Clinical Characteristics and Clinical Characteristics and Treatment Outcome of Treatment Outcome of

Childhood AcuteChildhood AcuteLymphoblastic Leukemia With Lymphoblastic Leukemia With

the t(4;ll) (q21;q23)the t(4;ll) (q21;q23)

By Ching-Hon Pui, Lawrence S. Frankel, Andrew J. Carroll, Susana C. Raimondi, Jonathan J. By Ching-Hon Pui, Lawrence S. Frankel, Andrew J. Carroll, Susana C. Raimondi, Jonathan J. Shuster, David R. Head, Shuster, David R. Head,

William M. Crist, Vita J. Land, D. Jeanette Pullen, C. Philip Steuber, Frederick G. Behm, and William M. Crist, Vita J. Land, D. Jeanette Pullen, C. Philip Steuber, Frederick G. Behm, and

Michael J. BorowitzMichael J. Borowitz

INTRODUCTIONINTRODUCTION

Acute lymphoblastic Acute lymphoblastic leukemia (ALL) is the most leukemia (ALL) is the most common form of childhood common form of childhood cancer. cancer. leukemiasleukemias..

Leukemia is a cancer of Leukemia is a cancer of the blood or bone marrow.the blood or bone marrow.

It is characterized by an It is characterized by an abnormal proliferation abnormal proliferation (production by (production by multiplication) of blood multiplication) of blood cells, usually white blood cells, usually white blood cellscells

Four major kinds of leukemiaFour major kinds of leukemia Cell typeCell type AcuteAcute ChronicChronic

Lymphocytic Lymphocytic leukemialeukemia

or lymphoblasticor lymphoblastic

Acute lymphoblasticAcute lymphoblastic

leukemialeukemia

((ALLALL))

Chronic lymphocytic Chronic lymphocytic leukemialeukemia

((CLLCLL) )

Myelogenous Myelogenous leukemialeukemia

also myeloid or also myeloid or nonlymphocyticnonlymphocytic

Acute myelogenousAcute myelogenous

leukemialeukemia

((AMLAML) )

Chronic myelogenous Chronic myelogenous leukemialeukemia

((CMLCML))

Acute leukemia is characterized by the rapid increase of immature blood cells .

Immunological classification of ALLImmunological classification of ALL

Type of Type of ALLALL

HLA-HLA-DRDR

TdTTdTCD10CD10CD19CD19aa

CyIgCyIgSIgSIgCD7CD7cCD3cCD3

Pro-B-ALLPro-B-ALL++++00++00000000

CommonCommon

ALLALL++++++++00000000

Pre-B-ALLPre-B-ALL++++++++++000000

B-ALLB-ALL++00-/+-/+++-/+-/+++++0000

Eerly-T-Eerly-T-ALLALL00++00+/+/000000++++

T-ALLbT-ALLb00++00+/+/000000++++

French-American-British (FAB) ClassificationFrench-American-British (FAB) Classification

L1 Small homogeneous with L1 Small homogeneous with scanty cytoplasm, moderate scanty cytoplasm, moderate basophilia, inconspicuous nuclei.basophilia, inconspicuous nuclei.

L2 Larger, heterogeneoys cells, L2 Larger, heterogeneoys cells, variable cytoplasm, basophilia, variable cytoplasm, basophilia, prominent nuclei.prominent nuclei.

L3 Larger, heterogeneoys cells, L3 Larger, heterogeneoys cells, with dark basophilic cytoplasm, with dark basophilic cytoplasm, prominent vacules, prominent prominent vacules, prominent nuclei.nuclei.

A translocation involving the long A translocation involving the long arms of chromosomes 4 and 11-arms of chromosomes 4 and 11-t))4;11))q21;q23) has been t))4;11))q21;q23) has been observed in patients with ALLobserved in patients with ALL..

In a recent review, it was reported In a recent review, it was reported that t)4;11) has been observed in that t)4;11) has been observed in 60% of lymphoblastic leukemias 60% of lymphoblastic leukemias in children under the age of 1 in children under the age of 1 yearyear..

t(4;11)(q21;q23) ) G-banding (left) - Courtesy Diane H. Norback, Eric B. Johnson, and Sara Morrison- Delap, UW Cytogenetic Services; R- banding (right) - Editor (above), and Courtesy Christiane Charrin (below

Aim of the studyAim of the study

In here, a Collaborative Study of 40 Cases In here, a Collaborative Study of 40 Cases with the t)4;11))q21;q23) with the t)4;11))q21;q23) chromosomal abnormality was studied in children with newly diagnosed chromosomal abnormality was studied in children with newly diagnosed acute lymphoblastic leukemia )ALL).acute lymphoblastic leukemia )ALL).

This study describe :This study describe :

- The frequency, - The frequency,

- Clinical and laboratory features, - Clinical and laboratory features,

- And treatment outcome in these 40 cases - And treatment outcome in these 40 cases

with t)4;11) ))q21;q23) .with t)4;11) ))q21;q23) .

SUBJECTSSUBJECTS

n = 2,724

N = 515 N = 40

N = 1471

1 2

Total Therapy Studies at St Jude Children's Research Hospital

)SJCRH)

Pediatric OncologyGroup (POG) studies

The total number accrued

Have the t))4;11)t))4;11))q21;q23))q21;q23)

were studiedwere studied

MethodsMethods

Morphologic studiesMorphologic studies

-Cases were classified according to French--Cases were classified according to French-American-British )FAB) based on bone marrow American-British )FAB) based on bone marrow cell morphology and cytochemical staining cell morphology and cytochemical staining characteristics,.characteristics,.

Ficoll-Hypaque gradientFicoll-Hypaque gradient : : -Bone marrow cells were separated by this -Bone marrow cells were separated by this method.method.

Flow cytometry Flow cytometry

--Cell surface antigensCell surface antigens were detected were detected

by a standard indirect by a standard indirect immuno -immuno -

fluorescence assay. fluorescence assay. -were considered positive -were considered positive

if they were expressed in if they were expressed in 20% or more of the blast 20% or more of the blast cells.cells.

A simplified illustration of Flow Cytometry (Gerstner et al., 2005)

With flowcytometry monoclonal antibodies was usedWith flowcytometry monoclonal antibodies was used to : to :

- lymphoid- associated antigens )CD2, CD5, CD7, CD19, CD20, - lymphoid- associated antigens )CD2, CD5, CD7, CD19, CD20,

CD21, CD22, and CD24),CD21, CD22, and CD24),

-Myeloid-associated antigens )CD13, CD15, and CD33), and -Myeloid-associated antigens )CD13, CD15, and CD33), and

-Nonlineage specific antigens )CD10, CD34, CD45, and HLA-DR-Nonlineage specific antigens )CD10, CD34, CD45, and HLA-DR).).

Cells were also testedCells were also tested for cytoplasmic Ig )cIg) for cytoplasmic Ig )cIg) . .

- - Significant cIg expression was defined by the presenceSignificant cIg expression was defined by the presence

of Ig in the cytoplasm of 10% or more of blastsof Ig in the cytoplasm of 10% or more of blasts..

Chromosome analysis wChromosome analysis was done as followsas done as follows::

Processing ofProcessing ofonly 0.1 mlonly 0.1 ml

of sedimented cells orof sedimented cells or less per centrifuge tubeless per centrifuge tube . .

Exposure of cellsExposure of cells to Colcemidto Colcemid

for a maximum of 25 minfor a maximum of 25 min..

Control of the totalControl of the total time oftime of

exposure toexposure to hypotonic solutionhypotonic solution..Slide preparationSlide preparation

by a specificby a specific edging-flamingedging-flaming

techniquetechnique . .

The cells were The cells were cultured incultured in

RPMI 1640 mediumRPMI 1640 medium . .SupplementedSupplemented

withwith 30% fetal calf 30% fetal calf serum, to support serum, to support

cellular activitycellular activity during specimen during specimen

transporttransport

1 2

3

- This procedure were finalized by doing natural - This procedure were finalized by doing natural aging of the slides to achieve optimal drying and aging of the slides to achieve optimal drying and

use of a modified G-banding procedure thatuse of a modified G-banding procedure that

employs Wright's stain. employs Wright's stain.

ResultsResults

Of the 1,986 cases studied, 40 )2%) were found to have a Of the 1,986 cases studied, 40 )2%) were found to have a leukemic cell line with the t)4;11))q21;q23). These children leukemic cell line with the t)4;11))q21;q23). These children ))25 25 girls and 15 boys) ranged in age from 1 month to 14 girls and 15 boys) ranged in age from 1 month to 14 years 8 months at diagnosis )median, 9 months). years 8 months at diagnosis )median, 9 months).

Clinical and Laboratory findings as in the following table:Clinical and Laboratory findings as in the following table:

Cell ImmunophenotypingCell Immunophenotyping

DiscussionDiscussion

The reported frequency of the t)4;ll) in patients with ALL has ranged from The reported frequency of the t)4;ll) in patients with ALL has ranged from 1.6% to 11% for 1.6% to 11% for children, children, and from and from 5% 5% to 8% for adultsto 8% for adults

In our study, this chromosomal abnormality occurred in 2%, Thus, the In our study, this chromosomal abnormality occurred in 2%, Thus, the t)4;ll) is one of the most common specific chromosomal translocations in t)4;ll) is one of the most common specific chromosomal translocations in childhood ALL.childhood ALL.

Our patients aged 1 to 9 years had a significantly better treatment outcome Our patients aged 1 to 9 years had a significantly better treatment outcome than infants and older patients with the t)4;ll).than infants and older patients with the t)4;ll).

Seven of eight patients in this age group, compared with 9 of the 32 other Seven of eight patients in this age group, compared with 9 of the 32 other patients, remain in remission. Thus, the adverse prognosis of the t)4;ll) is patients, remain in remission. Thus, the adverse prognosis of the t)4;ll) is related at least in part to its association with the poor-risk age groups.related at least in part to its association with the poor-risk age groups.

Ultrastructural, immunophenotypic, and in vitro culture studies Ultrastructural, immunophenotypic, and in vitro culture studies have demonstrated marked lineage heterogeneity in cases with the have demonstrated marked lineage heterogeneity in cases with the t)4;ll).t)4;ll).

- - Although many reported cases have had myelomonocytic Although many reported cases have had myelomonocytic characteristics, or mixed lineage marker expression most have characteristics, or mixed lineage marker expression most have been classified as B-precursor-cell ALL )CD19+, HLA-DR+)been classified as B-precursor-cell ALL )CD19+, HLA-DR+)..

- - Only rarely have or B-cell" phenotypes been reported in Only rarely have or B-cell" phenotypes been reported in patients with this translocation. Indeed, all 35 evaluable cases in patients with this translocation. Indeed, all 35 evaluable cases in this study had B-precursor-cell ALLthis study had B-precursor-cell ALL..

- - During this study period, they have not encountered any case During this study period, they have not encountered any case of acute myeloid leukemia with the t)4;ll)of acute myeloid leukemia with the t)4;ll)..

ConclusionConclusion

The t)4;ll) is one of the most common nonrandom translocations in The t)4;ll) is one of the most common nonrandom translocations in childhood ALL, accounting for childhood ALL, accounting for 2% 2% of newly diagnosed cases.of newly diagnosed cases.

Cases with the t)4;ll) are associated with female sex, very young age at Cases with the t)4;ll) are associated with female sex, very young age at presentation, hyperleukocytosis, the CDlOpresentation, hyperleukocytosis, the CDlO--/CD15/CD15++/CD19/CD19++/ CD24 / CD24 -/+ -/+

immunophenotype, and poor treatment outcome for infants and patients immunophenotype, and poor treatment outcome for infants and patients aged aged ≥ ≥ 10 years. 10 years.

Additional studies are clearly merited to determine the independent Additional studies are clearly merited to determine the independent

prognostic significance of the t)4;ll) and to assess possible molecular prognostic significance of the t)4;ll) and to assess possible molecular differences in this translocation for different age groups.differences in this translocation for different age groups.