CASE 2. Seven week old female infant presents with hepatosplenomegaly l and WBC 31.0k/mm 3, Hgb 9.2 g/dl, Plt 110k/mm 3 with 60% blasts

Transcription

1 CASE 2 Seven week old female infant presents with hepatosplenomegaly l and WBC 31.0k/mm 3, Hgb 9.2 g/dl, Plt 110k/mm 3 with 60% blasts A bone marrow biopsy and aspirate were performed (photos provided). Cytochemical stains for myeloperoxidase and non-specific esterase were negative in the blasts. Flow cytometry y performed on the bone marrow aspirate revealed the blasts were weakly positive for CD34, CD45 and CD61 and were negative for CD3, CD4, CD5, CD7, CD10, CD11c, CD13, CD14, CD19, CD20, CD22, CD33, CD38, CD56, CD117, glycophorin, myeloperoxidase, and TdT.

2 CASE 2 (continued) Cytogenetics performed on the bone marrow aspirate revealed the t(1;22)(p13;q13) in 100% of metaphases Discussion points: 1. What are the most common types of leukemia that present in infancy and early childhood? 2. How can immunoperoxidase studies assist in the diagnosis of acute leukemias? 3. What are the prognostic implications of the cytogenetic abnormality in this case?

3 CASE 2 Peripheral blood

5 CASE 2 Bone marrow

6 CASE 2 Bone marrow

7 CASE 2 Bone marrow aspirate

8 Differential diagnosis of leukemias in the neonatal period (No constitutional abnormality) 1. ALL 2/3 of infant ALL have MLL rearrangements at 11q23 2. AML myeloid markers 3. AMKL megakaryocytic markers most common AML under age 2 association with DS strongly associated with t(1;22)(p13;q13) ) association with non-seminomatous mediastinal germ cell tumors and i(12p) (rare) 4. JMML usually occurs in older age group (median age 22 months) male predominance 5. Sarcomas metastatic alveolar rhabdomyosarcoma, neuroblastoma, others 6. r/o infection and hemolysis

9 Differential diagnosis of AML with fibrosis AML NOS AML with multilineage dysplasia dysplasia associated cytogenetics myeloid not megakaryocytic markers Acute megakaryoblastic leukemia (AMKL) myelofibrosis megakaryocytic markers in 50% of blasts young age at presentation association with DS, hepatic fibrosis association with t(1;22)(p13;q13) and 3q26 rearrangements Acute panmyelosis with myelofibrosis rare, pancytopenia with hetergeneous blast population predominantly myeloid, not megakaryocytic markers considerable overlap with AML with multilineage dysplasia Sarcomas, metastatic carcinoma

10 Utility of immunoperoxidase studies for myeloid neoplasms 1. No aspirate 2. Extramedullary presentation (skin especially common) 3. Special situations -focal infiltrates of blasts in bone marrow -staining for cytoplasmic megakaryocytic markers (Platelets may adhere to blasts causing false positives in flow cytometry) T lymphoid B lymphoid Myeloid Megakaryocytic Erythroid Progenitor CD3 CD4/CD8 CD5 CD7 CD43* CD20 CD79a myeloperoxidase lysozyme CD13 CD15 CD33 CD68 CD31 (PECAM-1) glycophorin TdT CD41 (GPIIb/IIIa) hemoglobin CD34 CD61 (GPIIIa) C-KIT FVIIIR-Ag *also expressed in majority of AML

11 Immunoperoxidase cross reactivities confounding diagnosis of myeloid neoplasms 1. CD79a is expressed on 12% of AMLs and 40% of T-ALLs (Tiacci E et al. Cancer Research 2004;64: ) 2. CD3 is expressed on 10% of AMLs (Lewis R.E. et al. Exp Mol Pathol 83:462-3, 2007) 3. CD4 is expressed by 24% of AMLs (especially monocytic) (Drexler H.G. et al. Leukemia 7:489-98,1993) 4. CD7 is expressed by 28% of AMLs (Bradstock K et al. Blood 84: , 1994) Other pitfalls 1. Underestimating blast counts by C-KIT and CD34 staining 2. Myeloperoxidase negativity in monocytic leukemias

12 CASE 9183.CD4 2 Bone marrow CD4

16 CASE 9183.CD34 2 Bone marrow 400x CD34

17 CASE 9183.CD61 2 Bone marrow 400x CD61 (Platelet glycoprotein IIIa)

18 CASE 9183.CD31 2 Bone marrow 400x CD31 (PECAM-1)

19 CASE 9183.Factor 2 Bone marrow VIII related Factor VIII ag 400x related Ag

20 For comparison to Case 2 Here is a example of AML with multilineage dysplasia

21 AML with multilineage dysplasia

22 AML with multilineage dysplasia Glycophorin A

23 Megakaryocytes are positive Blasts are negative AML with multilineage dysplasia CD61 (Platelet glycoprotein IIIa)

24 Blasts are positive AML with multilineage dysplasia Myeloperoxidase

25 AML with multilineage dysplasia Myeloperoxidase

26 Pathobiology of t(1;22)(p13;q13) WILD TYPE RBM15-MKL1 (OTT-MAL) -NOTCH +NOTCH activation activation -NOTCH activation COREPRESSORS RBM15 RBPJ X RBPJ ICN MAML RBM15 MKL1 RBPJ Genes that promote proliferation Second hits (MPL mutation) Normal megakaryopoiesis AMKL After Mercher T. J Clin Invest 119: , 2009

27 Case 2 Diagnosis: Acute myeloid leukemia (megakaryoblastic) with t(1;22)(p13;q13) RBM15-MKL MKL Primarily infants without DS Median age at diagnosis 4 months Thrombocytosis or thrombocytopenia Giant platelets Megakaryoblasts (CD41, CD61 positive, CD13 and CD33 +/-, MPO-) Dysplastic megakaryocytes Median survival 8 months

28 Case 2 Follow up: The patient is currently in remission three months after induction chemotherapy The patient is experiencing respiratory insufficiency and impaired hepatic function believed to be secondary to pulmonary and hepatic fibrosis

29 CASE 3 33 week gestation male infant with Down Syndrome presented at birth with pericardial effusion, hepatosplenomegaly, coagulopathy and WBC 125K/mm 3 with 63% blasts, 21.5% neutrophils and bands, 2%metamyelocytes, 1% myelocytes, 2% monocytes, 0.5% eosinophils and 1% basophils A bone marrow aspirate was performed (slides provided). The aspirate was hemodilute but showed 62% blasts, 2.6% promyelocytes, 23.8% other granulocytic precursors and neutrophils, 5% erythroid precursors, 4.4% lymphocytes and 1.8% basophils and 0.4% monocytes. Cytochemical stains for myeloperoxidase and non-specific esterase were negative in the blasts

30 CASE 3 Flow cytometry performed on the bone marrow aspirate revealed the blasts were weakly positive for CD7, CD34, CD45 and were negative for CD3, CD4, CD5, CD10, CD11c, CD13, CD14, CD19, CD20, CD22, CD33, CD38, CD56, CD61, CD117, glycophorin, myeloperoxidase, and TdT. Cytogenetics performed on the bone marrow aspirate revealed 47 XY +21 in 100% of metaphases Discussion points: 1. What is the differential diagnosis of blast proliferations in Down Syndrome patients? 2. What molecular abnormality is likely to be present in this case? 3. How does the prognosis and therapy of Down Syndrome AML patients differ from patients without constitutional abnormalities?

32 CASE 3 Bone marrow clot section

33 CASE 3 Bone marrow aspirate

34 Differential diagnosis of blast proliferations in Down Syndrome 1. ALL most commonly common ALL CD10+, CD19+,CD79a+ hyperdiploid, +X, t(8;14), del(9p) JAK2 mutations in 20% Higher risk than most common ALL 2. AMKL usually under 4 years GATA1 mutations JAK3 mutations Low dose cytarabine Excellent prognosis (80% cure rate) 3. AML usually 4 years or older No GATA1 mutations Prognosis same as non-ds patients

35 4. Transient abnormal myelopoiesis (TAM) (aka transient myeloprolerative disease-tmd) Frequency: 3.8% of DS patients Median age at presentation: 7 days Hepatosplenomegaly p (56%) Petechiae (25%) Effusions (21%) Neutrophilia (80%) Thrombocytopenia (66%) Polycythemia (33%) Blasts usually CD34+, CD7+, CD33+, CD41+, CD61+, MPO- 100% association with GATA1 mutations Cytogenetic abnormalities limited to +21 In nearly 90% of cases blasts disappear, mean 58 days 17% die from complications (liver failure, DIC, effusions) May benefit from lose dose cytarabine Malinge S. et al. Blood 113: , 2009

36 GATA1 mutations in Down Syndrome GATA1 GATA1s GATA1 mrna GATA1s GATA1s mrna GATA1 mutations AD NF CF GATA1 protein NF CF GATA1s protein

37 +21 DSCR1 RUNX1 ERG ETS2 C21ORF +21 promotes expansion of megakaryocytic-erythroid progenitors Progression of leukemia in DS Healthy GATA1 mutation and expansion of GATA1 mutant cells 80% 20% 85% survive Additional genetic hits (i.e. JAK3 mutations) TAM 20% AMKL Fetal liver Bone marrow after Zwann M.C. et al. Ped Clin N Am 55:53-70, 2008

38 Case 3 Diagnosis: Atypical myeloblastic proliferation. The differential diagnosis includes transient abnormal hematopoiesis (TAM) and acute myeloid leukemia associated with Down syndrome. Close clinical follow up is recommended. DS or +21 mosaicism GATA1 mutations in all cases 85% spontaneously resolve 20% will develop AMKL, but these generally respond well to chemotherapy

39 Case 3 Follow up: The patient was treated with low dose cytarabine for presumptive TAM. The blasts disappeared from the peripheral blood over a two month period. At age 2 the patient is small for age and is being followed for a ventricular septal defect and patent ductus arteriosus, but is otherwise well

40 CASE 4 Nine day old infant girl presents with Blueberry muffin appearance and is found to have circulating i blasts. A skin biopsy of the right flank reportedly was worrisome for leukemia (slides not available). A bone marrow biopsy was performed (Biopsy #1, photos provided). Flow cytometry was consistent with AML. Cytogenetics revealed 46XX and t(8;16)(p11;p13) translocation in 100% of metaphases examined. FISH for MLL rearrangement was negative.

41 CASE 4 (continued) A diagnosis of AML was made along with the decision not to administer systemic chemotherapy. The patient s peripheral counts normalized over the course of the following two months and a repeat bone marrow biopsy at 11 months of age revealed normal cytogenetics and no evidence of fleukemia (Biopsy #2, photos provided). d) Discussion points: 1. What are the most common types of congenital leukemia? 2. How does cytogenetics contribute to the diagnosis and therapy of congenital and infant leukemias? 3. How common is spontaneous remission of acute leukemia and what does this tell us about leukemia biology?

42 CASE 4 Peripheral blood #1

44 CASE 4 Bone marrow #1

46 CASE 4 Bone marrow aspirate #1

49 CASE 4 Bone marrow aspirate #2

50 Congenital acute leukemia 4.7/million live births 2 year OS ~20% r/o congenital infection or hemolysis r/o DS or +21 mosaicism r/o sarcoma (congenital neuroblastoma, rhabdomyosarcoma) 1. ALL -majority have MLL rearrangements especially t(4;11) with MLL-AF4 and pro B cell phenotype -remainder mostly t(12;21) with TEL-AML1 all subtypes treated with combination chemotherapy 2. AML mostly monocytic or myelomonocytic y variety of chromosomal translocations -those with MLL rearrangement -those with other abnormalities, which occasionally undergo spontaneous remission leukemia cutis in up to 50% of patients 3. AMKL extremely rare, median age at presentation 15 months 4. JMML extremely rare, median age at presentation 22 months

51 Acute myeloid leukemia with t(8;16)(p11;p13) MYST3-CREBBP (MOZ-CBP) fusion involving two histone acetyltransferases Uncommon translocation in both de novo and therapy related AML Usually myelomonocytic Frequent extramedullary presentation Disseminated intravascular coagulation Erythrophagocytosis by blasts in about 50% of cases Poor prognosis: 4.7 months in a series of adult patients Appears to involve HOX deregulation similar to MLL Cámos M et al. Cancer Res 66: , 2006 Haferlach T. et al. Leukemia (online publication 2009)

52 Spontaneous remission of congenital acute leukemia with t(8;16) Sainati L. et al. Transient acute monoblastic leukemia with reciprocal (8;16)(p11;13) translocation. Pediatr Hematol Oncol 13: , 1996 Weintraub M. et al. Spontaneous remission of congential leukemia with an 8;16 translocation. Br J Hematol 111: , 2000.

53 What is the mechanism of spontaneous remission of congenital acute leukemia? Unknown, understanding this might lead to better AML therapy Immunologic: a number of cases of spontaneous remission of AML following bacterial infections or blood transfusion have been reported, suggesting immunologic mechanisms may play a role Jain N. et al. Spontaneous remission of acute myeloid leukemia. Clinical Leukemia 2:64-67, Self renewal properties of fetal stem cells: In addition, fetal liver hematopoietic stem cells differ considerably from adult stem cells. It seems likely that the mechanisms involved in TAM and spontaneous remission of AML are related. Williams, D.A. et al. Children are not just little adults, just ask their stem cells. J Clin Invest 116: , 2006.

54 Case 4 Diagnosis: Bone marrow #1 Acute myeloid leukemia with t(8;16)(p11;p13) Bone marrow #2 Normocellular marrow for age showing trilineage hematopoiesis No leukemia seen

55 Case 4 Follow up: At age 2 1/2 the patient is alive and well