Variant translocations or additional chromosomal abnormalities at diagnosis of chronic myeloid leukemia
Investigation of variant formation ways additional chromosomal abnormalities in clones. Simultaneous existence in mosaic karyotypes clones with additional quantity, structural chromosomal twinning witness for multi steps models of the clone evolution.
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SI «Institute of Haematology and Transfusiology of NAMS of Ukraine»
SI «The Scientific-practical Children's Cardiac Center» MHC of Ukraine
Variant translocations t(9;22)(q34;q11) or additional chromosomal abnormalities at diagnosis of chronic myeloid leukemia
S.V. Andreieva, K.V. Korets, E.E. Ruzhinskaya
Kyiv
Summary
Aim: investigation of the variant t(9;22) formation ways and additional chromosomal abnormalities in t(9;22) clones.
Materials and methods. The cytogenetic investigation of bone marrow cells of 86 patients at diagnosis of chronic myeloid leukemia (CML) and 3 with blast crisis of CML (aging 16-77years) are presented.
Results: All patients were divided in three groups according to chromosomal abnormalities: group 1 with classical t(9;22) (68 patients), group 2 with variant t(9;22) (7 patients) and group 3 with additional chromosome abnormalities in clones with t(9;22) (11 patients). Clinical and haematological indices (age, leukocytes, hemoglobin, platelet counts and blast cells in bone marrow) haven't shown differences (Р < 0,5). In one karyotype with variant t(9;22), six karyotypes with additional abnormalities in clone t (9;22) and 20 karyotypes with twinning translocation t(9;22) in near tetraploid clones were presented classic t(9;22).
Conclusions. Simultaneous existence in mosaic karyotypes variants t(9;22 clones), clones with additional quantity, structural chromosomal abnormalities and twinning t(9;22) in near tetraploid clones together the clone with t(9;22) witness for multi steps models of the clone evolution in CML.
Key words: chronic myeloid leukemia, variant translocations t(9;22), additional chromosomal abnormalities.
Резюме
ВАРІАНТНІ ТРАНСЛОКАЦІЇ t(9;22)(q34;q11) АБО ДОДАТКОВІ АНОМАЛІЇ ХРОМОСОМ НА ЧАС ВСТАНОВЛЕННЯ ДІАГНОЗУ ХРОНІЧНА МІЄЛОЇДНА ЛЕЙКЕМІЯ
С.В. Андреєва, К.В. Корець, О.Е. Ружинська
ДУ «Інститут гематології та трансфузіології НАНМ України», Київ
ДУ «Науково-практичний медичний центр дитячої кардіології та кардіохірургії МОЗ України», Київ
Мета. Дослідження шляхів формування варіантних t(9;22) та додаткових аномалій у клонах с t(9;22).
Матеріали і методи досліджень. Представлені результати цитогенетичних досліджень клітин кісткового мозку 86 пацієнтів на час встановлення діагнозу хронічна мієлоїдна лейкемія (ХМЛ) і 3 - у бластній кризі ХМЛ (віком 16-77років).
Результати та їх обговорення. За хромосомними аномаліями виділили три групи: 1 група - каріотипи з класичною t(9;22) (68 пацієнтів), 2 група - каріотипи з варіантними t(9;22) (7 пацієнтів) і 3 група - каріотипи з додатковими аномаліями хромосом у клоні з t(9;22) (11 пацієнтів). Не виявлено відмінностей за клініко-лабораторними показниками у виділених группах (Р < 0,5). В одному каріотипі з варіантною t(9;22), шести каріотипах з додатковими аномаліями в клоні с t(9;22) та 20 каріотипах з подвоєною t(9;22) у білятетраплоїдних клонах була присутня класична t(9;22).
Висновки. Одночасна присутність в мозаїчному каріотипі клонів з варіантними t(9;22), клонів з додатковими кількісними або структурними аномаліями хромосом, а також подвоєння t(9;22) в білятетраплоїдному клоні поряд з клоном t(9;22) свідчить про багатоступеневу модель еволюції клонів при ХМЛ.
Ключові слова: хронічна мієлоїдна лейкемія, варіантні транслокації t(9;22)(q34;q11), додаткові аномалії хромосом.
Резюме
ВАРИАНТНЫЕ ТРАНСЛОКАЦИИ t(9;22)(q34;q11) ИЛИ ДОПОЛНИТЕЛЬНЫЕ АНОМАЛИИ ХРОМОСОМ ПРИ ПОСТАНОВКЕ ДИАГНОЗА ХРОНИЧЕСКИЙ МИЕЛОИДНЫЙ ЛЕЙКОЗ
С.В. Андреева, Е.В. Корец, Ружинская Е.Э.
ГУ «Институт гематологии и трансфузиологии НАНМ Украины», Киев
ГУ «Научно-практический медицинский центр детской кардиологии и кардиохирургии МЗ Украины», Киев
Цель: исследование путей формирования вариантных t(9;22) и дополнительных аномалий в клонах с t(9;22).
Материалы и методы исследований. Представлены результаты цитогенетических исследований клеток костного мозга 86 пациентов при постановке диагноза хронический миелоидный лейкоз (ХМЛ) и 3 - в бластном кризе ХМЛ (возраст 16-77 лет).
Результаты и их обсуждение. С учетом хромосомных аномалий выделили три группы: 1 группа - кариотипы с классической t(9;22) (68 пациентов), 2 группа - кариотипы с вариантными t(9;22) (7 пациентов) и 3 группа - кариотипы с дополнительными аномалиями хромосом в клоне с t(9;22) (11 пациентов). Не выявлено отличий в клинико-лабораторных показателях в выделенных группах (Р<0,5). В одном кариотипе с вариантной t(9;22), шести кариотипах с дополнительными аномалиями в клоне с t(9;22) и 20 кариотипах с удвоенной t(9;22) в околотетраплоидных клонах присутствовала классическая t(9;22).
Выводы. Одновременное присутствие в мозаичном кариотипе клонов с вариантными t(9;22), клонов с дополнительными количественными или структурными аномалиями хромосом, а также удвоение t(9;22) в околотетраплоидном клоне наряду с клоном t(9;22) свидетельствуют о многоступенчатой модели эволюции клонов при ХМЛ.
Ключевые слова: хронический миелоидный лейкоз, вариантные транслокации t(9;22)(q34;q11), дополнительные аномалии хромосом.
Introduction
Chronic myeloid leukemia (CML) is characterized by the Philadelphia (Ph) chromosome created by the reciprocal translocation t(9:22)(q34;q11), resulting in the chimeric gene breakpoint cluster region (BCR)-Abelson (ABL). Variant Ph chromosome translocations involving chromosomes (Chr) other than 9 and 22 occur in 5-10% patients with CML had complex translocations including chromosome 9, 22 and third or fourth chromosomes. Practically almost all chromosomes be involved in form of the variant t(9;22) [1-3]. In these cases genomic instability can be observed and cause the secondary chromosomal abnormalities. The presence of the last one is connected with unfavorable outcome in therapy with inhibitor of bcr-abl tyrosine kinase [4]. Prognostic significance of this rearrangement is not clear.
Additional chromosomal abnormalities (ACAs) in Ph-CML are strongly associated with disease progression, but their prognostic impact and effect on treatment response are not clear. These abnormalities in clone t(9;22) were found at 5,0% - 20,0% patients in chronic phase and at 60,0-80,0% before or in blast crisis confirming the multistep pathogenesis of this disorder. Revealing of these abnormalities may have important significance because they appear before hematological and clinical symptoms and can define unfavorable prognosis [5, 6]. For example, appearance of monosomy 7 or 7q-besides the clone with t(9;22) is connected to quick (during 6 month) transformation into secondary acute myeloid leukemia (AML) [7].
Objective: The aim of this study is investigation of the variant t(9;22) formation ways and additional chromosomal abnormalities in t(9;22) clones.
Material and methods. We examined 86 patients (37 females and 49 males) with typical clinical and hematological features of CML and 3 patients with blast crisis of CML (1 female and 2 males) ranging in age between 16 and 77 years. This study comprised December 2010 to June 2014. Morphological diagnosis was determined according to the WHO classification [8]. Cytogenetic study was carried out according to the standard procedure after 17-24 hours of bone marrow cells cultivation and staining by G-banding technique. Only clonal chromosomal abnormalities were taken into consideration. In each case 20 methaphases were analyzed. The clonal chromosomal abnormalities were registered if at least two metaphases were having the same aberration (chromosome gain or structural rearrangement). In the case of chromosome loss abnormality the same loss had to be present in at least three cells (according to the International System for Human Cytogenetics Nomenclature (2013)) [9].
Results
Karyotype pattern were divided into 3 groups according to the complexity chromosomal abnormalities: 1) only translocation t(9;22) - 68 patients: 32 females, 36 males; 2) variant t(9;22) - 7 patients: 2 females, 5 males and 3) additional quantity and structural chromosomal abnormalities with or without t(9;22) - 11 patients: 3 females, 8 males. Clinical and haematological features of the 86 patients at diagnosis are summarized in table.
Table Clinico-haematological indices at the diagnosis CML in groups with classic t(9;22)(q34;q11), variants and additional chromosomal abnormalities
|
Clinico-haematological indices |
1 group |
2 group |
3 group |
|
|
n |
68 |
7 |
11 |
|
|
Sex: female : male |
32:36 (0,89) |
2:5 (0,4) |
3:8 (0,4) |
|
|
Age |
50,0 ± 6,4 |
49,3 ± 5,9 |
47,3 ± 5,1 |
|
|
Leukocytes (x 109/l) |
64,7 ± 6,1 |
68,1 ± 6,3 |
62,6 ± 6,8 |
|
|
Hemoglobin (g/l) |
96,3 ± 7,4 |
101,4 ± 8,1 |
91,0 ± 7,7 |
|
|
Platelet counts (x109/l) |
368,8 ±34,5 |
422,8 ±27,2 |
368,8 ±34,5 |
|
|
Blast cells in BM,% |
5,0 ± 0,7 |
4,3 ± 0,9 |
4,7 ± 0,5 |
Males more in the groups with variants and additional chromosomal abnormalities were presented (0,4 and 0,4 respectively). The comparison of others clinical and haematological indices (age, leukocytes, hemoglobin, platelet counts and blast cells in bone marrow) didn't show significant differences (Р < 0,5).
In the 1-st group 51 mosaic karyotypes had clone with t(9;22), normal and/or near tetraploid clones. In the rest karyotypes only clones with t(9;22) were registered. clone mosaic karyotype
In the 2-nd group the karyotypes with variant t(9;22) were formed with involving Chr 1, 2, 3, 6, 7, 8, 14 and 17. These abnormalities were observed in 8,1% cases and corresponded with another data [1-3]. Case of the variant translocation with two additional Chr 1 and 17 was observed in this group (karyotype № 3, see below). The additional normal clones were revealed in two cases (karyotypes № 1 and № 7). The additional near tetraploid clones presented by the twining variant t(9;22) were registered in the cases № 2 and № 4. These facts can be considered as a way of chromosomal abnormality evolution. We hadn't possibility to analyze the near tetraploid clones in the other karyotypes (№ 3, 5). In one case the second clone had the classic t(9;22) (karyotype № 1):
1. 46,XY,t(9;22;14)(q34;q11;q10)[3]/46,XY,t(9;22)(q34;q11)[2]/46, XY[6];
2. 46,XY,t(9;22;2)(q34;qU;q14)[21]/4n±,t(9;22;2)(q34;q11;q14)x2[4];
3. 46,XY,t(9;22;1;17)( q34;q11;p34.4;q23)[28]/4n±[2];
4. 46,XX,t(9;22;3)(q34;q11;p24)[22]/4n±,t(9;22;3)(q34;q11;p24)x2[3];
5. 46,XX,t(9;22;6)(q34;q11 ;q23)[22]/4n±[3];
6. 46,XY,t(9;22;8)(q34;q11;p23)[23];
7. 46,XY,t(9;22;7)(q34;q11;q22)[1]/46,XY[19].
In these cases we can suppose the presence of multistep process of abnormal karyotypes formation at the diagnosis of CML and that means t(9;22) evolution. The partial karyotypes of the variant t(9;22) are presented in figure 1.
In 3-rd group the karyotypes with ASAs were found in 11 cases (12,8%) that corresponds with literature data [5, 6]. The additional quantitative chromosomal abnormalities were found in clones with t(9;22), namely loss sex Chr Х (№ 1), Chr Y (№ 2, 3), trisomy Chr 8 (№ 4, 5) and Chr 9 (№ 6), marker Chr (№ 3) and additional derivation Chr 22 which have formed as duplication der(22) from t(9;22) (figure 2). The trisomy Chr 10 in second independent clone t(9;22) was found in one karyotype (№ 11). The derivate Chr 8, two translocations t(Y;20)(q11;q13) (№ 9) and t(7;8)(q32;q21) (№ 10) were found among structural chromosomal abnormalities. The second clone with classic t(9;22) was presented in six karyotypes (№ 1, 2, 4-7).
1. 45,X,-X,t(9;22)(q34;q11)[3]/46,XX,t(9;22)(q34;q11)[18]/4n±[3];
2. 46,X,-Y,t(9;22)(q34;q11)[3]/46,XY,t(9;22)(q34;q11)[17];
3. 46,X,-Y,t(9;22)(q34;q11),+mar[cp18]/4n±,idemx2[2];
4. 47,XX,+8,t(9;22)(q34;q11)[3]/46,XX,t(9;22)(q34;q11)[18]/4n±[4];
5. 46,XY,+8,t(9;22)(q34;q11),-20[2]/46,XY,t(9;22)(q34;q11)[6]/4n±[3];
6. 47,XY,+9,t(9;22)(q34;q11)[6]/46,XY,t(9;22)(q34;q11)[15]/4n±[4];
7. 47,XY,t(9;22)(q34;q11),+der(22)t(9;22)(q34;q11)[17]/46,XY,t(9;22)(q34;q11)[4]/4n±[4];
8. 46,X,der(X),t(9;22)(q34;q11)[29];
9. 46,XX,t(Y;20)(q11;q13),t(9;22)(q34;q11)[3]/46,XX,t(9;22)(q34;q11)[15]/4n±[2];
10. 46,idem,t(7;8)(q32;q21)[3]/46,XY,t(9;22)(q34;q11)[22];
11. 46,XY,t(9;22)(q34;q11)[14]/47,XY,+10/4n±[2]/46,XY[2].
The additional near tetraploid clones were karyotyped in 20 cases. The twinning translocation t(9;22) was found in all cases. This fact can be considered as clonal chromosomal evolution variant. In other cases we hadn't possibilities to karyotype chromosomes in near tetraploid clones. The frequency of chromosomal evolution at diagnosis CML consisted 33 cases (38,4%). These findings prove the multistep process of abnormal karyotypes evolution in CML formation.
Figure 2. Partial karyotypes with additional chromosomal abnormalities at diagnosis CML
Cytogenetic investigations of 3 karyotypes in BC CML showed in two cases: 1) additional derivation Chr 22, which was formed at t(9;22), 2) invertion inv(16)(p13q22). In both karyotypes the second clone bore classic t(9;22). In third case the single clone with t(9;22) was found:
1) 47,XX,t(9;22)(q34;q11),+der(22)t(9;22)(q34;q11)[16]/ 46,XX,t(9;22)(q34;q11)[4]/4n±,idemx2[5];
2) 46,XY,t(9;22)(q34;q11),inv(16)(p13q22)[9]/46,XY,t(9;22)(q34;q11)[16];
3) 46,XY,t(9;22)(q34;q11)[20].
These data can witness for possible mechanism of forming abnormal karyotype resistance at the diagnosis of CML.
Conclusions
1. Evolution frequency of chromosome clone abnormalities was 38,4% at diagnosis CML. It was expressed as variant translocations t(9;22), additional quantitative and structural chromosome abnormalities in clone with t(9;22) and twinning t(9;22) in near tetraploid clone.
2. The chromosomes 1, 2, 3, 6, 7, 8, 14 and 17 participated in variant translocation t(9;22) formation. Marker chromosome, loss of the chromosomes X and Y, trisomy of the chromosomes 8 and 9 were observed as additional quantitative abnormalities. Chromosomes X, Y, 7, 8 and 20 were involved in additional structural anomalies.
3. The reliable differences of clinical and laboratory indices at CML diagnosis wasn't revealed in groups with classic t(9;22), variant t(9;22) and additional chromosome abnormalities.
4. The simultaneous presence of variant t(9;22) clones, additional quantitative or structural chromosome abnormalities clones as well as twinning t(9;22) in near tetraploid clones with t(9;22) clone in mosaic karyotypes is the evidence of the multistep model of clone evolution at CML.
Literature
1. Studies of complex Ph translocations in cases with chronic myelogenous leukemia and one with acute lymphoblastic leukemia / D. Costa, A. Carrio, I. Madrigal [et al.] // Cancer Genet. Cytogenet. - 2006. - Vol. 166, № 1. - P. 89-93.
2. A masked BCR/ABL rearrangement in a case of chronic myeloid leukemia with translocation t(3;9)(p14;q34) / A. Bennour, H. Sennana, M.A. Laatiri [et al.] // Cancer Genet. Cytogenet. - 2008. - Vol. 181, № 1. - P. 72-74.
3. Fluorescence in situ hybridization dissection if chronic myeloid leukemia case bearing the appearently balanced translocations t(9;22) and (11;11)(p15;q13) / F. Malvestiti, D. Colombo, D. Perego [et al.] // Cancer Genet. Cytogenet. - 2009. - Vol. 188, № 1. - P. 42-47.
4. A novel five-way chromosomal translocation observed in chronic myelogenous leukemia / K. Ikuta, Y. Torimoto, J. Jimbo [et al.] // Cancer Genet Cytogenet. - 2008. - Vol. 183, № 1. - P. 69-71.
5. Chronic myelogenous leukemia exhibiting trisomy 14 due to a Robertsonian translocation with philadelphia chromosome / B. Durmaz, E. Karaca, F. Vural [et al.] // Acta Oncol. - 2008. - Vol. 47, № 8. - P. 1604-1606.
6. Isolated meylosarcoma development in an adolescent chronic myeloid leukemia patient with t(9;22),+8,+14,+21 and der(1)(p36) / H. Oren, S. Yilmanz, Z. Sercan [et al.] // Cancer Genet. Cytogenet. - 2008. - Vol. 182, № 1. - P. 43-45.
7. Factors influencing a second myeloid malignancy in patients with Philadelphia-negative -7 or del(7q) clones during tyrosine kinase inhibitor therapy for chronic myeloid leukemia / M. J. Groves, M. Sales, L. Baker [et al.] // Cancer Genet. Cytogenet. - 2011. - Vol. 204, № 1. - P. 39-44.
8. WHO classification of tumors of haemapoietic and lymphoid tissue / S.H. Swerdlow, E. Campo, N.L. Harris [et al] // Lyon: IARC Press. - 2008. - 439 p.
9. Shaffer L.G. An International System for Human Cytogenetic Nomenclature. Recommendations of the International Standing Committee on Human Cytogenetic Nomenclature // L.G. Shaffer, J. McGowan-Jordan, M. Schmid. - Karger. - 2013. - 140 p.
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