 28 mg/m2/hr. Among AML patients, two had a diploid karyotype and the remainder had complex unfavorable cytogenetic abnormalities. Two AML patients had a prior JAK2-positive MPD, transformed to AML, and then received MK-0457 as their 1st AML treatment. One AML patient received MK-0457 as first salvage, three as second salvage, and the remainder as salvage attempt three or higher. Both ALL patients failed prior multiagent chemotherapy; one of these patients had Philadelphia (Ph)-positive ALL and progressed after prior BCR-ABL inhibitor therapy, including dasatinib. The latter patient carried the BCR-ABL inhibitor resistance mutation, T315I. Four of 5 AML patients without baseline grade 3/4 myelosuppression in one cell line developed grade 4 neutropenia, including both JAK2-positive AML patients. Normalization of the platelet count during cycle one occurred in one MPD patient with thrombocytosis at baseline (~800 x 103/mL); Grade 3 thrombocytopenia occurred during cycle one in the other MPD patient with a normal baseline. The Ph+-ALL patient had eradication of peripheral blood blasts at the end of 2 cycles of therapy. No MK-0457 attributable extramedullary grade 2 or above adverse events were seen. Mild hair thinning was seen in some patients at dose levels 20 mg/m2/hr and above. Preliminary PK analysis showed dose-dependent linearity at steady state, with a biexponential decay at the end of infusion characterized by a rapid a decay followed by a slower b decay (t1/2 10–20 hrs).Conclusions. MK-0457 at well tolerated doses achieves myelosuppression in refractory AML and ALL patients. Its activity in JAK2+ transformed AML patients may be partially attributable to JAK2 inhibitory activity. The role of aurora kinase inhibition in the above responses is not yet established. As neither maximum tolerated dose nor dose limiting toxicity has been defined to date, dose finding on this Phase I study of MK-0457 is on-going in the acute leukemia population with 36 mg/m2/hr as the current dose level under investigation.

Membrane-Stable, Humanized CD154 Gene Therapy for Patients with CLL.

Chronic lymphocytic leukemia (CLL) is a malignancy ideally suited for therapeutic vaccines. CLL B cells, readily available from blood, express surface antigens that can be targeted for immune-recognition. Although usually stealth-like, CLL cells can be stimulated through ligation of CD40 by CD154, to express immune co-stimulatory molecules, such as CD80, CD86, and adhesion molecules (e.g. CD54), allowing them to stimulate T cells against leukemia-associated antigens. A phase I clinical trial with autologous CLL cells transduced to express murine CD154 previously demonstrated tolerability and clinical activity with reduction in leukemia counts and lymph node size associated with increases in leukemia-specific T cell counts (Blood 96:2917Blood 96:2000). In vivo bystander CD40 stimulation of non-transduced CLL cells also was noted following intravenous administration of CD154-transduced CLL cells. The acute decreases in leukemia counts were possibly due to induced expression of death-receptors (e.g. CD95 (Fas) and DR5) and pro-apoptotic proteins such as the BH3- interacting-domain death agonist (Bid), allowing for clearance of leukemia cells by innate immune effector mechanisms. Repeated dosing of transduced cells was initiated; however, some patients developed anti-murine CD154 antibodies, in some cases with neutralizing activity. Therefore, a new replication-defective adenovirus was constructed encoding a humanized, functional, membrane-stable CD154 (ISF35) that efficiently transduces CLL B cells. We are conducting a phase I clinical trial with a single dose of 1x108, 3x108, or 1x109 ISF35-transduced autologous leukemia cells to assess tolerability and activity. To date, 4 patients have had cells collected and transduced. Patient characteristics: Rai I=2, III=1, IV=1; ALC=21−135K/μL; 2 patients had CLL cells with 17p del, and another had CLL cells with trisomy 12 and complex cytogenetic abnormalities; 3 patients had CLL cells with high-level expression of CD38; 2 patients were previously treated and 2 were treatment-naive. Transduction efficiency was 49, 77, 53, and 57%, and viability of transduced cells was 92–95%. The ISF35-transduced CLL cells were induced to express CD95 in all cases. Three patients received their ISF35-transduced cells at the time of abstract submission. There have been no infusion-related toxicities. All 3 patients experienced fever (Grade less than 2) and fatigue (Grade less than 2) lasting 1–4 days following treatment; no dose-limiting toxicities were noted at the 1x108 cell dose. Acute reductions in ALC were 36, 64, and 0%, follow-up is 4, 2, and <1wk and continues. Preliminary data on leukemia cells from blood prior to and 48 hr post-infusion demonstrated induced expression of CD95 and DR5 on CLL cells, including on the leukemia cells in the patient with 17p del. Patient 4 will receive 3x108 ISF35 transduced cells; patients must be treated 2 wks apart; and enrollment and treatment will continue unless DLT is observed.

The clinical spectrum of adult acute myeloid leukaemia associated with core binding factor translocations

To better understand the spectrum of adult acute myeloid leukaemia (AML) associated with core binding factor (CBF) translocations, 370 patients with newly diagnosed CBF-associated AML were analysed. Patients' age ranged from 16-83 years (median 39 years) with a slight male predominance (55%); 53% had inv(16); 47% had t(8;21). Patients with t(8;21) tended to be younger (P = 0.056), have lower peripheral blood white cell counts (P < 0.0001) and were more likely to have additional cytogenetic abnormalities (P < 0.0001). Loss of sex chromosome, del(9q) and complex abnormalities were more common among patients with t(8;21), while +22 and +21 were more common with inv(16). Overall, 87% [95% confidence interval (CI) 83-90%] of patients achieved complete response (CR) with no difference between t(8;21) and inv(16); however, the CR rate was lower in older patients due to increased resistant disease and early deaths. Ten-year overall survival (OS) was 44% (95% CI 39-50%) and, in multivariate analysis, was shorter with increasing age (P < 0.0001), increased peripheral blast percentage (P = 0.0006), in patients with complex cytogenetic abnormalities in addition to the CBF translocation (P = 0.021), and in patients with t(8;21) (P = 0.025). OS was superior in patients who received regimens with high-dose cytarabine, a combination of fludarabine and intermediate-dose cytarabine, or haematopoietic cell transplantation.

Pediatric Renal Cell Carcinoma

We describe the clinical features, outcome, pathology, cytogenetics, and molecular aspects of 13 pediatric papillary renal cell carcinomas during a 19-year period. Seven cases (54%) had translocations involving Xp11.2 (TFE3). They were identified by cytogenetic, molecular, and/or immunohistochemical analyses. All Xp11.2+ translocations were TFE3+ by immunostaining. Cytogenetic and/or polymerase chain reaction analyses identified 3 cases with t(X17) and 1 case with t(1;17), and all had additional translocations. Histologic features in common in TFE3+ tumors also were present in some TFE3- tumors. One TFE3- tumor had complex cytogenetic abnormalities, 55XY,+2,del(3)(p14),+7,+8,+12,+13,+16,+17,+20[11 ], and 2 cases had normal karyotypes. None had t(6;11)/TFEB+ immunostaining. Five cases had focal, weak MITF tumor immunostaining. The key clinical findings were as follows: (1) The presence of an Xp11.2 (TFE3) translocation frequently is associated with advanced stage at initial examination. (2) All patients who underwent complete, partial nephrectomy with clear margins (adequate only for stage 1) and resection of metastases were alive and relapse-free at last follow-up. (3) The mean +/- SD event-free survival and overall survival rates at 5 years were both 92% +/- 7.4%. (4) One patients with a TFE3+ and MITF+ tumor and 66-87,XXY,der(1)t(1;8)del(4)(q?) der(11)t(11;15)der17t(X;17 abnormalities died 9 months after diagnosis.

Concurrent acute myeloid leukemia with inv(16)(p13.1q22) and chronic lymphocytic leukemia: Molecular evidence of two separate diseases

Acute myeloid leukemia (AML) occurring concurrently with or after untreated chronic lymphocytic leukemia (CLL) is rare. We report a case of a 59-year-old man who was evaluated for anemia, thrombocytopenia, and leukocytosis with circulating blasts. On the basis of the morphology and immunophenotyping results, a preliminary diagnosis of chronic myelomonocytic leukemia with concurrent CLL was considered. Subsequently, cytogenetic analysis of the leukemic blood specimen revealed inv(16)(p13.1q22) with secondary trisomy 22 in a sideline clone. Fluorescence in situ hybridization confirmed the CBFbeta rearrangement associated with inv(16) in myeloblasts and myelomonocytic cells, but not in CLL cells. Therefore, a final diagnosis of AML with inv(16) with concurrent CLL was made. After standard chemotherapy for AML, the patient achieved complete remission for both his AML and CLL. The unique aspects of this case include concomitant AML and CLL, which do not share clonality, complex cytogenetic abnormalities with trisomy 22 as a secondary abnormality associated with inv(16), and achievement of remission for both AML and CLL by AML chemotherapy regimen. This case also represents one of the rare instances where a diagnosis of AML can be established even when the blast percentage in the marrow and blood is less than 20%.

A subtle t(3;8) results in plausible juxtaposition of MYC and BCL6 in a child with Burkitt lymphoma/leukemia and ataxia-telangiectasia

Translocations involving 3q27 that affect the BCL6 gene are common and specific chromosomal abnormalities in B-cell precursor non-Hodgkin lymphoma (mainly diffuse large-cell and follicular lymphoma), but they have not been reported in Burkitt lymphoma. Here, we describe a case in which a BCL6 rearrangement and additional complex cytogenetic abnormalities occurred in a child with Burkitt lymphoma/leukemia and ataxia-telangiectasia. Although cytogenetic analysis of the bone marrow revealed clonal abnormalities of chromosome arms 8q and 14p and other subclonal abnormalities, the t(8;14) or its variants typically associated with Burkitt lymphoma were not observed. Fluorescence in situ hybridization with locus-specific probes and multicolor spectral karyotyping demonstrated a complex pattern of chromosomal rearrangements leading to a subtle t(3;8)(q27;q24.1) that rearranged BCL6 and placed it adjacent to MYC. We speculate that this genetic lesion occurred as a result of chromosomal instability due to the underlying disease.

Hypercalcemia in B-Cell Chronic Lymphocytic Leukemia: Report of a Case and Review of the Literature.

A 53 year old man with Rai stage IV CLL was being treated with R-HyperCVAD when he presented between cycles with fatigue, lethargy and pancytopenia. Clinical examination revealed diffuse adenopathy and splenomegaly. Serum calcium was 13.6 mg/dl, phosphorus level was 2.7 mg/dl, and alkaline phosphatase was 54 U/L. PTH was 4 Units/L (10–65), PTHrP < 0.2 pmole/L (0–1.9), 1–25 (OH) Vitamin D < 10pgm/ml (22–67). Quantitative immunglobulins: IgA 10 mg/dl, IgG 252 mg/dl, IgM 50 mg/dl. Immunofixation revealed a faint IgG lambda paraprotein. There were no lytic lesions on skeletal survey. Bone marrow biopsy revealed focal large cell transformation (Richter's syndrome). Cytogenetics revealed 3 metaphases with complex cytogenetic abnormalities, indicating clonal evolution. The hypercalcemia resolved with appropriate therapy, but despite subsequent treatment with CAMPATH, he died 2 weeks after diagnosis.A review of reported patients with CLL and hypercalcemia in the literature was performed from 1980 onwards using MEDLINE and PubMed; only those cases in which clinical aspects, biochemistry, PTH levels, imaging studies and concurrent pathology (if obtained) were documented, are summarized in this analysis (n=13).Rai stage: I n=1, II n=4, III n=3, IV n=5. Immunoreactive PTH levels were low or normal in 100% of patients. In 5 cases in which it was measured, 1–25 (OH) Vitamin D levels were not elevated. PTHrP was normal in 2 cases and elevated in 1. In nine patients, multiple lytic bone lesions were present on skeletal radiology. Two patients had osteopenia without lytic lesions. Two had no lytic lesions.Six of ten patients had evidence of transfomation on lymph node and/or bone marrow biopsy performed at the time of evaluation for hypercalcemia.Prognosis was poor (range 0.5–12 months) with only one patient surviving post allo-transplant.In conclusion, hypercalcemia in CLL is rare. Osteolytic lesions are present in the majority of cases. PTH levels are low, and thus this hormone is not mediating the hypercalcemia. The evidence is also against a role of elevated Vitamin D. Histological transformation is seen in half of the cases. Survival is poor after diagnosis of hypercalcemia. The mechanisms(s) of the osteolysis and hypercalcemia remain to be defined.

Myelodysplasia and acute myeloid leukemia following therapy for indolent lymphoma with fludarabine, mitoxantrone, and dexamethasone (FND) plus rituximab and interferon alpha

AbstractTreatment-related myelodysplasia (t-MDS) occurs less frequently with the nucleoside analogs than with DNA-damaging agents such as alkylators or topoisomerase II inhibitors. In a chemoimmunotherapy trial conducted between 1997 and 2003 in patients with stage IV indolent lymphoma, 202 patients were treated and 8 have developed MDS between 1 and 5 years after therapy, including 4 who received only fludarabine, mitoxantrone, and dexamethasone (FND) for 6 to 8 courses, with or without rituximab, followed by interferon alpha (IFN-α). Complex cytogenetic abnormalities were present in all patients. Abnormalities of chromosome 7 were present in 6 of the 8 patients, 3 of whom received only FND ± rituximab and IFN-α. The abnormalities of chromosome 7 were monosomy 7 in 4 patients (1 of which had add 7p in the remaining chromosome); 1 del 7q; and 1 der 7. MDS with features classically associated with DNA-damaging agents can occur following therapy with FND, with or without rituximab, and IFN-α. (Blood. 2005;105:4573-4575)

Myelodysplasia and Myeloproliferative Disorders in Children

Myelodysplastic syndromes (MDSs) are uncommon in pediatric patients; they account for less than 10% of hematopoietic malignancies. In about one third of children with MDSs there is a predisposing genetic condition. MDS in children is more difficult to classify using criteria applied to cases in adult populations, and there are often features present that bridge those of MDS and chronic myeloproliferative diseases. Two groups of MDSs are found in children: juvenile myelomonocytic leukemia, which is unique to infants and young children, and adult-type MDS. A high percentage of children with MDS have bone marrow cytogenetic abnormalities; monosomy 7 is the most common. Patients less than 1 year of age at diagnosis have a significantly better survival than older children. A low platelet count, elevated hemoglobin F (>15%), and complex cytogenetic abnormalities are unfavorable prognostic indicators. MDSs must be distinguished from the same nonneoplastic causes of myelodysplasia that occur in adults, but in addition there are a number of congenital disorders of hematopoiesis and inherited metabolic diseases that affect hematopoiesis in children.

Phase I Clinical Trial of Glivec in Combination with Tetra-Arsenic Tetra-Sulfide in the Treatment of CML Patients in Advanced Phase.

OBJECTIVE: To evaluate the safety and efficacy of Glivec in combination with As4S4 in the treatment of advanced CML patients.PATIENTS AND METHODS: 9 Ph+ CML patients in advanced phase were entered into the study. The first 3 patients received Glivec 400mg/d plus As4S4 150mg/kg/d (day 1–14, each month). If no patient were to experience grade 3/4 CTC toxicity after one month of treatment, the dose of Glivec would be increased to 600mg. All the patients were treated and followed up for 6 months. Adverse events, hematological, cytogenetic, molecular response and real-time RT-PCR were evaluated in each regular visit.RESULTS: From Dec.2003 to June.2004, 9 patients consisting of 6 males and 3 females were enrolled in this trial, 5 in accelerated phase and 4 in blast crisis, aged 22–53 years (median 33). The first 3 patients received Glivec 400mg/d plus As4S4, and other 6 patients received increased dosage of Glivec to 600mg/d. By the time of report, 6 patients had finished the study. 7/9 patients (77.8%) achieved complete hematological response (CHR). 2 patients relapsed after 4 and 5 months of treatment, respectively, and 2 patients withdrew from the study after 1 and 2 months respectively to receive chemotherapy due to progression of the disease. Notably, 3 of these 4 patients had complex cytogenetic abnormalities. Cytogenetic response was observed in 3 patients (33.3%), including 2 major cytogenetic response (1 complete response) and 1 minor response. No molecular response was obtained so far in any patients. Bcr-Abl fusion transcript copy number was measured by real-time RT-PCR in 3 patients, 1 patient with CCR had 3140 fold reduction of BCR-ABL DoseN. Non-hematologic toxicities such as gastrointerstinal discomfort, edema, liver dysfunction and myalgia/bone pain were common and mild (grade 1/2). Grade 3/4 hematological toxicities including neutropenia, thrombocytopenia and anemia occurred in 3 patients.CONCLUSIONS: Glivec in combination with As4S4 has potential effect in advanced CML with acceptable toxicities. Further investigation will be performed to compare the efficacy of Glivec/As4S4 combinative therapy with Glivec mono-therapy in advanced CML.

Management of Acute Myeloid Leukemia (AML) in First Relapse: Retrospective Analysis about 101 Adults Cases Receiving Homogeneous First-Line Therapy. Impact of Prognostic Factors and Treatment.

We retrospectively analyzed impact of prognostic factors and salvage therapy in 101 patients (pts) with AML in 1st relapse. All pts were treated as 1st line according protocols GOELAMs 1 (87–94) or 2 (95–99). They all achieved complete remission after one (85%) or two (16%) induction with a combination of anthracycline and cytarabine. Consolidation therapy included one course of high-dose cytarabine (HiDAC) and a second consolidation (amsacrine-VP16) or, for a subset of pts, intensification with allogeneic or autologous stem cell transplantation (SCT). Data were collected in 3 of the centers participating to these trials. Main characteristics of pts at initial diagnosis were: median age : 39 y (range 17–64); sex : 55 male, 46 female; WBC count > 30 000/μl in 42 (42%) pts; 16/85 (18%) pts had unfavorable karyotype. Median duration of 1st complete remission (CR1) was 10 months (range: 1–101). Duration of CR1 was shorter than 6 months in 22 (22%) pts, between 6 and 12 months in 41 (40%) pts and longer than 12 months in 38 (38%) pts. At time of 1st relapse, median age was 40 y (range 18–66) and 10/38 (26%) unfavorable karyotype.There were no specific recommendations in the GOELAMs protocols for the second line therapy: modalities of treatment were therefore left to investigator's decision. First step of relapse treatment was based on intensive chemotherapy in 79 (79%) pts including 55 pts who received a regimen containing HiDAC (Group 1) and 24 pts who received a chemotherapy without HiDAC (Group 2). Eight pts received an autologous SCT (4 pts) or an allogeneic SCT (4 pts) without any previous salvage chemotherapy (Group 3). One pt received gemtuzumab ozogamicin and thirteen pts received only oral chemotherapy and/or supportive care (Group 4).Fifty-seven pts (56%) achieved a second CR. Response rate and median survival according to initial therapy of relapse are shown in the following table. Differences are not significant.Complete response (%)Median survival (months)Group 1 (n = 55)39 (71%)11.5Group 2 (n = 2410 (42%)8Group 3 (n = 8)6 (75%)7.5Group 4 (n = 14)2 (14%)3.5Twenty seven pts out of the 49 pts who achieved a CR2 after intensive chemotherapy (Group 1 and 2) received subsequent intensification with either an allogeneic SCT (7 pts) or an autologous SCT (20 pts). Median survival of these pts subsequently transplanted was 18 months compared to only 10 months in the 22 pts of group 1 and 2 who did not receive a subsequent transplantation. Difference is not significant (log rank test, p = 0.65). Nine (33%) of the 27 transplanted pts are alive more than 36 months after relapse (range 41–120).Univariate analysis demonstrated that adverse prognosis factors on survival at 1st relapse were duration of RC1 shorter than 12 months (p= 0.005)and complex cytogenetic abnormalities (p= 0.0086).Conclusion: Intensive chemotherapy including HiDAC at 1st relapse in AML in adults provided a high rate of complete response. Intensification with SCT after CR2 was obtained can provide a very long survival in a limited number of pts. At 1st relapse, adverse prognostic factors on survival were short CR1 and unfavorable karyotype. Risk-adapted of AML in first relapse may therefore be warranted. [Display omitted]

Nonmyeloablative Unrelated Donor Hematopoietic Cell Transplantation (HCT) for Patients (pts) with Poor Risk, Relapsed or Refractory Multiple Myeloma.

We investigated the feasibility of HLA-matched unrelated donor (URD) HCT in pts with advanced stage, poor-risk multiple myeloma after nonmyeloablative conditioning. Nineteen pts, median age 52 years (range, 28–65), were treated between 5/2000 and 2/2004. Eight pts had known complex cytogenetic abnormalities including Δ13. At study entry, 12 pts had relapsed or refractory disease after a previous autologous HCT, 5 pts had refractory disease following multiple standard chemotherapy regimens, and 2 pts achieved a partial remission (PR) after standard chemotherapy. Before URD HCT, 10 pts underwent a planned high dose autologous HCT (Melphalan 200 mg/m2) to provide cytoreduction a median of 85 days prior to URD HCT, including 4 pts with relapsed/refractory disease after a prior autologous HCT. Three pts were in complete remission (CR) immediately prior to URD HCT. Nonmyeloablative conditioning consisted of fludarabine (30 mg/m2 x 3 days) and 2 Gy total body irradiation followed by PBSC grafts from URDs matched for HLA-A, −B, −C antigens and -DRB1 and -DQB1 alleles. Postgrafting immunosuppression included mycophenolate mofetil and cyclosporine. Durable engraftment was achieved in 18 of 19 pts. One pt had graft rejection at day +56 and received a second successful nonmyeloablative HCT from another URD. Acute GVHD occurred in 13 (68%) pts and was exclusively grades II and III in 11 and 2 pts, respectively. Chronic extensive GVHD occurred in 12/17 (70%) of evaluable pts. After allografting, 9 pts (47%) were in CR and 3 (16%) in PR, for an overall response rate of 63%. Four pts (21%) died of progressive disease and 4 pts (21%) died of non-relapse causes at a median of 5.3 months. The 2-year overall survival, progression-free survival and non-relapse mortality was 62%, 51% and 24%, respectively. The median follow-up was 25 months. Eleven of 19 pts (58%) were alive, 6 (32%) in CR, 1 (5%) in PR, 2 (10%) with stable disease (SD) and 2 (10%) with relapse after initially achieving CR. Of the 10 pts who underwent a planned high dose autologous HCT for cytoreduction followed by nonmyeloablative URD HCT, 8 were alive: 6 CR, 1 SD, 1 relapse. Of the 9 pts who underwent nonmyeloablative URD HCT without planned autologous HCT, 3 were alive: 1 PR, 1 SD and 1 relapse. Of the 12 pts who entered the study with relapsed/refractory disease after a previous autologous HCT, 5 were alive: 2 CR, 1 PR, 1 SD, 1 relapse. In summary, URD HCT after nonmyeloablative conditioning is feasible with relatively low non-relapse mortality and provides a high response rate for pts with relapsed or refractory multiple myeloma, including pts with disease relapse following an autologous HCT. The data suggest that a treatment strategy consisting of two sequential transplants (1) intensive cytoreductive therapy with autologous HCT followed by (2) nonmyeloablative URD HCT, may be highly effective for treating pts with poor risk, chemotherapy-refractory multiple myeloma or after relapse following autologous HCT.

Molecular cytogenetic study of a mantle cell lymphoma with a complex translocation involving the CCND1 (11q13) region

We describe a progressive mantle cell lymphoma (MCL) in which multicolor fluorescence in situ hybridization (M-FISH) on metaphases did not detect the characteristic t(11;14)(q13;q32), although translocations of chromosomes 11 with 15, and 14 with 15 were observed. When CCND1/IGH probes were hybridized to metaphases, however, cryptic fusion signals were detected on the der(11) and der(14) sites of CCND1 (11q13) and IGH (14q32), revealing a complex translocation involving chromosomes 11, 14, and 15. Interphase FISH with CCND1/IGH probes revealed varying patterns with one or two fusion signals, and some with no clear evidence of fusion. Loss of 17p and gain of 3q, known to be associated with disease progression in MCL, were detected with M-FISH and confirmed with the use of p53 and BCL6 probes together with comparative genomic hybridization, which detected also an interstitial deletion on 7p21. This case further illustrates the value of M-FISH in combination with fusion probes in elucidating complex cytogenetic abnormalities.

Primary Subcutaneous Primitive Neuroectodermal Tumor with Aggressive Behavior and an Unusual Karyotype: Case Report

Primitive neuroectodermal tumor/Ewing sarcoma (PNET/ES) rarely occurs in the skin and subcutaneous tissues. We present a case of a 16-year-old girl with primary cutaneous and subcutaneous PNET/ES of the abdominal wall. Despite wide local excision and chemotherapy, she rapidly developed cranial bone and brain metastases, followed by lung and skeletal metastases, and died shortly thereafter. The recurrent tumor exhibited light microscopic features of a small, round, blue cell tumor with intracytoplasmic glycogen. Immunohistochemical analysis showed positivity for CD99, CD56, S100, and glial fibrillary acid protein, and ultrastructural features included cytoplasmic glycogen and focal complex interdigitating synaptic junction-like cytoplasmic folds. Cytogenetic analysis of the relapsed tumor showed a complex karyotype: 47,XX,i(1)(q10), der(4)t(4;19) (q33 approximately q35;q13.1), + 8,t(15;17)(q24;p11.2 approximately p12),der(19)t (19;20)(q13.1;p11.2),der(22)t(20;22)(q13;q13). Cytogenetic, interphase fluorescence in situ hybridization, and molecular genetic analyses failed to show t(11:22) (q24;q12) or abnormalities of chromosome region 22q12. The clinical behavior and atypical and complex cytogenetic abnormalities exhibited by the tumor in this patient are unusual and represent the most aggressive end of the clinical spectrum of cutaneous and subcutaneous PNET/ES.

Comparative evaluation of microsatellite marker, AP-PCR and CGH studies in primary renal cell carcinoma

Renal cancer consists of a heterogeneous tumor group which is characterized by complex cytogenetic and molecular genetic abnormalities. In this study, three different techniques were applied to screen renal cancers for genetic alterations. We studied 99 primary, sporadic renal cancers (96 renal cell carcinomas and three other renal cancers) by a comparative evaluation of different microsatellite markers, comparative genomic hybridization (CGH) and AP-PCR. The AP-PCR produces a genomic fingerprint after an AluEI DNA restriction digest of tumor DNA samples. Microsatellite alterations were investigated using nine microsatellite markers spanning well-known regions of FhiT and VHL (3p14.2, 3p26) but also of oncogenes and tumor suppressor genes like Myc-L1 and TP53Alu (1p32, 17p13.1). To receive a genomic fingerprint, AP-PCR was carried out for all patient samples. Performing AP-PCR, only one case out of 99 displayed genomic imbalance. Seven of 99 investigated primary renal cancers showed alterations in up to four microsatellite loci (TP53Alu, Myc-L1, D3S1300, D3S1560, D3S1317, D3S4260). Three markers (Bat25, Bat26, REN) did not reveal any aberrations within the tested tumor samples. Six cases with microsatellite alterations and four without were examined by CGH. Five samples yielded aberrations, four of them were positive for microsatellite alterations. Only one tumor sample displayed microsatellite alterations, shift patterns in AP-PCR and alterations analyzed by CGH. Our data suggest that genomic aberrations found by microsatellite analysis are also detectable by CGH with the restriction of a minimum of alterated DNA of >10 Mb. Based on this study of RCC and in contrast to other reports for solid tumors, we conclude that AP-PCR is far less informative in investigation of renal cancers.

Long-Term Survivors in Myelodysplastic Syndromes: Clinical and Biological Characteristics

Twenty-eight of 285 patients (9.8%) with primary myelodysplastic syndrome (MDS) survived more than 5 yr (long-term survivors). There were 21 females and 7 males, median age 60 yr (range 18-84 yr). None had circulating blasts, and 14 had refractory anemia (RA), 8 RA with ringed sideroblasts (RARS) and 6 RA with excess of blasts (RAEB). Thirty-seven percent of the 27 patients who were karyotyped had an abnormal clone, but none of them had -7/7q- or complex cytogenetic abnormalities. Only one of the 13 patients tested had abnormal (i.e., "leukemic") in vitro growth of GM progenitors. During 5 yr following the diagnosis, none of the 28 patients progressed to AML. Two patients with an initial diagnosis of RA showed progression to RAEB and CMML. After 5 yr, 23 of the 28 long-term survivors had stable disease (follow-up period ranged from 64 to 216 mo). One patient progressed to AML (113 mo after diagnosis) and another to RAEBT (80 mo after diagnosis). Eight asymptomatic patients were not treated and 12 patients received only supportive therapy. Except for 6 of 8 treated patients who responded to low-dose Ara-C, danazol, androgens, or immunosuppressive treatment, prolonged survival seemed to result mainly from the natural course of the disease. Except for Valensia score (p=0.033), other scoring systems (Bournemouth, Dusseldorf, Lille, and IPSS score) proved of relatively limited value in differentiating between intermediate (2-5 yr) and long-term survivors.

Myelodysplastic syndrome after acute promyelocytic leukemia: the European APL group experience.

With improved treatment of acute promyelocytic leukemia (APL) by all trans retinoic acid (ATRA) combined to anthracycline-aracytin chemotherapy (CT), a larger number of those patients may be at risk of late complications. Recently, the Rome group reported five cases of myelodysplastic syndrome (MDS) or acute myeloid leukemia (AML, non-APL) occurring during the course of 77 APL patients (6.5%) in complete remission (CR). From 1991 to 1998, we treated 677 newly diagnosed cases of APL, and 617 of them achieved CR with ATRA combined to CT (n=579) or CT alone (n=38); 246 of them received subsequent maintenance CT with 6 mercaptopurine and methotrexate. With a median follow-up of 51 months, 6 patients (0.97%) developed MDS, 13-74 months after the diagnosis of APL. In all six cases, t(15;17) and PML-RARalpha rearrangement were absent at the time of MDS diagnosis, and karyotype mainly showed complex cytogenetic abnormalities involving chromosomes 5 and/or 7, typical of MDS observed after treatment with alkylating agents, although none of the six patients had received such agents for the treatment of APL. Our findings suggest that MDS can indeed be a long-term complication in APL, although probably at lower incidence than that previously reported.