Killer Cell Precursor Acute Leukemia Research Articles

Myeloid/natural killer (NK) cell precursor acute leukemia as a distinct leukemia type

Myeloid/natural killer (NK) cell precursor acute leukemia (MNKPL) has been described on the basis of its unique immunophenotype and clinical phenotype. However, there is no consensus on the characteristics for identifying this disease type because of its rarity and lack of defined distinctive molecular characteristics. In this study, multiomics analysis revealed that MNKPL is distinct from acute myeloid leukemia, T cell acute lymphoblastic leukemia, and mixed-phenotype acute leukemia (MPAL), and NOTCH1 and RUNX3 activation and BCL11B down-regulation are hallmarks of MNKPL. Although NK cells have been classically considered to be lymphoid lineage–derived, the results of our single-cell analysis using MNKPL cells suggest that NK cells and myeloid cells share common progenitor cells. Treatment outcomes for MNKPL are unsatisfactory, even when hematopoietic cell transplantation is performed. Multiomics analysis and in vitro drug sensitivity assays revealed increased sensitivity to l -asparaginase and reduced levels of asparagine synthetase (ASNS), supporting the clinically observed effectiveness of l -asparaginase.

Comprehensive Genetic Analysis Revealed Myeloid/Natural Killer (NK) Cell Precursor Acute Leukemia As a Novel Distinctive Leukemia Entity

Introduction: Myeloid/Natural killer (NK) cell precursor acute leukemia (MNKPL) is a rare hematologic malignancy prevalent in East Asia. MNKPL is characterized by extramedullary involvement, immature lymphoblastoid morphology without myeloperoxidase (MPO) reactivity, the CD7+/CD33+/CD34+/CD56+/HLA−DR+ phenotype. MNKPL is classified as mixed phenotype acute leukemia, and not otherwise specified rare types (MPAL NOS rare types) in WHO classification. However, its characteristic clinical feature and undetermined genetic feature suggests that MNPKL leaves open the possibility of a new independent disease concept. Here, we report clinical features and genetic alterations in patients with MNKPL. Methods: The Leukemia and Lymphoma Committee of the Japanese Society of Pediatric Hematology and Oncology (JSPHO) sent out questionnaires to 110 JSPHO affiliated hospitals and collected cases of MNPKL diagnosed during the period 2000-2013. Besides, the cases published as literature were recruited. The data of clinical features, cell surface antigen profiling, overall survival (OS), and event-free survival (EFS) defined as relapse or death were also collected as a secondary survey. The protocol of this retrospective study was approved by the review boards of JSPHO and Ehime Prefectural Central Hospital. Comprehensive genetic analysis including 13 whole-exome sequences (WES), 2 target sequence, 6 RNA sequence (RNA-seq), and 8 DNA methylation analysis was performed. We also performed single-cell RNA-seq using 1 sample of MNKPL patients and a normal bone marrow sample as the reference. The research protocol was approved by the review board of TMDU. Results: Sixteen children or young adults (< 39 years old) and 2 older adults with MNKPL were identified. The median age of MNKPL patients was 11 (0.5-75) years old. There are 12 males and 6 females. The extramedullary involvement was observed in 7 patients. Complete remission after induction therapy was achieved in 8/14 (57%) patients treated with acute myeloid leukemia (AML) type chemotherapy and 2/4 (50%) patients treated with acute lymphoblastic leukemia (ALL)/non-Hodgkin lymphoma type chemotherapy, respectively. Fifteen patients underwent hematopoietic cell transplantation (HCT). The median follow-up period was 3.8 (0.1-16.0) years. 5-year OS and 5-year EFS was 49.5% and 40.7%, respectively. In genetic analysis, median 388 somatic mutations in MNKPL were identified by WES. The recurrent mutations were observed in NOTCH1 (n=5), MAML3 (n=4), NRAS, MAP3K4, RECQL4, CREBBP, ASXL2, and KMT2D (n=3, respectively), and MAML2, MAP3K1, FLT3, CARD11, MSH4, FANCI, WT1, ZNF384, and ERG (n=2, respectively). The distinct expression pattern, higher expression of RUNX3 and NOTCH1, and lower expression of BCL11B were identified in MNKPL samples which were compared to MPAL, AML, and T cell ALL in RNA-seq. The distinct methylation profile, hypomethylation of RUNX3 regulatory region, and hypermethylation of BCL11B regulatory region were identified in DNA methylation analysis. Single-cell RNA-seq analysis also showed distinct 4 subsets of MNKPL. Discussion and Conclusions: NK cells are the founding member of a family of innate lymphoid cells (ILC). Genetic abnormality of NOTCH1 pathway is a hallmark of MNPKL. RUNX3 is required for NK cell survival and proliferation in response to IL-15 signaling. RUNX3 high expression and hypomethylation of RUNX3 regulatory region also characterize MNKPL. Currently, MNKPL is classified as MPAL NOS, our genetic analysis revealed that MNKPL is a distinct group from MPAL. The prognosis of MNKPL was not satisfactory even though HCT was performed. The development of new therapeutic approaches based on these genetic analyses is highly expected. Disclosures Saito: Toshiba Corporation: Research Funding. Nakazawa:Toshiba Corporation: Research Funding.

Clinical Feature and Genetic Alterations in Myeloid/Natural Killer (NK) Cell Precursor Acute Leukemia and Myeloid/NK Cell Acute Leukemia

Introduction: Myeloid/Natural killer cell precursor acute leukemia (MNKPL) and myeloid/NK cell acute leukemia (MNKL) is a rare hematologic malignancy prevalent in East Asia. MNKPL is characterized by marked extramedullary involvement, immature lymphoblastoid morphology without myeloperoxidase (MPO) reactivity, a CD7+/CD33+/CD34+/CD16−/CD15−/+/HLA-DR+ phenotype, myeloid chemosensitivity, and a poor prognosis. By contrast, MNKL shows no extramedullary involvement, a HLA‐DR−/CD33+/CD16−/CD34−/+ phenotype, myeloid chemosensitivity, and a good prognosis. However, analysis of outcome and genetic alterations in these leukemias are limited. Here, we report outcome and genetic alterations in the patients with MNKPL and MNKL.Methods: The Leukemia and Lymphoma Committee of the Japanese Society of Pediatric Hematology and Oncology (JSPHO) sent out two questionnaires to 110 JSPHO affiliated hospitals. The first questionnaire requested details of the number of pediatric patients with MNKPL or MNKL had been diagnosed during the period 2000-2013. The second questionnaire requested more detailed information about clinical curses. Overall survival (OS) and event free survival (EFS) defined as relapse or death was analyzed. The protocol of this retrospective study was approved by the review boards of JSPHO and Ehime Prefectural Central Hospital.We also performed whole exome sequence (WES) using 7 children's samples (5 MNKPL, 2 MNKL) and target sequence using 2 adult's samples (2 MNKPL) from this and another independent cohort. The research protocol was approved by the review board of TMDU.Results: Thirteen children with MNKPL and 6 children with MNKL were identified. Median age of MNKPL was 8 year-old (range; 0.5-17) and median age of MNKL was 10 year-old (range; 2-13). There are 8 males and 5 females in MNKPL and 4 males and 2 females in MNKL. In MNKPL, central nervous system, mediastinum and lymph node involvement was observed in 1 case respectively. Nasal sinus involvement was observed in 1 case in MNKL. Eleven patients with MNKPL and 3 patients with MNKL were treated with acute myeloid leukemia style chemotherapy and 1 MNKPL patients and 3 MNKL patients were treated with acute lymphoblastic leukemia/non-Hodgkin lymphoma style chemotherapy. Complete remission after induction therapy was achieved in 8/13 MNKPL children and 4/6 MNKL children. Twelve out of 13 MNKPL children and all 6 MNKL children underwent hematopoietic cell transplantation (HCT) with myeloablative conditioning regimen. Median follow up period was 5.3 years in MNKPL and 3.8 years in MNKL patients. 5-year OS of MNKPL and MNKL was 67.3 % and 41.7 %, 5-year EFS of MNKPL and MNKL was 52.7 % and 41.7 % respectively.In genetic analysis, average 148 somatic mutations in MNKPL and 88 somatic mutations in MNKL were identified by WES. In combined analysis using adult cases, the recurrent mutations were observed in NOTCH1, NRAS (n=3, respectively), MAML2, MAP3K1, SIRPA (n=2, respectively) as activating signal genes, and CLTCL1 (n=2) as cell adhesion molecules, and RECQL4 (n=2) as cell cycle/DNA repair molecules, and PRDM2, CREBBP, SETBP1 (n=2, respectively) as epigenetic modifiers, and WT1, ZNF384, BCLAF1 (n=2, respectively) as transcription factors.Conclusions: Previously, it has been reported that outcome of MNKL is relatively good than MNKPL. MNKPL and MNKL children had a poor prognosis in our cohort even though most patients received HCT. We identified alteration of molecules involved in NOTCH signaling and RAS-MAPK pathways. In addition, mutations of several transcription factors such as WT1 were identified. The drugs targeting RAS pathway and epigenetic factors may have the potential to improve outcome. An international collaboration for clinical and cytogenetic research of MNKPL and MNKL is needed as they are complex and rare diseases. DisclosuresNo relevant conflicts of interest to declare.

Sjögren's Syndrome Complicated by Myeloid/Natural Killer Cell Precursor Acute Leukemia: Case Report and Review of the Literature.

We report a case of Sjögren's syndrome (SS) complicated by myeloid/natural killer (NK) cell precursor acute leukemia (M/NKPAL). A 75-year-old woman with a previous SS history for 2 years was routinely treated. Peripheral blood progenitor cells were increased, and subsequent bone marrow cell morphology examination showed the presence of acute myeloid leukemia type M4. However, flow cytometry analysis revealed that CD7/CD56/CD33/CD34/HLA-DR/cCD3 were all positive and myeloperoxidase- (MPO-) specific staining, other T cells, NK cells, and myeloid markers were all negative. Clonal T-cell receptor (TCR)β/TCRγ/TCRδ gene rearrangements and Epstein-Barr virus (EBV) were negative. The diagnosis of M/NKPAL was therefore confirmed. Unfortunately, this patient did not receive chemotherapy and later died of acute left heart failure and respiratory failure. SS complication with M/NKPAL is relatively rare. Combined with the relevant literatures, our study offers new insights into the clinical characteristics, pathological features, possible pathogenesis, and differential diagnosis of this rare disease.

Myeloid/natural killer cell precursor and myeloid/natural killer cell acute leukemia

With the popularity of flow cytometry, the classification of leukemia become more detailed. Myeloid/natural killer cell precursor acute leukemia and myeloid/natural killer cell acute leukemias are generally recognized as two kinds of rare leukemias and have poor prognosis. The cells expressed both myeloid and lymphatic antigens in these two leukemia and can not be diagnosed by morphology. The only basis to make a definite diagnosis is their unique Immunophenotyping. The role of CD7 and CD56 in these two leukemia are compelling, in the other hand, as the progress of cell differentiation research, there are many new awareness of NK cell differentiation. In this article, the biological origin, clinical manifestation, diagnosis, treatment and the role of CD7 and CD56 in these two leukemia are briefly summarized.

Loss of mismatched HLA in myeloid/NK cell precursor acute leukemia relapse after T cell-replete haploidentical hematopoietic stem cell transplantation

Myeloid/natural killer cell precursor acute leukemia (MNKL) is an aggressive disease with a high relapse rate even after allogeneic hematopoietic stem cell transplantation (SCT). We report a patient with MNKL who had a donor lymphocyte infusion (DLI) for relapse after T cell-replete human leukocyte antigen (HLA)-haploidentical SCT, but relapsed again 20 months later with loss of mismatched HLA. This case suggests that a strong graft-versus-leukemia effect of haploidentical SCT can be expected in MNKL patients. In the haploidentical setting, DLI should be considered for patients with relapsed leukemia whose leukemic cells have not lost HLA cell surface expression.

Myeloid/natural killer cell precursor acute leukemia diagnosed by cell marker analysis

Myeloid/natural killer cell precursor acute leukemia diagnosed by cell marker analysis

A child with myeloid/natural killer cell precursor acute leukemia treated successfully with acute myeloid leukemia-oriented chemotherapy incorporating l-asparaginase

A child with myeloid/natural killer cell precursor acute leukemia treated successfully with acute myeloid leukemia-oriented chemotherapy incorporating l-asparaginase

Myeloid/natural killer cell precursor acute leukemia with multiple subcutaneous nodules as the initial presentation: a case report and literature review

Myeloid/natural killer (NK) cell precursor acute leukemia is a rare neoplasm, which is characterized by high incidence of extramedullary infiltration, especially in the mediastinum and lymph nodes, an aggressive course and poor prognosis. As coexpressing myeloid and NK-cell antigens, myeloid/NK-cell precursor acute leukemia (MNKL) may pose diagnostic difficulty. Because the developmental pathway of normal NK cells is not well understood, neoplams of NK-cell origin are not clearly identified. To our knowledge, there have been only about 30 cases with this disease published previously. In the current paper, we present a case of a 21-year-old male patient whose initial presentation showed numerous subcutaneous nodules without bone marrow involvement. A diagnosis of MNKL was finally made by skin biopsy, bone marrow immunohistochemistry and immunophenotypic analysis. Although bone marrow achieved complete remission using DA chemotherapeutic regimen, the skin nodules did not regress. However, FLAG chemotherapeutic regimen, including fludarabine, cytarabine and G-CSF, was effective for both bone marrow and skin involvement. To the best of our knowledge, this study is the first to describe the effect of FLAG regimen for the treatment of this disease, indicating that it may be effective against the skin involvement of MNKL.

Transformation of myelodysplastic syndrome into myeloid/natural killer cell precursor acute leukemia involving mainly lymph nodes

Myelodysplastic syndrome (MDS) is a clonal disorder of haematopoietic stem cells that is characterised by ineffective haematopoiesis and susceptibility to transform into acute myeloid leukemia. Alt...

Myeloid/natural killer cell precursor acute leukemia with tetraploidy

Myeloid/natural killer (NK) cell precursor acute leukemia is characterized by coexpression of myeloid and natural killer cell antigens and an aggressive clinical course. Here we report a case of myeloid/NK precursor acute leukemia in a 37-year-old woman. Clinical presentation was correlated with leukemic blast morphology, immunophenotype, and cytogenetic analysis. The patient had noted fever, weakness, purpura, peripheral lymphadenopathy, and moderate hepatosplenomegaly. Peripheral blood smears and bone marrow aspirate smears at presentation revealed blastic cells, which were generally L2 shaped, with variation in cell size, round to moderately irregular nuclei and prominent nucleoli, pale cytoplasm, and a lack of azurophilic granules. Immunophenotypic analysis of the blasts displayed coexpression of myeloid and natural killer cell antigens with relatively immature phenotype: CD7 +, CD33 +, CD34 +, CD56 +, CD57 +, CD16 −, MPO −. Cytogenetic analysis of marrow cells showed 62% of cells with a normal female karyotype; in the remaining 38%, tetraploid changes were detected, where the chromosome number was 92, with no preferential losses or gains of chromosomes. Fluorescence in situ hybridization analysis revealed the same abnormality. The patient did not respond to chemotherapy (cytosine arabinoside and idarubicin) and died of a septic complication on the 34th day after admission. To our knowledge, this is the first description of tetraploidy in myeloid/NK cell precursor acute leukemia.

Challenge in diagnosis of CD56+ lymphoproliferative disorders: two cases of CD56+CD33+ lymphoma/leukemia.

Two cases of CD56+CD33+ leukemia/lymphoma are reported. The patient in case 1 presented with skin rash, diffuse lymphadenopathy, and hepatosplenomegaly. Blasts with monocytoid and lymphoid features were present in the peripheral blood. The tumor cells expressed HLA-DR, CD4, CD33, CD38, and CD56. Cytogenetic analysis revealed del(2)(p13),del(9)(q22),add(6)(q25),add(12)(p12),-13,-18, and -20. The clinicopathologic features were similar to those of blastic natural killer cell leukemia/lymphoma or type 2 dentritic cell leukemia. The patient in case 2 presented with generalized weakness and skin erythema not responding to antibiotics. Circulating blasts with monocytoid features were seen in the peripheral blood. The tumor cells expressed CD7, CD13, CD33, CD38, and CD56, and cytogenetic analysis revealed -5,add(7)(p22),-8, del(10)(p11.2),-12,der(13; 14)(p10;p10),+14,-16,-18,-19, and del(20)(q13.1). The clinicopathologic features were consistent with a myeloid/ natural killer cell precursor acute leukemia. Both disorders are aggressive hematopoietic malignancies that have similar clinical presentation and morphology but differ in immunophenotype and cytogenetic features.

Prognostic significance of CD7+CD56+ phenotype and chromosome 5 abnormalities for acute myeloid leukemia M0.

Myeloid/natural killer (NK) cell precursor acute leukemia is an entity of acute leukemia characterized by poor prognosis and a CD7+CD56+ myeloid antigen+ phenotype without light-microscopic myeloperoxidase reactivity. This disease shares several clinical characteristics with acute myeloid leukemia (AML) M0. To clarify the relationship between these 2 leukemias, we analyzed 105 cases of AML M0. Among them, 17 were CD7+ and CD56+, 77 were negative for either antigen, and 11 could not be determined. CD7+CD56+ AML M0 showed onset at significantly lower patient age (median 46 versus 63 years, P = .004). The disease localization and the hematological manifestations were significantly different: CD7+CD56+ AML showed more frequent extramedullary involvement, fewer circulating leukemic blasts, less anemia, and less thrombocytopenia than did AML M0. The cytogenetic aberrations were also unique, because no 5q abnormalities were found in CD7+CD56+ M0. The prognosis of CD7+CD56+ M0 was poor in patients younger than 46 years (P = .03). Multivariate analysis showed that the CD7+CD56+ phenotype was a significant prognostic factor for AML M0, as well as age, circulating blast percentage, and chromosome 5 abnormalities These findings suggest that AML M0 consists of heterogeneous subgroups to be managed separately, and CD7+CD56+ M0 constitutes a distinct subtype of AML M0.

Acute T-lymphoblastic leukemia relapsed with the character of myeloid/natural killer cell precursor phenotype: a case report

The leukemic lymphoblasts of a patient expressed CD7, CD13, CD33, CD34, HLA-DR and cytoplasmic CD3ε. He was diagnosed with acute lymphoblastic leukemia (ALL), and successfully treated with a conventional chemotherapy for ALL. The disease relapsed three times, and the character of the cells gradually altered, i.e. CD56 expression increased and CD13, CD7 and cCD3ε decreased. The phenotype of the relapsed ALL was, therefore, compatible with myeloid/natural killer cell precursor acute leukemia (M/NK-AL). Some of M/NK-AL may be closely related with T/myeloid-biphenotypic pro-T blasts, and both types of acute leukemia may develop a tendency to express myeloid antigens, and they may belong to the category of immature T lymphoid precursors.

Clinicopathological features of myeloid/natural killer (NK) cell precursor acute leukemia

Four patients (three males and one female) were diagnosed as myeloid/natural killer (NK) cell precursor acute leukemia in our department. Two patients showed the extramedullary involvement at initial presentation. Leukemic cells expressed CD7, CD33, CD45 and CD56 in all patients. Additionally, CD13, CD34, HLA-DR, cytoplasmic CD3 and myeloperoxidase were expressed in some patients. Trisomy 10 was found in two patients, which has not been reported in this disease. Therefore, myeloid/NK cell precursor acute leukemia might be rather heterogeneous especially in chromosomal abnormality though it seemed to constitute the distinct clinical entity among acute myeloid leukemia of M0 subtype.

Detection of acute leukemia cells with mixed lineage leukemia (MLL) gene rearrangements by flow cytometry using monoclonal antibody 7.1

Translocations involving 11q23 are among the most common genetic abnormalities in hematologic malignancies, occurring in approximately 5-10% of acute lymphoblastic leukemia (ALL) and 5% of acute myeloblastic leukemia (AML). In 11q23 translocations, the mixed lineage leukemia (MLL) gene on chromosome 11, band q23, is usually disrupted. The human homologue of the rat NG2 chondroitin sulfate proteoglycan molecule, as detected by the monoclonal antibody (moab) 7.1, was shown to be expressed on leukemic cells with MLL rearrangements of children with acute leukemia. We further investigated the reactivity of the moab 7.1 on 533 cell samples of adults (n = 215) and children (n = 318) with acute leukemias (271 AML, 217 B-lineage ALL, 37 T-lineage ALL, eight CD7+ CD56+ myeloid/natural killer cell precursor acute leukemias) by flow cytometry. In AML, 38 samples were positive for moab 7.1 ('20%-cut-off-level'). These moab 7.1-positive AML cases revealed a myelomonocytic-differentiated immunophenotype with coexpression of the NK cell marker CD56 in 33 of 38 cases. Two of eight cell samples of the recently described CD7+ CD56+ myeloid/natural killer cell precursor acute leukemia entity reacted with moab 7.1. In ALL, 35 samples mostly of the pro-B-ALL subtype (33 pro-B-ALL, one common-ALL, one pre-B-ALL) were positive for moab 7.1. 58 (81%) of 72 samples with MLL rearrangements were positive for moab 7.1 including 28/31 with a t(4;11), 16/17 with a t(9;11), 3/5 with a t(11;19), and 2/6 with a del(11)(q23). All moab 7.1-positive ALL (n = 34) and childhood AML (n = 17) cases revealed MLL rearrangements as detected by Southern blot analysis and RT-PCR. However, 11 adults with AML, and one adult with moab 7.1-positive CD7+ CD56+ myeloid/natural killer cell precursor acute leukemia were negative for MLL rearrangements as proved by Southern blot analysis. We conclude that moab 7.1 is a sensitive but not entirely specific marker for the identification of 11q23-associated AML and ALL by flow cytometry in children and adults.

Secondary myeloid/natural killer cell precursor acute leukemia following essential thrombocythemia

The de novo leukemic transformation of essential thrombocythemia is a rare event, and usually associated with previous treatments. We describe a patient who received treatments with nitrosourea for long-standing essential thrombocythemia and subsequently developed extramedullary tumors, tentatively diagnosed as lymphoblastic lymphoma. Combination chemotherapy was initially successful, but relapsed with marked bone marrow involvement. Surface marker analysis revealed that the tumor cells had CD5, CD7, CD33, CD34, and CD56 antigens but lacked other T-cell, and B-cell markers. Immunogenotypical studies revealed germline configurations for both T-cell receptors and immunoglobulin genes. These clinical and phenotypical features are consistent with a myeloid/natural killer cell precursor leukemia, a recently proposed distinct clinical entity. To our knowledge, this is the first report of secondary leukemia of myeloid/natural killer cell precursor origin, and suggest that myeloid/natural killer cell precursor might be a potent target of therapy-related leukemia.