Case Reports Changing
Picture in an
Acute Myeloproliferative ELIZABETH W. BERRY,
and JANE F. DESFORGES,
Boston, Massachusetts Described herein is a case of acute myeloproliferative disorder in which the presenting pancytopenic picture was associated with multiple chromosomal abnormalities including a major hypodiploid line, a ring form, aneuploidy, polyploidy and fragmentation. The overt leukemic phase which occurred three and a half months later was preceded and accompanied by an additional hyperdiploid line. The close relationship between the chromosomal change and clinical course suggests that repeated cytogenetic studies in this type of patient may be useful from the prognostic and therapeutic point of view.
BNORMALITIES of chromosomal number and structure are common in acute leukemia. Although there is considerable individual variation, the changes tend to remain constant throughout the disease in any one patient [I]. Similar changes have also been noted in preleukemic or potentially leukemic disorders, most of which subsequently progressed to overt leukemia [Z]. In contraSt to acute leukemia, a consistent abnormality, the Philadelphia (Ph’) chromosome, is found in chronic granulocytic leukemia. In association with the blast cell crisis, one or more aneuploid lines frequently appear . Described here is an acute myeloproliferative disorder in which the presenting pancytopenic picture was associated with an hypodiploid chromosome line. Overt leukemia subsequently developed, following the appearance of an hyperdiploid clone of cells. The significance of this chromosomal finding in relation to the clinical course and the similarity to the blast cell crisis of chronic granulocytic leukemia is discussed.
A forty-five year old white housewife (B.C.H. No. 2076088) was referred to the Tufts Hematology Laboratory on January 10, 1967, for investigation of pancytopenia. She had had ulcers in the mouth for one month and generalized aching and fatigue for a week. Her prior medical history was unremarkable and the hematocrit in August 1966 was normal. There was no family history of anemia or blood dyscrasia, and no known exposure to drugs or toxins. The positive findings on physical examination were fever, pallor and raised indurated ulcers on the buccal mucosa and the posterior fauces. Hematologic studies included hemoglobin 6 gm. per 100 ml., hematocrit 19 per cent, white blood cell count 2,900 per cu. mm., platelets 82,000 per cu. mm. and reticulocytes 1.8 per cent. White blood cell differential was as follows: neutrophils 38 per cent, myeloblests 3.5 per cent, eosinophils 0.5 per cent, small lymphocytes 52.5 per cent, monocytes 5.5 per cent, a rare nucleated red blood cell, moderate aniso- and poikilocytosis; burr and pencil forms were noted on smear as well as pseudo-Pelger anomaly and giant platelets. Bone marrow was cellular, with a myeloid to erythroid ratio of I:1 and abundant dysplastic megakaryocytes. There
* From the Hematology Laboratory (Tufts), Boston City Hospital, Boston, Massachusetts 02118. This work was aided by Institutional Grant IN-23 of the American Cancer Society, New York, New York. Requests for reprints should be addressed to Dr. Jane F. Desforges. Manuscript received September 5, 1968. t Charlton Research Fellow. Present address: Auckland, New Zealand. VOL.
1~2s .L moderate increase in basophilit normoblasts IJut maturation was occurring. OCC;lsiolldl I,i- and multinucleated forms wc’rv prtwnt in all stages of de\ elopnien~. Some tells wrre Iniltlly rnc~aloblastic, manv were periodic acict-Schifl-positi\? arid iron \taiu showed a small number of siderol)lasts. Dysplastic young forms predominalcd in the myeloid series, and there were foci of blast lorms ar~tl I>]-omyelocytes. Many cells had a pseudo-Pelger anom sly. \‘acuoles were present in the nucleus and o;toplasm of cells of all types. ‘4 second bone marrow hiopry performed three weeks later for I ! togenctic studv showed much less erythroitl acti\iry. Other laboratory studies included a berum vitanlin B,, level of 745 ppg. per ml., serum folio acid 1 I.9 mbg. per ml.,* serum iron 11i mg. per 100 ml., leukocyte alkaline phosphatase score 37 1, lx tic acid dehydrogenase 241 units, uric acid 4 tug. per cent. erythemotosus cell Lupus preparations iIIld Coombs’ test were negative, and hcntoglol)in electrophoresis was normal. The provisional diagnosis was aleukemic acute leukemia. The patient was treated initially and for the four subsequent months by transfusion alone. Her hematologic course is shown in Figure 1. Pyridoxine therapy failed to alter her transfusion requirements. Her mouth ulcers persisted. The clinical course was complicated by pneumonia and left axillary furunculosis, both of which responded to appropriate antibiotic therapy. On May 4 the
FIT.. 1. Hematologic course. Time sequence and material used for cytogenetic studies are indicated by PB (peripheral blood) and BM (bone marrow).
* M’e are indebted to Thorndike Memorial for folate and vitamin B1?measurements.
q Bone Morrow l-31-
m 50 -
Bone Morrow 4-17-67 PeripheralBlood 5-7-67
40 30 20 IO -
The distribution of chromosome counts from several specimens is summarized in Figure 2. Bone marrow cells were examined directly by the method of Tijo and Whang , and details of karyotypes are shown in Table
43 43 43 43 44 44 44 45 45 45 46 88 88
1 2 1 1 5 3 1 3 1 1 2 1 1
At autopsy the spleen, which had never been palpable, weighed 410 gm. and showed myeloid metaplasia with striking erythroid and megakaryocyte activity. Occasional megakaryocytes were present in the liver sinusoids and lymph node sinuses. Small foci of nucleated red cells were found in the lamina propria of the renal pelvis and in the myocardium. Both cell series appeared abnormal. The bone marrow was hypercellular, with erythroid and megakaryocyte predominance. There was no fibrosis.
patient had a temperature of ~OO’F., bilateral periorbital ecchymoses and widespread petechiae over the chest and abdomen. The white blood cell count was 4,000 per cu. mm. and a peripheral smear showed 76 per cent blast forms. Combined therapy (VAMP) was started (vincristine 1.5 mg. weekly, methotrexate 25 mg. twice weekly, 6-mercaptopurine 100 mg. daily, prednisone 60 mg. daily). Three days later the patient had menorrhagia and gastrointestinal bleeding, and a chest roentgenogram revealed bilateral pulmonary infiltrates. Over the next two weeks she was treated with VAMP, whole blood and platelet transfusions and a variety of antibiotic agents. The white cell and platelet counts fell precipitously. Just prior to her sudden death from Bacillus pyocyaneus septicemia on May 20 she had 300 white blood cells per cu. mm. in the peripheral blood with 30 per cent neutrophils.
Bone Marrow -2 -2 -2 -2 -2 -2 -2 -1 -1 -1 N -4 -4
... ... ... ...
... ... ... ...
. L s
‘2s Peripheral Blood
3 1 2 1
:z +4 +3
+3 +3 +1
;: +7 t-7 +8
+7 +7 +7
-2 N -1
1 2 1 1 1 1 1 2 1 6
44 46 46 47 52 54 57 57 57 58 57 58 58 58 58 59 59
J fFt -i
FIG. 3. Metaphase plate and karyotype forty-five chromosomes, including a ring are missing.
The findings in the initial sample Uanuary 31, 1967) were as follows: (1) a major hypodiploid stem line lacking two group C chromosomes, (2) aneuploidy, (3) a ring chromosome of variable size (present in 10 of 141 mitoses), Figure 3, (4) fragments (present in 1 per cent of mitoses including some with ring forms), (5) polyploidy (7.8 per cent) and (6) endoreduplication (2 mitoses). The second bone marrow specimen obtained on April 16, 1967, was technically inadequate and contained only three analysable mitoses with 43, 44 and 59 chromosomes. The first two were similar to the initial major stem line lacking two group C chromosomes whereas the third mitosis contained eight extra group C, three G, one E and one F chromosomes. I.
16 - I6 (El
and X (C)--l
11, ” 21- 22 on4 Y (6)
bone marrow mitosis showing One C and one F chromoEotllc
Peripheral blood was cultured in GIBCO prepared tubes+ (165 and 167s). The seventy-two hour peripheral blood culture (April 17, 1967), with phytohemagglutinin (PHA), showed a normal female karyotype, the only abnormality being a 10 per cent incidence of breaks and gaps. I\ forty-eight hour peripheral blood culture without PH.4 inoculated when there were 76 per cent blast forms in the peripheral blood (May ‘7, 1967) grew vigorously and yielded many hyperdiploid mitoses as well as the original 44 chromosome line found in the bone marrow. There was a second mode of 58 with considerable scatter between 54 and 60 (Fig. * Tissue Biological
culture medium prepared Co.. Grand Island, N. Y. AMERICAN
FK. 4. Metaphase plate and karyotype from peripheral blood culture (without phytohemagglutinin) showing fifty-eight chromosomes. There are seven extra group C, one D, one E and three G chromosomes and a fragment.
2). Representative karyotypes were basically similar to each other (Fig. 4, Table I), showing consistent gains in C and G groups and variable additions to the D, E and F groups. This presumably reflected the process of variation and selection in a blast cell population. Although it seems likely that the hvperdiploid lines arose from the original hypodiploid cell line, there was neither a marker chromosome nor mitoses with an intermediate number of chromosomes to confirm this impression. Minute fragments were present in 20 per cent of cells. In retrospect it was apparent that the second group of clones was present at least three weeks prior to the appearance of overt leukemia, as evidenced by the mitosis with 59 chromosomes VOL.
and similar karvotype marrow specimen.
The “mveloproliferative syndrome” is a group of disorders characterized by self perpetuating proliferation of various marrow elements in the bone marrow or potential bone marrow sites . Although specific entities are defined by the clinical picture, chromosomal findings and variations in leukocyte alkaline phosphatase score, there are many transitional or mixed forms, and evolution from one variant to another is common. The case described, which showed hvperplasia and dysplasia of all the marrow elements during the five month course, illustrates the difficulties in precise
diagnosis. Initially, tile picture was that of a or erythroleukemia with mixetl leukemia prominent megakaryocyte involvement. ‘This eventually progressed to typical acute ,granulocytic leukemia and terminated in a picture which could be termed “acute erythromegakaryocyte myelosis” . The less specific term “acute myeloproliferative disorder” best describes this polyphasic sequence. A variety of chromosomal abnormalities affecting mainly groups C, G, D and E have been reported in acute leukemia. Similar findings have been noted in cases of pancytopenia with “preleukemia” and with leukemia. The initial bone marrow specimen in this case showed a ring chromosome of variable size and increased polyploidy in addition to the predominant hypodiploid line involving the C group. Ring chromosomes have been demonstrated in man in several conditions, including acute leukemia , other types of neoplasia  and following cytotoxic therapy . They are not a common feature in acute leukemia, and this patient as well as most of those described in the literature had prominent erythroicl [IO-I?]. Erythrotoxic agents involvement could not be implicated as a causative factor in this instanc:e as the patient was untreated. A ring chromosome has also been found in sicleroachrestic anemia . The origin of the polyploid mitoses is imthey could have possible to assess because arisen from multinucleated red cells and binucleate early myeloid cells as well as from megakaryocytes. The interesting cytogenetic feature of this case is the development of frank leukemia following the emergence of a hyperdiploid clone of cells. Although minor alterations of the modal karyotype have been observed particularly following chemotherapy in both acute
tloul)ling ot tile marker chromo~on~es ill Ilvperdiploid cells and by the progressi\:<. cl~ronioxomal loss iu the hypodiploid cclla. Recently DeGrouchy et aI. [ lN/ qmrted a case of subacute grauulocytic leukemia with ring sicleroblasts in which pwl ial tlelet ion of one F group cl~ronioson~e was found iuitinlly. ‘I‘M.0 months later, when the lieniatolo~ic~ state had deteriorated, there was l~ypertliploidy with extra D, C, G and E chromosomes in ;I pat.tern suggestive of clonal evolution. The I; group anomaly had also been notetl in sir\ c;~ses of sideroachrestic anemia. An analogy was made with the chronic and acute phase of chronic granulocytic leukemia in which “the acquisition of supernumary chromosomes reflects a clonal evaluation towards an acute transforIn the blast cell rrisis of chronic mation.” aneuploidy, particugranulocytic leukemia, larly hyperdiploidy and structural change, frequently occur in Ph’ positive cells. This indicates that the acute transformation is the result of evolution of the chronic granulocytic leukemia rather than an unrelated acute granulocytic leukemia. In the experience of many but not all investigators  the appearance of considerable aneuploidy with several cell lines is a good indication of acute transformation or imminent transformation even in the absence of morphologic evidence. Clinically such an observation can be of use prognostitally and in selection of chemotherapeutic agents [ZO]. In this case the absence of a common marker chromosome neither proves nor disproves that the second group of clones was derived from the first. However, several endoreduplicated metapliases were seen in the initial marrow, and partial endoreduplication of groups C, D, E, F and G could have given rise to a new hyperdiploid stem cell. Although there was considerable scatter about the mode of 58, karyotypes do suggest a common ancestry for these cells, and there is evidence of explosive clonal evolution with acquisition of further supernumerary chromosomes particularly in the C and G groups. Although survival in acute leukemia correlates well with the induction of a good remission , an appreciable number of cases of pancytopenia with immature and dysplastic bone marrows “smoulder” along for months or even years without any apparent response to aggressive tlierapv. For AMERICAN
this reason some workers advocate symptomatic treatment initially, and the withholding of chemotherapeutic agents until the acute flare-up. In the present case, the appearance of a new line heralded the development of blast cell crisis. Such a finding may be the first indication of change in course, and aggressive treatment should perhaps begin at this point. Acknowledgment: We wish to thank Dr. R. Bain at the Mallory Institute of Pathology who performed the postmortem examination.
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