Leukemic Transformation in Patients with the 5q- Alteration: Analysis of the Behavior of the 5q-Clones in Preleukemic to Leukemic Phases

Javier Benitez, Carmen Martinez Frejo, Carmen Toledo, Jose Sanchez Fayos, and Carmen Ramos

ABSTRACT: Serial cytogenetic studies have been performed in four patients with myelodysplastic syndromes. In all four a 5q- alteration was present, but with a different pattern of presenta- tion. One patient presented 5q- as the only alteration since diagnosis; two patients acquired this alteration during the course of the disease; and the fourth showed a 5q- plus other alter- ations since the first cytogenetic study. Likewise, three of the four patients showed a clone with trisomy 8 and without 5q-.

According to these observations and others from the literature with similar cytogenetic behavior, we have analyzed the following points: a) 5q- as a primary event and as the only alteration, b) 5q- as a secondary event, c) 5q- plus other alterations, and d) presence of cytogenetically different clones.

Analysis of these points suggests that the 5q- alteration can represent an early mutation conferring a slow capacity of expansion to the affected clones, with the possibility of cytage- netic evolution during the progression of the disease (about 30% of the patients). Likewise, the association of trisomy 8 clones with 5q- clones can be a nanrandom event.

INTRODUCTION

Although the 5q- anomaly was initially described in patients with refractory ane- mia (RA), macrocytosis, and non- or poorly lobulated megakaryocytes [1, 2,], we know today a wide variety of myeloproliferative and lymphoproliferative hemato- logic diseases with this anomaly [3-5]. In a recent review of the literature, Van den Berghe et al. [5] analyzed the breakpoints and the clinical course of 208 of these patients with 5q- alone or with other alterations. However, only a few cases had been followed from preleukemic to leukemic phases, and no conclusions were dis- closed about the cytogenetic behavior of the 5q- clones in the evolution of the disease.

The aim of this study is to present four patients with myelodysplastic syndromes (MDS) followed clinically and cytogenetically from a preleukemic phase to leu-

From the Department of Genetics and Hematology, Fundacion Jimenez Diaz, Madrid (J.B., J.S.F., C.R.), and the Department of Hematology, RS Virgen de la Salud, Toledo (C.M.F., C.T.), Spain.

Address requests for reprints to Dr. ]avier Benitez, Genetics Department, Fundacion Jime- nez Diaz, Av. Reyes Catolicos 2, Madrid 28040, Spain.

Received March 17, 1986; accepted May 6, 1986.

1 9 9

© 1987 Elsevier Science Publishing Co., Inc. Cancer Genet Cytogenet 26:199-207 (1987) 52 Vanderbilt Ave., New York, NY 10017 0165-4608/87/$03.50

200 J. Benitez et al.

kemic transformation; in all cases a 5 q - was present, ei ther as a pr imary or sec- ondary event. These findings afford the oppor tuni ty to analyze the behavior of these clones.

MATERIALS AND METHODS

Serial cytogenetic studies were performed on four patients with MDS from preleu- kemic to leukemic phases; diagnosis was made according to FAB criteria [6, 7]. In the first cytogenetic study, pat ient 1 had RA, pat ient 2 a refractory anemia with excess of blasts (RAEB), pat ient 3 a s ideroblast ic anemia (RA-S), and pat ient 4 a secondary MDS classified as RA.

In all cases chromosome analysis was performed on direct bone marrow samples or in cultures from per iphera l blood (24 hours). Banding studies were carried out using GTG and QFQ techniques. The cytogenetic findings of patients 1, 2, and 3 during the pre leukemic phase have been previous ly publ i shed [8].

CASE REPORTS

Patient 1

The patient was a 69-year-old female, seen in May 1981, because of abdominal pain and dizziness.

Hematologic data on admiss ion were as follows: Hb 5 g/dl, Hct 16.6%, WBC 4 x 109/L, platelet count 230 × 109/L. Bone marrow aspirate showed normal cel lular i ty wi th clear morphologic dyshemopoies i s of all three components , a slight increase of megakaryocytes (poorly lobulated), and the presence of r inged sideroblasts (less than 10%). A diagnosis of RA was made. The pat ient received only blood transfu- sions, but no medicat ions.

Serial bone marrow studies showed no change unti l March 1983, when an in- crease in blasts appeared (7%). Nine months later (December 1983) the number of blasts increased to 27%. In March 1984, hematologic invest igat ion revealed the presence of blasts in per iphera l blood, wi th an increase of WBC and a decrease in the platelet count to 70 × 109/L in July 1984; the blasts were now 90%. A diagnosis of M1 was made. The pat ient was then treated with cytarabine but she d ied a few days later.

Patient 2

The pat ient was a 47-year-old female s tudied in November 1979; she presented with a 12 month his tory of progressive pal lor and weakness. Anemia refractory to folic acid, v i tamin B12 and steroid t reatment was discovered. She had no history of hemorrhage or fever. Physical examinat ion showed mucocutaneous pal lor and no visceromegaly.

Hematologic data on admiss ion were as follows: Hb 8.6 g/dl, MCV 127.4 fl, WBC 3.5 × 109/L, platelet count 421 x 109/L. Bone marrow aspirate and b iopsy speci- mens revealed an increase in cellulari ty, wi th a high propor t ion of megakaryocytes, some of which were dysmorphic; granulocyt ic immatur i ty with part ial myelobla- tosis (7%); moderate macroblast ic hyperp las ia of the erythroid component wi thout r inged sideroblasts; and dyshemopoie t ic signs and moderate myelofibrosis.

A diagnosis of RAEB was made. The patient was treated with vi tamin B6, folates, and androgens with no clear hematologic response except for a slight rise in the Hb level to 10 g/dl. One year later Hb values, WBC, and platelet counts began to de- crease slowly. From this t ime on she needed frequent transfusions.

Leukemic Transformation and 5 q - Anomaly 201

The clinical picture remained unchanged until 1984, when infectious complica- tions appeared. In July 1985 the bone marrow showed RAEB in transformation (29% blasts). A treatment trial with low dose cytosine arabinoside was unsuccessful and the number of blasts increased to 35%- in November 1985. The patient died 1 month later.

Pat i en t 3

The patient was a 62-year-old female studied in April 1974; she had been suffering from weakness for 2 months. Physical examination revealed pallor without viscer- omegaly.

Hematologic data on admission were as follows: Hb 5.4 g/dl, Hct 16%, WBC 4.7 × 109/L, platelet count 550 × 109/L. Bone marrow aspirate showed normal cellu- larity with megakaryocytic hyperplasia and dysmorphic forms; myeloid cells were normal and the erythroid precursors showed 17% ringed sideroblasts.

A diagnosis of RA-S was made. The patient was given steroid treatments, which induced an increase of the Hb level to 11 g/dl. Anemia remained moderate and stable until 1979, but not requiring blood transfusions. In June 1979 the platelet count decreased and the Hb level fell to 7 g/dl, requiring blood transfusions. In October 1979, 3% blasts appeared in the bone marrow, increasing the 10% by March 1980; the platelet count was then 140 x 109/L and the WBC 12 x 109/L. In August 1980 further signs of transformation appeared, with 12% blasts in periph- eral blood, rising to 40% in November 1980. At that time a bone marrow aspirate showed 70% blasts. A diagnosis of M1 was made. The patient died in April 1981 in very poor general condition.

Pat i en t 4

The patient was a 66-year-old male with a diagnosis of multiple myeloma since June 1980. He was treated with chemotherapy (melphalan and prednisone) until 1982, and then received 30 cycles of cyclophosphamide. In January 1985 treatment had to be discontinued because of thrombocytopenia, leukocytosis, and dysmorphic forms. Hematologic data in July 1985 were as follows: Hb 12.3 g/dl, Hct 39.5%, MCV 79 fl, WBC 14.8 × 109/L, platelet count 35 x 109/L. Bone marrow aspirate showed a definitie hypercellularity with decreased megakaryocytes, some of which were dysmorphic; myeloid hyperplasia, and dyserythropoietic signs without ringed sideroblasts. A diagnosis of RA was made. Transfusions were started, but progres- sive anemia developed. In October 1985 a bone marrow aspirate showed dyshemo- poietic signs in all series and the presence of 12% blasts; the number of blasts increased in the peripheral blood rising to 20% by November 1985. The patient died a few days later with a diagnosis of leukemia (M5).

CYTOGENETIC RESULTS

The cytogenetic results of the four patients are summarized in Table 1. Patient 1 with RA at diagnosis and 5q- as the only alteration developed leukemia 4 years later with the same chromosome alteration. During this period of time we per- formed five cytogenetic studies; only cells with 5q- were found, except in the third study, where a new clone with trisomy 8 and without a 5q- arose in a small per- centage of cells. However, this clone disappeared later (fourth and fifth study) and only cells with 5q- were found.

Patients 2 and 3 with RAEB and RA-S at diagnosis both presented a similar cytogenetic picture; they initially showed, during 5 years and 5 months, respec- tively, a trisomy 8 without the 5q- alteration. However, with the first signs of

202

~D

CD

0

I

~D ~D O

°~

Z~

%

0

m~

Q

X

c~

,-q

+ +~ ~

e4

~ r ~ ~ ~ ~ ~ ~=

Leukemic Transformation and 5 q - Anomaly 203

leukemic transformation the patients developed a new clone with 5q-, where- as, the clone with trisomy 8 disappeared; the stem line in the leukemic phase in patient 2 was defined as 45,XX,- 19, - 22,del(5)(q13q31), + M1, and as 45,XX,- 10, del(5)(q13q31),del(12)(p11) in patient 3.

Patient 4 presented a previous history of malignancy. A diagnosis of multiple myeloma had been made 5 years earlier and he was treated with chemotherapy. He developed a secondary MDS showing complex abnormalities including 5q-. The stem line was defined as 45,XX,-10,t(3;17)(p21;p13),del(5)(q13q31),t(6;?)(q15;?). Four months later he developed leukemia with a similar karyotype (Fig. 1).

DISCUSSION

The four reported cases represent a group of MDS with different clinical and cyto- genetic behavior. Patient 1 presented 5q- as the only alteration since diagnosis; patients 2 and 3 acquired this abnormality during the course of their disease, and patient 4 presented a 5q- plus other alterations since the first cytogenetic study. Likewise, patients 1-3 showed, in addition to the 5q- clone, a different one with trisomy 8.

According to these cytogenetic observations, which represent three situations usually reported in the literature, we have analyzed the points that follow.

Figure 1 Bone marrow cell from patient 4 with the karyotype 47,XY, + 13,t(3;17)(p21;p13), del(5)(q13q31),t(6;?)(q15;?) (variation of the stem line).

204 J. Benitez et al.

5q- As a Primary Event and as the Only Alteration

Twelve percent of the patients with MDS and 5q- as the only alteration at diagnosis evolve to leukemia [5]. However, in addition to our patient 1, we only know of six MDS cases in the literature with serial cytogenetic studies from preleukemic to leukemic phases [9-14]. In the total of seven cases there was a long evolution with a mean survival time longer than 35 months. Cytogenetically, four of these cases [11-13; patient 1] started with normal and abnormal cells, showing a subsequent loss of the normal cells. These findings suggest that clones with 5q- have a slow but progressive capacity of expansion similar to the clones with a Ph chromosome in the chronic phase of chronic granulocytic leukemia.

On the other hand, five of these cases [10, 11, 13, 14; patient 1] showed 5q- as the only alteration during the transformation; the other two patients [9, 12] showed a clonal evolution, although having the clone with 5q- as the starting point. There- fore, the acquisition of other alterations during the course of the disease can be a frequent event (about 30% of the cases).

5q- As a Secondary Event

The acquisition of a 5q- during the course of the disease is an infrequent event, only described in a few cases of polycythemia vera [15], acute nonlymphocytic leukemia (ANLL) [16, 17], and secondary ANLL [18, 19]. In patients with MDS we only know three cases [12, 20, 21] in addition to our cases 2 and 3; however, only Geraedst et al. [20] reported complete evolution of a patient; he started with a nor- mal karyotype but during transformation he presented a clone with the 5q- altera- tion. Our patients had an abnormal karyotype with trisomy 8 that was observed during 5 years and 5 months, respectively; in the first case, a clone with 5q- as the only alteration arose concurrently with signs of transformation; a few weeks later, the patient showed a hypodiploid and complex karyotype with other alterations in addition to the 5q-. The second patient showed a 5q- plus other alterations since transformation.

Although the three cases reported here had different karyotypes, they presented similar findings. The presence of clones with 5q- was concurrent with evident signs of a clinical change; the three patients evolved to leukemia, and the mean survival time was only 8 months. Thus, 5q- as a secondary event can be strongly related to progression of the disease; apparently, clones with this alteration can expand rap- idly, but it is possible that they were present since diagnosis, although in a small percentage of cells undetectable with cytogenetic observations. This will be dis- cussed later.

5q- Plus Other Alterations

The evolution of these patients is very similar to that described in patients with 5q- as a secondary event. Twenty-nine percent of the cases evolve to leukemia and the mean survival time is only 5 months [5]. Our case 4 supports these data; the patient had secondary MDS with a complex karyotype at diagnosis (including 5q-); 4 months later he underwent leukemic transformation with similar abnormalities. Kerkofs et al. [22] suggested that in patients with these findings, either evolution has taken place rapidly, or the initial 5q- alteration was present without affecting the clinical condition. The long evolution observed in patients with 5q- as the only alteration, and the evolution found in some of them during transformation (5q- plus other alterations), suggest the second possibility. It is possible that most of these patients represent the expression of a late diagnosis of the disease. It is of interest

Leukemic Transformation and 5 q - Anomaly 205

that 66% of the pat ients reviewed by Van den Berghe et al. [5] with MDS and 5q- as the only al terat ion at diagnosis had RA, whereas, 66% of the patients wi th 5q- plus other al terations at diagnosis had RAEB or secondary MDS. However, it is also possible that the heterogeneity of this marker and the different patterns of presen- tation had some correlat ion with the init ial disease.

Presence of Different Clones

We have found two different clones in three of the four cases; clones wi th 5q-, and clones with t r isomy 8 (cases 1-3). Al though the presence of different clones is a rarely reported event [8, 16, 23-26], it is a relat ively frequent finding in patients wi th 5q-, specifical ly the presence of clones wi th t r isomy 8 and other clones wi th 5q-. In Table 2 we have summar ized the patients descr ibed in the l i terature (in- cluding our cases) wi th 5q- and other clones; 16 of the 17 repor ted cases show clones wi th t r isomy 8, in addi t ion to clones wi th 5q-. These data strongly suggest a nonrandom associat ion between the two clones, al though we do not know the meaning of this phenomenon. Likewise, we do not know the frequency of this as- sociation, though it could be higher than observed; cells with t r isomy 8 are usual ly present in these patients in a small percentage (less than 10%), and this percentage can be modif ied by methodologic variants (direct methodology versus culture) (Car- bonell , unpub l i shed data); perhaps a deta i led cytogenetic analysis p lus a s tudy with both methodologies in pat ients wi th 5q- as the only alteration, could disclose a higher number of cases with both clones; this explanat ion can be the same in the opposi te s i tuat ion i.e., 5q- as a secondary event (our cases 2 and 3).

We believe that clones wi th 5q- are an excel lent model to unders tand the behav- ior and progression of neoplast ic clones; however, a large number of these cases with an adequate fol low-up fol lowing diagnosis is necessary in order to more fully unders tand these phenomena.

Table 2 Patients wi th clones in addi t ion to 5q- descr ibed in the l i terature {including our cases}

Ref. Diagnosis ~ Clones

[31 RAEB [27] RA-S [51 RA

[13] RA RA RA

[12] RA PLS

[21] RA RAEB RAEB

[12] ET [27] PV [5I PV

Patient I RA Patient 2 RAEB Patient 3 RA-S

46,XX,5q-/47,XX, + 8 46,XX,5q-/47,XX, ÷ 8 46,XX,5q-/47,XX, + 8 46,XX,5q-/47,XX, + 8 46,XX,5q-/47,XX, ÷ 8 46,XY,5q-/47,XY, + 8 46,XX,5q-/46,XX,t(9;11}/47,XX, + 8 46,XY,5q-/47,XY, + 8 46,XX,5q-/46,X, - X, + 8/47,XX, + 8/47,XX, + 14 46,XX,5q-/47,XX, + 8 46,XX,5q-/47,XX, + 8 46,XX,5q-/47,XX, ÷ 8 46,XX,5q-/47,XX, + 8 46,XX,5q-,20q-/46,XX,11q-/46,XX,13q- 46,XX,5q-/47,XX, ÷ 8 46,XX,5q-/47,XX, + 8 46,XX,5q-/47,XX, + 8

aDiagnosis according to FAB criteria; PLS, preleukemic syndrome; ET, essential thrombocytopenia; PV, polycythemia vera.

206 J. Benitez et al.

Supported in part by Grant 1170 from Comision Asesora de Investigacion y Ciencia. The authors thank Dr. F. Carbonell for constructive comments on the manuscript. We also

acknowledge the valuable technical assistance of C. Gacituaga.

REFERENCES

1. Van den Berghe H, Cassiman J, David G, Fryns JP, Michaux JL, Sokal G (1974): Distinct haematological disorder with deletion of long arm of no. 5 chromosome. Nature 251:437- 438.

2. Sokal J, Michaux JL, Van den Berghe H, Cordier A, Rodhain J, Ferrant A, Moriau M, De Bruyere M, Sonnet J (1975): A new hematologic syndrome with a distinct karyotype: The 5q- chromosome. Blood 46:519-533.

3. Dewald GW, Davis M, Pierre R, O'Fallon JR, Hoagland HC (1985): Clinical characteristics and prognosis of 50 patients with a myeloproliferative syndrome and deletion of part of the long arm of chromosome 5. Blood 66:189-197.

4. Wisniewski LP, Hirschorn K (1983): Acquired partial deletions of the long arm of chro- mosome 5 in hematologic disorders. Am J Hematol 15:295-310.

5. Van deh'Berghe H, Vermaelen K, Mecucci C, Barbieri D, Tricot G (1985): The 5q- anom- aly. Cancer Genet Cytogenet 17:189-225.

6. Bennett J, Catovsky D, Daniel M, Flandrin G, Galton D, Gralnick M, Sultan C (1976): Pro- posal for the classification of the acute leukemias. Br J Haematol 33:451--458.

7. Bennett j, Catovsky D, Daniel M, Flandrin G, Galton D, Gra]nick M, Sultan C (1982): Pro- posal for the classification of the myelodysplastic syndromes. Br J Haematol 51:189-199.

8. Benitez J, Carbonell F~ Sanchez Fayos J, Heimpel H (1985): Karyotypic evolution in pa- tients with myelodysplastic syndrome. Cancer Genet Cytogenet 16:157-167.

9. Verhest A, Lustman FI Wittek M, Van Schonbroeck F, Naets JP (1977): Cytogenetic evi- dence of clonal evolution in 5q- anemia. Biomedicine 21:211-212.

10. Cabrol C, Abele R (1978): Chromosome 5q- in the medullar cells of a patient with anaemia which later developed into acute nondifferentiated leukaemia. J Genet Hum 26:195-202.

11. Jume'an HG, Libnoch jA (1979): 5q- myelodysplasia terminating in acute leukemia. Ann Inter Med 91:748-749.

12. Swolin B, Weinfeld A, Ridell B, Waldenstrom J, Westin J (1981): On the 5q- deletion. Clinical and cytogenetic observations in 10 patients and review of the literature. Blood 58:986-993.

13. Carbonell F, Heimpel H, Kubanek B, Fliedner T (1985): Growth and cytogenetic charac- teristics of bone marrow colonies from patients with 5q- syndrome. Blood 66:463-465.

14. Ayrand N, Donzean M, Raynaud S, Lambert JC (1983): Cytogenetic study of 88 cases of refractory anemia. Cancer Genet Cytogenet 8:243-248.

16. Van den Berghe H, Broeckaert-Van Orshoven A, Louwagie A, Verwilghen R, Michaux JL, Sokal G (1979): Transformation of polycythemia vera to myelofibrosis and late appearance of a 5q- chromosome anomaly. Cancer Genet Cytogenet 1:157-167.

16. Testa JR, Mintz U, Rowley JD, Vardiman JW, Golomb HM (1979): Evolution of karyotypes in acute non lymphocytic leukemia. Cancer Res 39:3619-3627.

17. Fitzgerald PH, Morris CM, Fraser GJ, Giles LM, Hamer SW, Heaton DC, Beard JE (1983): Non random cytogenetic changes in New Zealand patients with acute myeloid leukemia. Cancer Genet Cytogenet 8:51-66.

18. Oshimura M, Hayata I, Kakati S, Sandberg AA (1978): Chromosome and Causation of hu- man cancer and leukemia. XVII. Banding studies in acute myeloblastic leukemia (AML). Cancer 38:748-761.

19. Papa G, Alimena G, Annino L, Anselmo AP, Ciccone F, De Luca AM, Granati L, Petti N, Mandelli F (1979): Acute nonlymphoid leukemia following Hodgkin's disease. Clinical, biological and cytogenetic aspects of 3 cases: Scand J Haematol 23:339-347.

20. Geraedst J, Weber R, Kerkofs H, Leeksma J (1980): The preleukemic syndrome: II Cytoge- netic findings. Acta Med Scand 207:447-454.

21. Knuutila S, Teerenhavi L, Borgstrom G (1984): Chromosome instability is associated with hypodiploid clones in myelodysplastic syndromes. Hereditas 101:19-30.

Leukemic Trans fo rma t ion and 5 q - A n o m a l y 207

22. Kerkofs H, Hagemeijer A, Leeksma CH, Abels J, Den Ottolander GJ, Somers R, Gerrits WBJ, Langenhuiyen MMA, Von den Borne AEG, Van Hemel JO, Geraedts JPM (1982): The 5q- chromosome abnormality in haematological disorders: a collaborative study of 34 cases from the Netherlands. Br J Haematol 52:365-381.

23. Morse H, Ducore J, Hays T, Peakmen D, Robinson A (1978): Multiple leukemic clones in acute leukemia in childhood. Hum Genet 40:269-278.

24. Testa J, Kanofsky H, Rowley J, Baron J (1981): Multiple cytogenetically abnormal clones in two polycythemia vera patients. Hum Genet 57:165-168.

25. Whang Peng J, Lee E, Knutsen T, Chang P, Nienhui A (1978): Cytogenetic studies in pa- tients with myelofibrosis and myeloid metaplasia. Leuk Res 2:41-56.

26. Fourth International Workshop on Chromosomes in Leukemia, 1982 (1984): Karyotypic patterns in multiple clones. Cancer Genet Cytogenet 11:322-325.

27. Teerenhovi L, Borgstrom GH, Lintula R, Ruutu T, Lahtinen R, De la Chapelle A, Vuopio P (1981): The 5q- chromosome in preleukemia and acute leukemia. Scand J Haematol 27:119-120.