Ann Hematol (2001) 80:763–766 DOI 10.1007/s002770100378
C A S E R E P O RT
M. Sakugawa · K. Kojima · K. Kaneda · K. Masuda H. Dansako · K. Shinagawa · F. Ishimaru · K. Ikeda K. Niiya · M. Harada · M. Tanimoto
Therapy-related myelodysplastic syndrome/acute myeloid leukemia M2 and translocation (8;21) Received: 19 April 2001 / Accepted: 18 August 2001 / Published online: 13 October 2001 © Springer-Verlag 2001
Abstract An 80-year-old woman developed therapy-related myelodysplastic syndrome with translocation (8;21), which was successfully treated with an acute myeloid leukemia oriented chemotherapy. Five years before admission she had received cyclophosphamide, epirubicin, and carboplatin for endometrial cancer. The leukemia cell morphology alerted us to the possibility of the presence of t(8;21) before cytogenetic results were obtained, and AML1/ETO fusion transcript was detected by reverse transcription polymerase chain reaction. She achieved complete remission after one course of idarubicin and cytosine arabinoside. She has remained in complete remission for 6 months. Our experience suggests that recognition of typical morphological features for de novo M2 acute myeloid leukemia with t(8;21) would be important in diagnosis of therapy related myelodysplastic syndrome/acute myeloid leukemia with this translocation, which could respond to an intensive chemotherapy. Keywords Translocation (8;21) · Therapy-related myelodysplastic syndrome · Therapy-related acute myeloid leukemia · Cell morphology · Anthracycline
similar clinical characteristics to those of M2-AML with t(8;21), the clinicopathological association between the two disease entities with this translocation is still controversial. Since most MDS patients with t(8;21) evolve into AML relatively rapidly, some researchers have postulated that the low blast count seen in MDS with t(8;21) may be a feature of the timing of the bone marrow rather than an intrinsic characteristic of the leukemia [5]. On the other hand, a majority of mature neutrophils have been shown to originate from clonogenic blast progenitor in MDS with t(8;21) at presentation, suggesting that t(8;21)-positive MDS may represent a minor subtype of M2-AML in which the evidence of granulocytic maturation arrest is unremarkable [6, 7]. It has been well known that peripheral blood and bone marrow specimens of M2-AML patients with t(8;21) exhibit characteristic morphological features which are most prominent in granulocytic lineage cells [8, 9, 10]. In this report we describe one further case of t(8;21)-positive MDS and discuss the significance of t(8;21) in an etiology of MDS from a morphological perspective.
Case report Introduction A t(8;21)(q22;q22) is frequently associated with de novo acute myeloid leukemia with maturation (M2-AML), and usually predicts a good response to chemotherapy with high remission rates [1]. This cytogenetic abnormality, however, has also been identified in scattered cases of myelodysplastic syndromes (MDS) [2, 3, 4]. Since the limited number of MDS cases have shown M. Sakugawa · K. Kojima (✉) · K. Kaneda · K. Masuda H. Dansako · K. Shinagawa · F. Ishimaru · K. Ikeda · K. Niiya M. Harada · M. Tanimoto Department of Medicine II, Okayama University Medical School, 2-5-1 Shikata-cho, Okayama 700-8558, Japan e-mail:
[email protected] Tel.: +81-86-2357227, Fax: +81-86-2328226
An 80-year-old woman was admitted to our hospital because of pancytopenia on December 13, 2000. Five years before admission she was found to have endometrial cancer, which was successfully treated with total hysterectomy followed by three courses of systemic chemotherapy with cyclophosphamide, epirubicin, and carboplatin (at a total dose of 1370 mg, 137 mg, and 873 mg, respectively). Thereafter she intermittently received a combination of tetrahydrofuranyl-5-fluorouracil and uracil at a dose of 400 mg/day orally for 3 years. We found hemoglobin concentration of 10.5 g/dl, white blood cell count 1.6×109/l with 5% blasts, 0.5% promyelocytes, 2% myelocytes, 0.5% metamyelocytes, 38% neutrophils, 0.5% eosinophils, and 53.5% lymphocytes, and platelet count 37×109/l. Leukocyte alkaline phosphatase level was decreased (104, normal range:190–370). A bone marrow film revealed a hypercellular marrow with 19.6% blasts, more than 90% of which were myeloperoxidase-positive. Auer bodies were frequently present in their blasts. A tentative diagnosis of MDS was made according to the French-American-British (FAB) classification. She was started on an AML-oriented chemotherapy with idarubicin and cytosine ara-
764 binoside (idarubicin 8 mg/m2/day for 3 days and continuous cytosine arabinoside 80 mg/m2/day for 7 days), and complete remission was achieved after one course. Two weeks after the diagnosis a report of conventional chromosome analysis confirmed the presence of t(8;21)(q22;q22) as a sole chromosome abnormality. After the chemotherapy both the dysplastic features and the chromosome abnormality disappeared. She has remained in complete remission for 6 months. Cell morphology was assessed on May-Grünwald-Giemsa stained peripheral blood and bone marrow films. Particular attention was paid to the presence of morphological features considered to be suggestive of t(8;21). We also used two previously published score systems suggested by Nucifora et al. [9] and Andrieu et al. [10] that were originally proposed to distinguish M1/M2-AML cases with t(8;21) from those without t(8;21). Immunophenotyping of blast population was performed on bone marrow cells with flow cytometric analysis, as described previously [11]. Cases were considered to be positive if more than 20% of the blast population expressed the relevant antigen. The following antibodies were used: CD13, CD19, CD33, CD34, CD56, and HLA-DR. Reverse transcriptase polymerase chain reaction (RT-PCR) analysis was performed using two pairs of nested primers for an AML1/ETO fusion transcript, with a sensitivity of 10–4, as described previously [12]. Positive and negative control cDNAs were prepared from Kasumi-1 and HL-60 cells, respectively.
neutrophils contained thin Auer rods in their cytoplasm, suggesting an abnormal maturation. Except for the FAB classification the cell morphology fulfilled the separately proposed two criteria [9, 10], strongly suggesting the presence of t(8;21). Immunophenotyping analysis revealed that the blasts expressed myeloid antigens HLA-DR, CD34, CD33, and CD13 but did not express CD19 or CD56.
Results Cell morphology and immunological markers Granulocytic lineage cells showed prominent dysplasia, while we could not detect any dysplastic features in erythroblasts and megakaryocytes. Large basophilic blasts had a nucleus indented by a prominent golgi zone, Auer rods, cytoplasmic vacuoles, numerous large azurophilic granules, and pseudo-Chediak granules (Fig. 1). Mature neutrophils were characterized by pseudo-PelgerHüet anomaly, homogeneous pink-colored cytoplasm, and basophilic rim (Fig. 2). Approximately 5% of the
Fig. 1 A Large blasts with irregular nuclear contour and basophilic cytoplasm which contains numerous large azurophilic granules and an Auer rod (arrow). May-Grünwald-Giemsa stain, ×1000. B Myeloid lineage cells frequently had giant granules in their cytoplasm (arrowhead). Dysplastic features in erythroblasts were unremarkable. May-Grünwald-Giemsa stain, ×1000
Fig. 2 A Neutrophils with pseudo-Pelger-Hüet anomaly (arrows). May-Grünwald-Giemsa stain, ×1000. B Auer rods were detected in mature neutrophils as well as blasts (arrowheads). May-Grünwald-Giemsa stain, ×1000
Fig. 3 Agarose gel electrophoresis of RT-PCR-amplified AML1/ ETO chimeric transcripts. Lane 1 This patient; lane 2 positive control (the cell line Kasumi-1); lane 3 negative control (the cell line HL-60)
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RT-PCR As would be expected for a standard t(8;21), the AML1/ETO chimeric transcript was detected. The size of the amplified DNA fragments was identical with that in a cell line Kasumi-1 (Fig. 3).
Discussion To distinguish cases of t(8;21)-positive MDS from those of ordinary MDS is critical because their therapeutic strategies may be different. Previous studies have shown that t(8;21)-positive MDS often responds well to AMLoriented chemotherapy, and that prolonged survival may be achieved [2, 3, 4, 5, 6]. The complete remission rate has been over 80%, which is uncommon for typical MDS. Although conventional chromosome analysis and molecular detection of AML1/ETO fusion transcript can provide the specificity necessary to confirm the diagnosis of t(8;21)-positive MDS, results of the former is unavailable at diagnosis and the latter is still not practical in a routine diagnostic setting. Other practical landmarks are therefore required for a diagnosis of t(8;21)-positive MDS. Interestingly, the leukemia cell morphology in our patient showed typical features of that seen in M2-AML with t(8;21). Large basophilic blasts with a nucleus indented by a prominent Golgi zone, fine Auer rods close to the Golgi, numerous large azurophilic granules and pseudo-Chediak granules, and neutrophils with pseudoPelger-Hüet anomaly, homogeneous pink-colored cytoplasm and basophilic rim, that were detected in our case, are all features suggestive of M2-AML with t(8;21) [8, 9, 10]. Indeed, these morphological findings prompted us to determine the AML1/ETO chimeric transcript, and based on its positive result we recommended that she receive AML-oriented chemotherapy despite her advanced age. Since morphological features can always be evaluated in all patients at diagnosis, a profound recognition of typical cell morphology in t(8;21)-positive leukemias may provide a useful information to distinguish t(8;21)positive MDS from ordinary MDS. It has been suggested that cases with blast counts below 30% but with a demonstrable t(8;21) and myelodysplastic features in one or more lineages may not necessarily need to be forced into the confines of the FAB classification MDS [13]. MDS with t(8;21) often responds well to AML-oriented induction chemotherapy, while t(8;21)-positive AML can be associated with marked dysplastic changes in all lineages [14, 15]. It is therefore plausible that this case should be considered as an early stage or a minor subtype of t(8;21)-positive AML. We could not clarify whether the previous chemotherapy for endometrial cancer indeed affected the development of MDS, because the cytomorphological, immunophenotypical, and cytogenetic findings in this case were all identical with those of de novo AML with t(8;21). However, the risk of MDS/AML with balanced translo-
cations involving 21q22 has been found to be related to previous therapy with anthracyclines and alkylating agents [16, 17]. We therefore speculate that the development of MDS was at least partly linked with the treatment for the primary tumor as well as common carcinogenic and host susceptibility factors. As has been suggested in cases of secondary AML with t(8;21) [17], we think that therapy-related MDS patients with this translocation can enjoy durable remission if they are treated with AML-oriented chemotherapy. Acknowledgements We thank Dr. N. Kamada (Hiroshima University, Hiroshima) for the Kasumi-1 cell line.
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