Positive Chronic Granulocytic Leukemia Research Articles

Molecular analysis in chronic granulocytic leukaemia: location of breakpoints within M-BCR and relationship with presentation platelet counts

Summary Rearrangements within the major breakpoint cluster region (M-BCR) were demonstrated by Southern blot analysis for 74 of 80 patients with Philadelphia (Ph1) positive chronic granulocytic leukaemia (CGL) and for one and three patients with Ph1 negative CGL. Multiple restriction enzyme digestion permitted the breakpoint within the M-BCR to be localized relative to the central Hind III site for 71 patients. 62% had 5′ rearrangements and 38% had 3′ rearrangements. Those with 3′ rearrangements had significantly higher platelet counts at presentation than those with 5′ rearrangements (P < 0.001). We examined factors (such as patient selection criteria and retrospective analysis) which may have influenced previous reports of the prognostic value of the breakpoint location within M-BCR. For patients diagnosed after November 1988 (prospective cases), no significant difference was observed for the duration of chronic phase for patients with 5′ or 3′ rearrangements (P= 0.83, Logrank test). We conclude that, although higher presentation platelet counts were associated with 3′ rearrangements, the location of the breakpoint within the M-BCR appears to be of limited prognostic value.

Changes in Oncogene Expression Implicated in Evolution of Chronic Granulocytic Leukemia from its Chronic Phase to Acceleration

Expression of nine oncogenes was investigated in cell samples from fifteen patients with Philadelphia chromosome (Ph)-positive chronic granulocytic leukemia (CGL) both at diagnosis and at the onset of accelerated phase (AP) of the disease. The bcr-abl fusion gene, the H-ras gene and the c-myb gene were universally expressed. In comparison with the chronic phase (CP) of the disease, an increase in the levels of bcr-abl-, c-myb- and H-ras-related transcripts was found in three, two and three AP samples, respectively. Elevation of the bcr-abl-related message was associated with duplication of the Ph chromosome and amplification of the bcr-abl fusion gene in one AP sample. No CP samples were positive for c-myc or c-sis expression. On the contrary, c-myc and c-sis were expressed in three and four AP samples, respectively. The presence of c-myc-related transcript was associated with trisomy 8 with or without amplification of the c-myc oncogene in leukemia cells of two patients with CGL in AP. No changes of oncogene expression were found in four AP samples. However, we observed deletions of chromosome 13 and 17 or i(17q) in three of them, suggesting that tumor suppressor gene alterations may also be responsible for the development of AP of CGL. Our data indicate that heterogeneous alterations in oncogenes and tumor suppressor genes accompany the evolution of CGL-CP to the AP of the disease.

Early transformation to acute myeloblastic leukaemia with the acquisition of inv(16) in Ph positive chronic granulocytic leukaemia

Early transformation to acute myeloblastic leukaemia with the acquisition of inv(16) in Ph positive chronic granulocytic leukaemia

The myeloproliferative disorders. An historical appraisal and personal experiences.

According to strict morphological, biochemical and cytogenetic criteria Philadelphia chromosome positive essential thrombocythemia and chronic granulocytic leukemia constitute a separate malignant and individual disease entity, whereas Philadelphia chromosome negative essential thrombocythemia, polycythemia vera and agnogenic or megakaryocytic myeloid metaplasia form a chronic proliferation of three hematopoietic cell lines. Histopathology from bone marrow biopsies permits the characterization and diagnostic differention of the various myeloproliferative disorders and appears to be a main and specific diagostic criterion for polycythemia vera and essential thrombocythemia. Hemorrhagic thrombocythemia is a clinical syndrome of recurrent spontaneous mucocutaneous and secondary hemorrhages often preceded by thromboses, extremely high platelet counts, pseudohyperkalemia, increased bone marrow cellularity and frequently splenomegaly. The diagnostic criteria of essential thrombocythemia with paradoxical occurrence of thrombotic events and hemorrhagic manifestations are a platelet count in excess of 1000 x 10(9)/L and increased bone marrow cellularity in the majority of the cases. Erythromelalgia and other microcirculatory ischemic or thrombotic events or accidents in essential thrombocythemia and polycythemia vera already occur at platelet counts in excess of the upper limit of normal. First line treatment options in essential thrombocythemia and polycythemia vera are control of platelet function with low-dose aspirin and reductive control of platelet count and erythrocytes by bloodletting, interferon and busulfan or hydroxyurea monochemotherapy.

Ph1Positive Chronic Granulocytic Leukaemia Developing in a Patient with Primary Proliferative Polycythaemia: Case Report and Literature Review

A patient with primary proliferative polycythaemia (PPP), who after treatment with radio-phosphorous, developed Philadelphia chromosome positive chronic granulocytic leukaemia (CGL) with typical bcr rearrangement but with a high neutrophil alkaline phosphatase (NAP) score is described. Other similar reported cases are reviewed.

Is the histological classification of chronic granulocytic leukaemia justified from the clinical point of view?

By means of morphometric techniques, in 100 untreated Ph'-positive chronic granulocytic leukaemia (CGL) patients the main features from the initial bone marrow biopsy were analyzed, with particular attention being paid to morphological and quantitative study of megakaryocytes. The number of megakaryocytes per mm2 of marrow tissue showed a mean value of 25.3 (SD +/- 18.8), and was positively correlated with either platelet counts, blood percentage of basophils and blast cells, or spleen and liver size. Based on the number and morphological characteristics of megakaryocytes, patients were classified as having granulocytic CGL (67 cases) or the so-called chronic megakaryocytic-granulocytic myelosis (33 cases), but except for higher platelet counts and blood percentages of basophils and blast cells in the latter, no relevant clinical, evolutionary or prognostic differences were observed between the groups. Such results cast doubt on the validity of histological classification of CGL from the clinical point of view.

Longitudinal study of serum ferritin concentrations in chronic granulocytic leukaemia.

In 60 patients with Ph1-positive chronic granulocytic leukaemia (CGL) the serum ferritin concentration was measured as a part of the initial evaluation of the disease. The mean value (+SD) was 285 +/- 368.6 ng/ml, normal or slightly increased values being obtained in most cases. In 38 patients serum ferritin was again determined in clinical remission following busulphan treatment. Although the levels generally remained within the normal range, a significant decrease was observed with respect to the initial values (p = 0.0000004), suggesting that serum ferritin at presentation of CGL may be partially influenced by the disease activity. Finally, a further determination of serum ferritin concentration was made in a subgroup of 21 patients when they were diagnosed as being in the accelerated or blastic phases of CGL. Although no substantial increase was found with respect to the values obtained at presentation, a significant increase (p = 0.0008) was observed when accelerated-blastic phase ferritin levels were compared with those obtained in clinical remission. Although in patients in blast crisis no correlation was found between blast cell mass and serum ferritin, the differences observed between the different phases could indicate that in CGL serum ferritin concentrations roughly parallel the disease activity.

Decreased bone marrow iron in chronic granulocytic leukaemia: a consistent finding not reflecting iron deficiency.

The iron status of 50 patients with Ph'-positive chronic granulocytic leukaemia (CGL) was evaluated at diagnosis by means of bone marrow and blood studies. A decreased or absent iron in semiquantitative estimation on bone marrow smears was observed in 92% of patients, and 88% had a low sideroblast score. In contrast, normal Hb and serum iron concentrations were found in the majority of cases, and only two out of the 50 patients displayed a decreased serum ferritin. To ascertain whether the bone marrow pattern of iron depletion could be due to an expansion of the red cell mass, the latter parameter was measured by isotopic methods in a subgroup of 11 patients. Normal or slightly increased values were obtained in all cases. We conclude that absent or decreased marrow iron is a common feature in the chronic phase of CGL, that generally does not reflect true iron deficiency. Since such a finding is also usual in polycythaemia vera and idiopathic myelofibrosis, it should be included among the features shared by the chronic myeloproliferative disorders.

Ph1-negative chronic granulocytic leukemia: a nonentity.

Clinical, hematologic, and prognostic differences between Philadelphia chromosome (Ph1)-positive and Ph1-negative chronic granulocytic leukemia (CGL) have been described. However, Ph1-negative disease may be a mixture of other entities. The authors identified 24 patients given the diagnosis of Ph1-negative CGL after evaluation by the Hematology Department of the Mayo Clinic between January 1976 and August 1984. Each patient was Ph1-negative, and a bone marrow examination was interpreted as CGL. Initial peripheral blood and bone marrow samples were available for review in 22 patients. Their disorders were reclassified as chronic myelomonocytic leukemia (13 patients), chronic myelomonocytic leukemia in transformation (1 patient), preleukemic syndrome (3 patients), and undifferentiated chronic myeloproliferative disease (5 patients). Median survival for the 22 patients was 17 months.

Iron stores in chronic granulocytic leukaemia at presentation.

In 87 patients with Ph1 positive chronic granulocytic leukaemia (CGL), the bone marrow iron content was studied on smears obtained at diagnosis. A low sideroblast score and a decreased or absent marrow iron on semiquantitative estimation were found in 91% and 85% of cases, respectively. These findings did not correlate with blood parameters reflecting iron status such as Hb concentration, mean corpuscular volume, mean corpuscular haemoglobin, serum iron, total iron-binding capacity and transferrin saturation, which were normal in most cases. In 30 patients, initial serum ferritin was estimated, normal or slightly increased levels being as a rule found. In 24 of such patients, serum ferritin was again measured in remission following busulphan and, although values remained normal, a significant decrease was observed with respect to the initial levels (P less than 0.001). Thus, in spite of the consistent marrow pattern of iron depletion, initial iron stores appear to be normal in CGL. It seems, however, that the disease activity may partially influence the serum ferritin levels.

An immunohistochemical study of hemoglobin A, hemoglobin F, muramidase, and transferrin in erythroid hyperplasia and neoplasia.

The bone marrow biopsy specimens of 35 patients with benign and malignant erythroid hyperplasias were examined for the presence of hemoglobin A, hemoglobin F, muramidase (lysozyme), and transferrin, using an indirect immunoperoxidase method (PAP) on Zenker's-fixed paraffin-embedded bone marrow biopsy specimens and particles. Five cases of each of the following entities were studied: erythroleukemia and erythremic myelosis, acute granulocytic leukemia with maturation (FAB M2), polycythemia rubra vera, myeloproliferative syndrome in childhood, megaloblastic anemia (B12 and folate deficiency), erythroid hyperplasia (regenerating bone marrow and hemolytic anemia), and Ph' chromosome positive chronic granulocytic leukemia. Hemoglobin A was present in both the early and late erythroid precursors in all conditions. Hemoglobin F was the predominant hemoglobin in early erythroblasts of pernicious anemia and in both early and late erythroid elements in erythroleukemia and erythremic myelosis. Small quantities of hemoglobin F were present in a few isolated clusters in other conditions. Staining for hemoglobin F may be useful in identifying immature erythroid precursors and in distinguishing some cases of dysplastic erythroid hyperplasia from neoplasia. Additionally, these findings suggest that the maturational switch in hemoglobin synthesis operates with distinct pathways under different conditions.

Monosomy 7 in a girl with Ph 1 positive chronic granulocytic leukemia

A case is reported of an 11-year-old girl with Ph 1-positive chronic granulocytic leukemia. Very early in her illness the original 46,XX,t(9:22) cell population in the marrow became replaced by a second abnormal cell line, 45,XX,−7. This hypodiploid clone then remained dominant in the marrow until her death from myeloid blast crisis over 3 years later. It is suggested that the 45,XX,−7 cell line may have been induced by chemotherapy, and this possibility is discussed with particular reference to similar changes seen in secondary ANLL following treatment for lymphomas and other hematological malignancies.

Allogeneic marrow transplantation for chronic granulocytic leukemia.

Six patients with Philadelphia-chromosome (Ph' +)-positive chronic granulocytic leukemia were transplanted from their HLA-identical siblings after conditioning with cyclophosphamide and 1'000 rad total body irradiation. All received cyclosporin-A for prophylaxis of Graft-versus-Host disease. All patients showed prompt engraftment and all are cytogenetically and clinically in complete remission. Two patients had transient mild signs of Graft-versus-Host-disease and one patient had unilateral facial nerve paresis of unknown origin. All are ambulatory and well 6-18 months (median 10 months) after transplantation.

Treatment of Chronic Granulocytic Leukemia with Chemoradiotherapy and Transplantation of Marrow from Identical Twins

Twelve patients in the chronic phase of Ph1 (Philadelphia)-positive chronic granulocytic leukemia (CGL) received chemoradiotherapy and marrow from their normal, identical twins. All had a complete remission, with disappearance of all Ph1-positive cells. One patient died of pneumonitis while in remission. Three had a cytogenetic relapse 22 to 30 months after grafting; only one of these three entered blast crisis and died. Eight remain in complete remission 21 to 65 months (median, 30) after transplantation. Thus, the Ph1-positive clone can be ablated and blast crisis delayed or prevented. Of 10 patients with CGL who received transplants during the terminal phase, eight died soon after, one is in complete remission 11 months after receiving a second graft, and one remains in complete remission 71 months after transplantation. This experience suggests to us that every patient with CGL and an identical twin should receive a marrow graft, preferably in the chronic phase. On the basis of our results, trials of allogeneic-marrow transplantation for CGL seem justified.

Defective platelet aggregation and increased platelet turnover in patients with myelofibrosis and other myeloproliferative diseases.

In 9 patients with myeloproliferative diseases (MPD) (6 with myelofibrosis, MF, 1 with Ph1 positive chronic granulocytic leukaemia, CGL, 1 with primary eosinophilia, PE, 1 with pre-leukaemia syndrome, preL) collagen, epinephrine, and ADP-induced aggregation, N-ethylmaleimide-induced malondialdehyde (MDA) production, beta-thromboglobulin (beta-TG) plasma levels, and platelet turnover were studied. Collagen-induced aggregation was found to be normal in 7 patients, absent in 1, and reduced in 1. In all but 3 patients, aggregation with ADP was markedly reduced. Epinephrine-induced aggregation was decreased in 7 patients. No difference was found between mean MDA production in MPD (3.21 +/- 0.50 nmol/10(9) PLTs) and in control group of 21 normal subjects (3.04 +/- 0.26 nmol/10(9) PLTs). Mean beta-TG levels were significantly higher (P less than 0.01) in MPD patients (165.00 +/- 28.29 ng/ml) than in healthy controls (81.76 +/- 14.63 ng/ml). Mean platelet production half-time was significantly shorter in MPD (2.48 +/- 0.24 d) than in the control group (3.43 +/- 0.17 d), after adjustment for age by covariance analysis (P less than 0.005). Our data do not indicate an abnormal prostaglandin synthesis and are consistent with the hypothesis that a disseminated intravascular platelet aggregation might take place in MPD patients.

Significance of Ph -Negative Marrow Cells in Ph -Positive Chronic Granulocytic Leukemia

Fifty-six of 195 Ph1-positive patients with chronic granulocytic leukemia were found to have Ph1-negative metaphases in marrow aspirates on one or more occasions. In 22 cases, Ph1-negative cells were found prior to initiation of antileukemic therapy. Five patients were in the blastic stage of the disease when Ph1-negative mitoses were seen. The finding of Ph1-negative cells appeared to be related principally to short duration of CGL and to administration of antileukemic therapy (conventional agents and doses, in most cases). Ph1-negative cells were usually not found more than 2 yr after the diagnosis of leukemia, but in a few cases, they were seen as long as 5-10 yr after diagnosis. Only a minority of metaphases analyzed were Ph1-negative, except in the case of 6 patients who transiently had 50% or more Ph1-negative cells after antileukemic therapy. The presence of Ph1-negative cells in marrow was not associated with any survival advantage in this series.

Extramedullary pleural blast crisis during otherwise chronic phase in chronic granulocytic leukaemia

A patient with Ph 1 -positive chronic granulocytic leukaemia with extramedullary myeloblastic transformation in the pleural cavity is presented. The clonal origin of the blast cells obtained from the pleural fluid was confirmed by the presence of the Ph 1 chromosome. In addition, each cell had 4 extra chromosomes ( +8, +21, +21, + mar) indicating independent clonal evolution. The patient survived for 6 months after the occurrence of pleural relapse. The peripheral blood never showed transformation, but other systemic involvements of primitive myeloblasts were noted at autopsy.

Ultrastructural Localization of Peroxidases in ‘Undifferentiated’Blasts during the Blast Crisis of Chronic Granulocytic Leukaemia

Twelve cases of Philadelphia chromosome positive chronic granulocytic leukaemia (CGL) in blast transformation have been investigated using ultrastructural peroxidase detection. In all cases, the leukaemic blasts were negative for myeloperoxidase on the basis of standard cytochemistry. In nine cases a variable proportion of blasts contained peroxidase activity detectable only by electron microscopy, permitting definition of their myeloid nature. By their distinct characteristics and localization, different peroxidase activities were recognized. Thus, several types of blasts were identified: megakaryoblasts (MKB), basophil promyelocytes (BPM), myeloid blasts with small granules containing peroxidase (MyB), and proerythroblasts (ProE). MKB were predominant in two cases and present in four cases, mixed with other myeloid blasts. BPM were abundant in one case and present in seven cases. MyB were identified as a majority in four cases. Three cases remained without any peroxidase. It is concluded that ultrastructural detection of peroxidases is of value for the identification of early myeloid blasts. Their high incidence and the simultaneous presence of several myeloid precursors suggest that during the blast crisis the target cell is frequently a pluripotent myeloid stem cell.

Chronic Granulocytic Leukemia in a Patient With a Renal Allograft

A man received a cadaver renal allograft for end-stage renal failure. After 35 months of immunosuppressive therapy with azathioprine and prednisone, he developed septicemia and a high leukocyte count. In spite of successful treatment of the infection, the leukocyte count continued to rise and a diagnosis of Philadelphia chromosome positive chronic granulocytic leukemia was made. An increased incidence of malignant disease, especially lymphoreticular malignancy, is well described in immunosuppressed patients with allografts. However, the association of chronic granulocytic leukemia and immunosuppressive therapy previously has not been reported. An additional etiological factor in this patient may have been the extensive diagnostic radiological investigations undertaken in childhood. The recent addition of allopurinol to the immunosuppressive therapy has normalized the platelet and leukocyte counts, probably by potentiating mercaptopurine.

A Variant Chromosomal Translocation Found in a Series of 24 Patients with Philadelphia Positive Chronic Granulocytic Leukaemia*

The bone marrow chromosomes of 24 patients with Philadelphia positive (Ph 1) chronic granulocytic leukaemia (CGL) were studied using banding techniques. In 23 patients, the Ph(1) had been produced by the standard translocation between chromosomes 9 and 22, but in the remaining patient, the Ph(1) chromosome had been formed by a translocation between chromosomes 16 and 22. Clinical and haematological details of this patient are reported.