ciated with the aniridia syndrome, is characterized by a specific constitutional deletion of a minimal segment of llp13 (RICCARDI et al. 1978; FRANCKE et al.
Hereditas 97: 273-288 (1982)
Acute myelogenous leukemia in a child with primary involvement of chromosomes 11 and X ELISABETH NACHEVA’, PATRICIA FISCHER2, OSKAR HAAS*, YANKA MANOLOVA3, GEORGE MANOLOV3 and ALBERT LEVAN4 Institute for Cancer Research. University of Vienna, Austria, on leave from the Oncological Research Institute, Medical Academy, Sofia, Bulgaria, Institute f o r Cancer Research, University of Vienna, Austria, :3 Oncological Reseurch Institute, Medical Acudemy, Sofia, Bulgaria, Institute of Genetics, University of Lund, Sweden l
P., HAAS, O., MANOLOVA,Y.,MANOLOV, G.and LEVAN, A. 1982. Acute myelogenous leukemia in a child with primary involvement of chromosomes I 1 and X. -Hereditas 97: 273-288. Lund, Sweden. ISSN 0018-0661. Received July 7, 1981. Manuscript revised August 3, 1982
NACHEVA, E., FISCHER,
The chromosomes of a case of acute myelogenous leukemia in an infant of 7 months were analyzed by means of high resolution banding achieved without mitotic synchronization. The analyses were based on 2 cell samples taken, (1) at diagnosis before treatment, and (2) 3 months later during partial remission, before the onset of the terminal phase. All cells of both samples contained 2 deviating chromosomes resulting from rearrangements of X at q22 and of I 1 at p13, pl5 and q23. Twenty-seven per cent of the cells of the first sample and 51 % of the second sample in addition had an inverted (mirror) duplication of the “variable” region of the long arm of chromosome 1 (lq12). At the second fixation this cell clone had undergone further evolution leading to one clone with trisomy for the distal half of the short arm of chromosome 6 (6p21.2-pter) and another clone with rcp t(7;12) (q13;q15). The involvement of chromosome 1 1 in malignant blood disorders is discussed with special emphasis on acute nonlymphocytic leukemia of the childhood. Elisabeth Nacheva. Oncological Research Institute, Medical Academy, 1156 Sofia, Bulgaria
Acute nonlymphocytic leukemia (ANLL) is comparatively rare in children, and our knowledge of the chromosomes of childhood ANLL, analyzed by banding techniques, is still highly insufficient. Adult ANLL, on the other hand, is, together with chronic myeloid leukemia (CML), one of the human neoplasms that have been most widely studied with modern chromosome-banding techniques, and it is well documented that about 50 % of the ANLL cases show chromosomal abnormalities, while 50 % have karyotypes that are apparently normal (First International Workshop on Chromosomes in Leukemia 1978). Based on 496 cases of ANLL, mostly from the literature, MITELMAN and LEVAN (1981) ascertained that the chromosomes most often involved in aberrations in ANLL were Nos. 7, 8, 17 and 21. Among them chromosome 7 was usually involved in monosomy or deletion of various segments of the long arm, chromosome 8 in trisomy or in t(8;21), chromosome 17 in the t(l5;17) of acute promyelocytic leukemia (APL), chromosome 21 either a s mono-
somy or trisomy. All these aberrations have also been reported from children, but as single observations. HAGEMEIJER et al. (1979), studying 14 cases of ANLL in children, including acute myeloid leukemia (AML), APL, acute myelomonocytic leukemia (AMMoL) and erythroleukemia (EL), found clonal chromosome abnormalities in 9 of them, viz. monosomy 7, del(7) (q22), trisomy 8, t(8;21) and monosomy 21. The t(15;17) did not occur among them but was reported by VANDEN BERCHE et al. (1979a) in a child with APL. FISCHER et al. (1980) reported trisomy 8 in a child with AML, and KANEKO et al. (1978) reported t(8;2l) in 2 children with APL. BENEDICT et al. (1979), studying 28 children with ANLL, found that half of the 22 cases in which the chromosomes were analyzed had clonal aberrations in the malignant cells and thus conformed in this respect with the situation in adult ANLL. In their material, however, the types of chromosomal aberration differed from the findings in adult ANLL. Furthermore, in studies by MITELMAN
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et al. (1978, 1981) it has been shown that the cation involving both the short arm and the long chromosomal pattern was different in 2 groups of arm of 1 1 and the long arm of X . Additional chroadult A N L L patients, one of which had been ex- mosome markers were also present and will be posed occupationally to agents with potential mu- described. tagenic/carcinogenic action, the other with no such exposure. The typical chromosome changes Case history were decidedly more common among the patients of the former group. Now, Benedict and cowork- The patient, a male infant of 7 months, was admiters suggested that childhood A N L L may consti- ted to the St. Anna Children’s Hospital, Vienna, tute a special unit etiologically, more comparable on July 3, 1979. H e had blood in the stool, swelling to the disease in patients who had not been in and reddening of the left leg, fever of 38.8”C and prolonged contact with carcinogenic influences. enlargement of the liver, spleen and parotid This conclusion is somewhat at variance with the glands. The laboratory data were as follows: observations of Hagemeijer et al. just quoted, and Hemoglobin 8.2/100 ml, white blood cells (WBC) it is obvious that the pattern of chromosomal 72,000/mm3. differential count: bands 1 %, polychanges in childhood A N L L is urgently in need of morphonuclear leukocytes 2 I 95, lymphocytes further study, as was also emphasized by Benedict 19 %, myeloblasts 59 %. The bone marrow (BM) and coworkers. was highly cellular with 87 % myeloblasts. CytoChromosome 11 is primarily involved in genetic analysis of peripheral blood (PB) and BM changes in the case of childhood leukemia dealt was performed on July 4, 1979. A diagnosis of with in the present paper. This chromosome was AML was made and the patient treated with cytocomparatively little involved in the 496 cases re- statics according to the schedule of Bekesi (cytoviewed by MtTELMAN and LEVAN (1981), its total sine arabinoside and dexoruticin). Partial remisinvolvement amounting to 44 cases (8.9 9%). Ab- sion was achieved with diminishing of the blast normalities have been reported in A M L as single cells in the BM to 8 5% and the WBC to 1,750/mm3 observations with involvement of the short arm with no blasts in the PB. A second cytogenetic segments 1 l p l l (PHILIPet al. 1978), 1 l p l 5 (ROWLEY analysis was performed of both mother and patient 1978) and the long arm segments 1 lq23 (ROWLEY during a routine check on October 8, 1979. At this 1978) and 1 lq23-25 (OSHIMURA et al. 1976). Also, time he had 3,400 WBC with no blast cells in the changes in the long arm of chromosome 11 involv- PB. On November 20, 1979, blast cells again aping the segments q14 and q22-25 have been re- peared in the PB (4 75).In spite of treatment the ported in 5 out of 7 patients with poorly differen- increase in blasts could not be controlled, rising to tiated acute monocytic leukemia ( AMoL) (BERGER 76 9% on February 22, 1980. The patient went into et al. 1980). These observations with a relatively coma and died o n March IS. 1980. high incidence of chromosome aberrations and nonrandom involvement of 1 Iq are impressive. We shall return to this situation in the discussion part below. Materials and methods On the other hand, nonrandom changes of 1 Iq are also well documented in lymphoid malignan- Chromosomes were studied in direct preparations cies. The segments I lq13 (FLEISCHMAN and PRIGO- from BM or in preparations from 24h cultures of G l N A 1977; MARKe t al. 19781, 1Iq21-23 (FLEISCHBM or PB in RPMI 1640 medium with 5 % CO, atmosphere. In some samples nucleated cells were MAN and h l G O G l N A 1977; MARKet al. 1979; V A N DEN BERGHEet al. 1979b) have been designated separated in a Ficoll hypaque gradient and placed “hot spots”, and the t(11;14) (q14;q32) has been in culture at a density of lob: cells per ml medium. recognized as a new characteristic karyotype Phytohemagglutinin (PHA) was added to one alianomaly of lymphoproliferative disorders (VAN quot of the patient’s and the mother’s blood, and DEN BERGHEet al. 1979c), as has also t(4;11) the cells were harvested after 72h. Chromosome (q21;q23), found in 19 among 234 cases reviewed preparations were made according to the air-dryby the Third International Workshop on Chromo- ing technique, and slides were G-banded with a slight modification of the technique of WANGand somes in Leukemia, 1980 (1981). We present here another case of A M L in a child FEDOROFF ( 1972). with chromosome 11 abnormalities. The malignant Suitable metaphases, as well as earlier stages stemline was characterized by a complex translo- with less condensed chromosomes were analyzed
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and karyotyped. The high resolution analysis of the G-bands, achieved without mitotic synchronization, was aided by diagrams and nomenclature that have been elaborated by one of us (G. M.) and will be published in detail in a forthcoming paper. The diagrams of Fig. 2, 5 , 6 and 7 of the present paper represent 4 levels of chromosome condensation with roughly 300, 400, 600 and 900 bands per haploid autosomal set + X and Y. The 300-band level is reprinted from the Paris Conference 1971 (1972); the other 3 levels will appear in the paper by G. Manolov just mentioned. For brevity we often refer to the chromosomes of the latter 3 stages of condensation as mesomes, intersomes and prosomes, respectively. The prosome corresponds to the maximal degree of structural differentiation. At the extreme right in the diagrams of the figures mentioned, all prosomic subbands have been given individual numbers which can readily be related to the band numbers of the Paris diagram at the extreme left. The designations for chromosome regions and bands are basically the same in the present nomenclature as in the Paris Conference 1971 (1972) and in the ISCN high-resolution banding ( I98 1). When occasionally our designation of a certain subband differs from that of the ISCN 198 I , we have added the latter in parenthesis after our designation. The very tiny digits in the first and last columns of the rightmost field of the diagrams relate to a parameter (speed of band dedifferentiation) which will be dealt with in a forthcoming paper by G. Manolov.
ACUTE MYELOGENOUS LEUKEMIA
in the following are founded on material of this kind. The second culture was set up from PB during remission, 6 weeks prior to any detectable reappearance of the blast cells. Chromosome analysis revealed that dona1 evolution had taken place with structural rearrangements of chromosomes 4, 6, 7 and 12, leading to further marker formation (Table I ) . In the following, the different marker chromosomes will be described in some detail. All of them will be referred to as “mar” followed by the designations of the chromosome or chromosomes taking part in the marker. When 2 chromosomes are involved, the one with the centromere is written first. The paper is concluded with a discussion mainly dealing with the possible role of chromosome 11 in leukemias. Description of the marker chromosomes MarlllX and marXI11
The detailed analysis of the abnormal chromosomes X and 11 (Fig. la, b) revealed that 2 structural changes were involved: ( 1 ) A reciprocal translocation t(X; 1 l)(q22;q23) laccording to ISCN (q22.3;q23.3)/, and (2) an inverted insertion of the segment 1lp13+p15.22(15.3) into Xq at the Xq22 (q22.3) break point and proximal to the interchanged 1 1q23(23.3)+qter segment (Fig. 2). The 2 markers resulting had the following constitutions: rnarlllx rnarXl I I
Results General survey PHA-stimulated blood cultures both from the patient and from the mother showed normal chromosome constitution. Altogether 183 spontaneously dividing cells from the BM and PB of the patient were analyzed under the microscope, 98 of which were karyotyped. All of them, except 8, had 46 chromosomes; those deviating showed random hypodiploidy. At the onset of the disease 100 % of the BM cells possessed abnormal chromosomes X and 1I . In 27 % of the mitoses an additional structural aberration was found in one of the chromosome 1 homologues. Two complete karyotypes, showing the 3 abnormal chromosomes mentioned, are presented in Fig. la and b. The former picture is a sample of our prosome karyotypes, the latter is a mesome karyotype. The detailed conclusions
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1 lpter- 11p15.22(15.3):: 1 lp12 1 1q23(23.3)::Xq22(22.3)+Xqter Xpter-Xq22(22.3): :1 1p 15.22(15.3)
-1lp13::1lq23(23.3)+1lqter The interpretation of the structure of the 2 markers was based on the following facts and considerations. The distal half of the long arm of marX/I 1 consisted of 2 segments. The distal one of these segments was identified as the end of the long arm The proximal segof 11, viz. llq23(23.3)-qter. ment was dominated by the strongly Giemsa-positive band llp14, surrounded by parts of p13 and p15. Since 1 lp13 is a very narrow band, the break point must have been located close to p14, while-especially in the mesome and intersome -the G-negative band p15.1 is relatively larger and therefore caused the light zone next to p14 to appear wider, as can be seen clearly in marX/I 1 (Fig. 2). At an early stage (Fig. la) it was seen that the more distal of the 2 break points in I l p cut through 11~15.22, thus leaving the G-positive llp15.21 in the proximal of the two chromosome
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i
3
do E
Fig. lb. Fig. la and b. Two stemline karyotypes from BM cells of the present case of acute myeloid leukemia of the childhood. a prosomes. b mesomes. Note the 3 markers, marl, marl I/X and marXl1 I . Bars = 10pm.
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Table 1 . Incidence of markers in the sternline (2 upper boxes) and sidelines (4 lower boxes) on the 2 occasions of study: ( I ) at diagnosis, July 4, 1979 (to the left), and (2) one month before relapse, October 8, 1979 (to the right) marlliX +marxi11
73%
49%
t rnarlliX + m a r x i l l + m a r l
During remission before relapse
At onset of disease 4
18Wo
D
11 segments that formed the distal half of marX/l lq. This interstitial segment of 1 lp, containing p14 and parts of p13 and p15.22, could have been inserted into marX/11 in 2 ways, direct or inverted. The direct insertion would require the sequence p13, p14 and p15 in proximal-distal direction, while the inverted insertion requires the opposite sequence. As seen from the band structure of marX/ I I in Fig. 1 and 2, the insertion is an inverted one. The G-negative proximal part of the inserted segment is, moreover, too large to comprise just llp15.22 and must also include material from the X. Apparently, the break in Xq22(22.3) has taken place near the G-positive Xq23 with the consequence that most of the Xq22 has been left in the centromeric part of the broken long arm of the X. In marll/X, the end of the long arm is formed by the translocation of the segment Xq22-qter to the long arm of 1 1 at 1 lq23. At the region of interchange in marl l/X there is a G-negative structure mainly belonging to 1 1 , recalling the G-negative structure of marX/11 at the point of fusion between Xq22 and I lpI5.22. The removal from I I p of the interstitial segment of l l p l b ~ 1 5 . 2 2followed , by the attachment of the terminal part of Ilp, i.e. Ilpter+p15.22(15.3)at llp12, are the changes that underlie the formation of the short arm of marl I/X.
It has been a general observation at the study of marker chromosomes that the G-band pattern of regions involved in breaks and reunions display characteristic changes in appearance: G-positive structures that usually are colored only moderately are expressed more strongly, whereas G-negative structures that normally are tinged become relatively lighter. Actually the segments involved in structural rearrangements exhibit the appearance of an earlier stage of banding differentiation, while the banding pattern of the unaffected segments of the same chromosomes display the same more condensed appearance as the rest of the chromosomes of the cell. The detailed band pattern of the 2 markers, marX/11 and marlI/X, described above is another example of local prosomization, as reported by MANOLOVA et al. (1979) and MANOLOV et al. (1979). A similar effect was recently reported by HECHTand KAISERMCCAW ( 1981a, b) . The formation of the 2 markers, marll/X and marX/l I , could be the result of one event, involving 3 breaks in I 1 and I in X (Fig. 3). A close spatial relationship of the chromosomes involved has to be postulated to enable the hypothetical agent to produce the breaks, as indicated by the broken lines in the figure. A 2-stage mechanism is a possible alternative (Fig. 4), the first stage effecting the inverted insertion of the interstitial l l p segment into the long arm of 11 at q23, forming a
X/i
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hypothetical variant of 1 1 called t l I in the figure. The second step would be the reciprocal translocation between t l l and X . This would require 3 breaks for the first step and 2 for the second. In Fig. 4, t 11 has been drawn in outline only to emphasize the hypothetical nature of this chromosome that has not been observed so far. Marl In 27 o/o of the BM mitoses, one of the chromosome 1 homologues showed a very characteristic deviation: In the long arm, the region close t o the centromere, the lq12, was obviously double its normal size. The appearance of this chromosome at a stage around 400 bands is shown in Fig. 5. Normally at this stage the lq12 region consists of one massive G-positive, hyperchromatic structure proximally (q12. I ) and one decidedly narrower G-positive, hypochromatic structure distally (q12.3). separated by a wide chromatically tinged, G-negative structure (q12.2). Both in the Paris Conference (1971) and in the ISCN (1981) diagrams, the lq12 is calles a “variable” band. The analysis of the enlarged lq12 region of marl revealed that it had undergone inverted duplication (mirror duplication). The break points must have been close to the boundaries of q 12 in the G-negative, neighboring bands q 1 1 and q2 I . Marl I/X, marX/I 1 and marl are chromosome rearrangements that characterize the initial stage of the disease studied. They were again found on the second occasion of study, during remission, before relapse. On the second occasion, however, the malignant cell population had undergone further clonal evolution. As a result new marker chromosomes had been formed, involving chromosomes 4, 6, 7 and 12 (Table I ) . These markers will be described in the subsequent 2 sections. Mur4/6
In the sample from the remission period, 23.6 3’% of the BM mitoses and 12.5 9% of the PB mitoses contained an abnormal chromosome 4, the short arm of which was too large. The band analysis showed that a segment of chromosome 6, viz. 6~21.2-pter had been translocated onto the distal part of 4p. The 2 chromosomes involved, 4 and 6, as well as our interpretation of the origin of mar4/6 are presented in Fig. 6. At the analysis of the short arm of mar4/6 special attention was paid to the possible origin of the narrow G-positive structure, located in the large G-negative segment in the
x
11
11
mar H I X
mar X / 11
Fig. 3. Diagram of the spatial relationships of X and I I enabling marl I/X and marX/l I to be formed by a onestep event. As indicated by the broken lines to the left, 3 breaks are induced in chromosome I I and 1 break in X; the segment Xq22(22.3)+qter is translocated onto 1 lq23 (23.3) and the segment I lp15.22(15.3)-+llp13onto Xq22 (22.3) proximal of the segment 1I q Z S q t e r , which forms the end of the long arm of marX/ 1 1.
middle of the short arm of the mar4/6. Apparently, this G-positive structure could not be the most distal G-positive band 4 ~ 1 6 . 2 ,which actually is detectable only with difficulty. Neither did it fit in with the too wide dimensions of 6 ~ 2 1 . 2 .Our conclusion was that the break point in chromosome 6 must have been in the G-negative 6 ~ 2 1 . 2 2(see prosome diagram of Fig. 6). The band 61321.2 at the 900 band stage was not subdivided in ISCN (1981). At this site (6~21.22)the end segment of 6p has been attached to the G-positive 4 ~ 1 6 . 2During . the prosome stage, this latter band is split into 2 G-positive substructures, 4~316.21and 16.23, separated by the very narrow G-negative band 4 ~ 1 6 . 2 2 (see prosome diagram of Fig. 6). In case half of the G-positive 6p2 I .2, i.e. 6p2 I .23, associates with half of the G-positive 4 ~ 1 6 . 2 ,i.e. 4 ~ 1 6 . 2 1 ,after breakage in 4 ~ 1 6 . 2 2 , the resulting G-positive structure would be narrower than 6 ~ 2 1 . 2and would correspond well with the dimensions of the G-positive band in the middle of the short a r m of mar4/6, as seen in Fig. 6. The cells with mar4/6 contain I normal chromosome 4 and 2 normal chromosomes 6. It is reasonable to assume that this situation has developed by a reciprocal translocation t(4;6)(p16.22;~21.22), after which only one of the resulting translocation products has been maintained. Both the tiny 4p16.2Spter and the large 6~21.22-qter have disappeared. The segment 6 p 2 1 . 2 h p t e r carried by the mar4/6 is present in trisomic state.
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X
ACUTE MYELOGENOUS LEUKEMIA
11
tll
11
281
mar 11 / X mar X / l l
Fig. 4. Diagram of the formation of marl l/X and marX/11 by a two-step event: (1) Segment l l p l k 1 5 . 2 2 is inserted in inverted position into the long arm of the same chromosome at 11q23(23.3) forming the transient (hypothetic) mart1 I (drawn in outline); (2) the segment distal of the 1 lq23(23.3) of this mart1 1 is exchanged reciprocally for the segment Xq22(22.3)+qter. These events will require 3 breaks for step (1) and 2 for step (2).
1 - 17
w-
n--
--
:R t iJ
! c-
4%
13
I 0
,
.)I
1
1
mar 1
Fig. 5. Formation of marl by reversed (mirror) duplication of the “variable” band lq12.
Mar7112 and mar12/7 The products of one more reciprocal translocation were present in a fraction of BM and PB cells from the second occasion of study. In 9.5 % of the BM and 12.5 % of the PB mitoses both translocation chromosomes were found. The translocation was the following: t(7; 12)(p13;q15). The chromosomes involved, the 2 markers and diagrams of their mode of formation are pictured in Fig. 7.
Discussion Chromosome 11 markers
In the preceding section we have described in some detail the chromosomal characteristics of the present case of childhood AML. The different markers have been analyzed with the aid of high resolution banding. Among them, the 2 markers 1 1/X and XI11 had been formed after rearrange-
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ments in 1 1 at p13, p15.22(15.3) and q23(23.3) and in X at q22(22.3). As pointed out above, chromosome 11 is not usually involved in abnormalities, numerical o r structural, in ANLL. Some of the childhood A N L L cases, in which chromosome 1 1 has played a part in marker formation, will be mentioned. In the first report of t(8;21) in childhood A M L (KANEKO et al. 1978) one of the 2 cases described contained a clone with a chromosome 1 1 marker formed as the result of a t( 1 1 ;12)(pI 1 ;q 13). BENEDICTet al. ( 1979) found chromosome 1 1 derived markers in fixations from 2 patients, who had initially shown normal karyotype. One of them was an I Iq- marker, the other a t(l;I I ) . Among 12 children with A N L L and chromosomal abnormalities, M O R Set~ al. (1979) found 2 with chromosome 1 I involvement in translocations. One was a case of AMoL with t(11;19) (q23;p13), the other was a case of AMMoL with t(l l;l2)(pll;pl3). Thus in the former case the long arm of I I was affected, in the latter case the short arm. In the material of F’R~COGINAet al. (1979), including 78 cases of acute myeloid and lymphoid leukemias, more than half (46 cases) were from children below 16 years. Among them, 4 cases of AMMoL had involvement of chromosome 1 lq. HACEMEIJER et al. (1979) reported, among the 14 cases of childhood A N L L referred to above in the introduction, one AMMoL with a translocation t(l l ; l 3 ) , which attracts special interest in relation to the present case. This translocation had several features in common with our t(X;l I ) . Thus, both arms of chromosome 1 I were involved with break points in almost the same sites as in the present case, viz. p12 and q23 in their case, p13, p15 and q23 in ours. In both cases a reciprocal translocation was involved plus another structural change: a pericentric inversion in their case, the insertion of a segment of I l p into the Xq in ours. In the results section above we brought up the hypothetical question whether the X/l I and the 1 I/X markers could have originated in one step or in two. Hagemeijer and coworkers assumed a two-step event in their case: first the pericentric inversion ( I l)(p12;q23), then the rcp t(invI 1;13)(q23;q21). It would probably be feasible also in their case to envisage a spatial arrangement of the 2 chromosomes involved, by which both steps could be taken simultaneously. A priori, there are arguments both for and against each of the alternatives, and so far the question must be left open which alternative is most likely. It should be remembered that in neither case was the first step actually seen in the microscope.
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Since only very limited data exist from chromosome studies with banding in childhood A N L L , it is too early t o venture any far-reaching conclusions concerning the possible significance of the detailed patterns of rearrangement leading to marker formation in chromosome 11. It may be mentioned, however, that among the approximately 90 cases lately submitted to banding analysis, 15 had abnormalities in chromosome 1 I , 2 of which involved the short arm, 10 the long arm, 2 both arms and 1 unspecified (KANEKO1978; et al. 1979, 1982; BENEDICT et al. 1978; HACEMEIJER MORSEet al. 1979; PRICOCINA et al. 1979; BERCER et al. 1980; the present case). et al. 1980; FISCHER A rough scanning of the recent literature, including I19 cases of myelo- and lymphoproliferative disorders, in which chromosome I I was involved in structural changes with one o r more known exact break points, resulted in the diagram of Fig. 8. In this diagram the percentage distribution of altogether 136 break points (7 1 in myeloid, 65 in lymphoid cases) among the different bands of chromosome 1 1 is plotted (myeloid cases-black bars, lymphoid cases-open bars). As seen from the diagram, one of the break points of the present case, I lq23, was the one most often involved both in myeloid and lymphoid cases (35 92 and 43 %, respectively). The 2 classes of leukemias were fairly concordant in the distribution of the break points. In the myeloid ones, however, a larger proportion of break points was found in the short arm of 1 1 , 23 9% versus 9 52 in the lymphoid ones. In rhe lymphoid series, I lq13 with 17 9% breaks was the second most frequent break point, whereas in the myeloid series I lq13 and q25 each had 10 92 breaks and shared the room as second most frequent break points. In the lymphoid series 1 lq25 had just I break ( I .5 %I). Among the 119 cases scanned there were 23 childhood leukemias, 13 among the myeloid and 10 among the lymphoid ones. They had, in total. 27 break points, which were distributed roughly in accordance with the pattern of the adult cases. The important aspects now discussed will be dealt with separately o n a later occasion. In spite of the relative scarcity of the material, we feel that the breakage pattern of chromosome I 1 in A N L L , in lymphomas, and even in rnalignancies in general, may have a bearing on certain theoretical notions concerned with cellular rnechanisms at cancer induction and development. In the multistep hypothesis for cancer development, LEVANand collaborators (1977) speculated on 2 kinds of chromosome changes, qualitative and
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zation, referred to above in connection with the t(X;ll) and first described in the t(8;14) of the Burkitt lymphoma (MANOLOVA et al. 1979) is un40 doubtedly suggestive. Whatever significance the chromosome breakage may have in cancer devel30 opment, it is notable that one of the break points found in 100 % of the cells of the present leukemia is located in the same band as the deletion that has 20 7 a decisive (secondary?) effect on the development of the aniridia-Wilms’ tumor syndrome, the pri10 mary change in these cases perhaps being a mutation at the corresponding locus of the nondeleted Q I nfl n 11 homologue. p15 I 4 13 12 11 qll 12 13 14 21 22 23 24 25 It is also notable that reciprocal translocations Fig. 8. Percentage distribution of break points in chro- between the same 2 chromosomes X and 1 1 with mosome 11, Abscissa: the bands of chromosome I 1 from break points in the same regions as in our case of pter to qter (left to right), ordinate: per cent breaks in AML characterize the constitutional karyotypes each of these bands in 59 cases of myeloproliferative disorders with 71 break points (filled-in bars) and 60 of 2 women with primary amenorrhea t(X;ll) cases of lymphoproliferative disorders with 65 break (q22;q13) and t(X;l I)(q25-26;q23) studied by DORUSet al. (1979) and RUDAK et a]. (1979), repoints (open bars). spectively. A follow-up of cases with constitutional (X;I I ) translocations with a view of possible development of malignancy, in particular of leukequantitative, also referred to as primary or active, mia, would be of unquestionable interest. Incidenand secondary or passive (MITELMAN and LEVAN tally, one of the childhood AMMoL cases of PRI. 1981). The primary changes are thought to be in- GOGINA et a]. (1979) contained a t(X;l l)(q25;q23), duced by direct interaction between the carcino- thus almost the same karyotype as the latter congenic agent and the genetic material of the target stitutional karyutype just mentioned, and a recent et al. 1982) had cell. The secondary changes amplify the effect of case of adult AMMoL (DEWALD the primary change, and even though they arise t(X;l l)(q13p 15). through accidental disturbances of mitosis, they still show a certain measure of nonrandomness, The chromosome 1 marker because only those will be sustained that enhance the action of the primary change and thus possess Marl differed from the normal chromosome 1 selective value. Whereas primary changes are homologue by having band lq12 of about double characterized by break point specificity, the hall- size. The detailed analysis showed that band q12 mark of the secondary changes is the minimum had undergone a mirror duplication with its 2 subsegment resulting from duplications and deletions. bands repeated in reverse order proximal of the In this context it should be noted that quite ordinary q12. The Paris Conference 1971 (1972) another type of malignancy, Wilms’ tumor asso- and the ISCN (1981) both apply the term “variciated with the aniridia syndrome, is characterized able’’ to the lq12 region and represent this band in by a specific constitutional deletion of a minimal the diagrams with a scratched area to distinguish it segment of llp13 (RICCARDI et al. 1978; FRANCKE from “ordinary” bands. This is because the et al. 1979; YUNIS and RAMSAY1980; TURLEAU et al. C-band of this region is characterized by variable 1981). It is true that in our AML case it is another size and often exhibits heteromorphism between kind of change of the I lp13 band, a translocation the homologues. It also happens that part of the with the break point in this band and with no C-banded material gets located on the short arm perceivable loss or gain of substance. The fact that side of the centromere, a phenomenon called “inso many primary chromosome changes in cancer version” of lq12 (see review by ATKINand BRIare expressed as translocations with constantly TO-BABAPULLE 1981). We wish to emphasize that the same break points makes it reasonable to with the trypsin technique as practised by us, the assume that a qualitative change in the nature of a lq12 band reveals the same “dynamic” structural mutation or a position effect is also involved. The appearance as all other chromosome segments change in chromosome phenotype called prosomi- (see diagram and photos of Fig. 5). It is thus per%
50
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fectly possible even in the Iq12 to distinguish a reported by G A H R T et ~ Nal. (1978) in a case of reproducible pattern of subbands. In our patient myelofibrosis with t( 1 ;6)(q23;p21). In this case the heteromorphism of the lq12 region was of there was monosomy for the segment 6p2I-+pter. It another nature than that reviewed b y Atkin and is interesting that partial trisomy for the segment Brito-Babapulle. Their heteromorphism and in- 6p2I-pter was the only chromosomal deviation of versions of this region were constitutional and in- the so-called 6p syndrome, which is expressed heritable, whereas the heteromorphism of the phenotypically as multiple malformations (PAGANO present case was limited to the malignant cells. et al. 1980). Both homologues of No. I were normal in the The other 2 new markers, mar7112 and mar12/7, peripheral blood lymphocytes from the patient and had been formed by a rcp t(7;12)(p13;q15). Since the mother. the normal homologues of 7 and 12 were also According to the survey of 1371 cases of neo- present, no change of chromosome length was plasia repeatedly referred to earlier ( MITELMAN and involved. Translocation involving 7p, 12q and a LEVAN1981) chromosome I was specifically af- third unidentified chromosome was reported by fected in 7 of the 16 subgroups of neoplasms that NOWELL (1978) in a case of myelofibroand FINAN the material was divided into. In 4 of them, which sis. The break points were not given and the stemcontained between 56 and 496 individual cases, line contained several other chromosome changes, the percentage of cases with No. I abnormalities including monosomy 11. Translocation 7;12, but varied from 21 9% in acute lymphocytic leukemia, with other break points, namely 7q36 and 1 2 ~ 1 3 , i in malignant was described by HAGEMEIJER 22 9% in polycythemia Vera, and 5 I 7 et al. (1979) as a lymphoma to 61 95 in carcinoma. It is now well clonal change in a child with AMMoL. established that structural aberrations of chromosome 1 are specifically correlated to certain maligConcluding remarks nant diseases. Furthermore, it has been demonstrated that trisomy for the long arm segment During recent years it has become more and more lq21-32 is frequent both in solid tumors and in evident that clonal chromosomal aberrations are leukemias (ATKINand BAKER1977; ROWLEY 1977; significant expressions of the malignant transforKOVACS1978; ALIMENA e t al. 1980). In ROWLEY mation, development and progression. In a n in(1977), for instance, there are pictured 2 direct creasing number of cases, quite specific duplications of the lq21-32 segment from cases of chromosomal changes have been ascertained as myelofibrosis and plasma cell leukemia and I re- strictly correlated to individual kinds of tumors. versed (mirror) duplication from a histiocytic lym- The break points by which they become estabphoma. Pictures are also given of trisomy for the lished are persistently in the same chromosomal same segment but complicated with translocations sites, and they may serve as useful diagnostic to other chromosomes. tools. In other cases, the clonal chromosome deSince in our case the fraction of cells with marl viations form patterns that are not easily underhad gone up from 27 92 in the first sample to 5 I 97 stood. The markers may seem more or less acciin the second, it is likely that the trisomic state of dental and the break points may not fall into any lq12 was associated with positive proliferating identifiable pattern. The leukemia case forming capacity. the object of the present study may belong t o this second type of neoplasms: its 2 most consistent markers are unique in their way. However, when The other markers, mar4/6, mar7/12 and mar12/7 the break points forming these markers were conOn the second occasion of sampling the malignant sidered, it was found that quite a number of other cell population consisted to two thirds of the same neoplasms had the same o r similar break points karyotypes as the first sample. One third of the and had evidently undergone evolutionary cells, however, had developed new markers. This changes that were partially the same. change had taken place in 2 clones also containing It is an important task for cancer cytogenetics to marl. It was demonstrated above, in the Results collect detailed information concerning marker section, that one of the new markers, mar4/6, had formation in tumors, preferably in many individual originated by translocation of the short arm seg- tumors of each kind. Only after large numbers of ment 6~21.22-pter onto chromosome 4 at 4 ~ 1 6 . 2 2 , such data have become available, can we expect making these cells trisomic for the distal half or to start finding sensible patterns and common demore of the short a r m of 6. Breakage in 6p21 was nominators. This will eventually elucidate funda-
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mental problems, as the relation between etiology and chromosomal change, the influence on cancer development of the gene content of the chromosome sites affected. In this type of work the new high resolution banding analysis will hopefully be an effective helper. Acknowledgements. - The authors wish to express their gratitude to Professor P. Krepler, Professor H. Gardner and the medical and nursing staff of the St. Anna Childrens’ Hospital, Vienna, for their interest and cooperation. We also thank Mrs. Gertrud Ganster for her valuable technical assistance. The work of A. L. was supported by grants from the Swedish Cancer Society, the John and Augusta Persson Foundation and the Cancer International Co-Operative (CANCIRCO), which is gratefully acknowledged.
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